In Nursing, there exists a culture of lateral violence and bullying, I have finally come to the realization that what we are seeing is the symptom of something much larger, something that starts, grows, and is nurtured with our own participation. We communicate in ways that have the ability to support each other, but we can also communicate in ways that are hurtful, mean, and contribute to a culture of oppression. We need to change our culture.
Better Communication in Nursing - Ending Nursing Violence
1. — Saturday, November 7th, 2015, 9am - 3pm
— Regina SK:Wascana Rehabilitation Center Auditorium
Better Communication in Nursing
Ending NursingViolence
LateralViolence – Lateral Kindness
Greg Riehl RN BScN MA
2. “The real voyage of discovery consists not in seeking new
landscapes but in having new eyes.”
Marcel Proust
3. Outline
• Cultural safety in the workplace
• Communication senses – eyes and ears
• Functional versus dysfunctional conflict
• Intergenerational communication
• Discussion
4. And if there is time…
• What is lateral violence
• What causes lateral violence
• What are the effects of lateral violence
• Who gets targeted
• Types of bullies
• Hierarchy
• Mobbing
• Identify terms used to describe negative coworker behavior
• Describe an experience with negative coworker behavior
• Discuss strategies to manage negative coworker behavior
• Cultural competence and culture
• Zero tolerance policies
• Functional versus dysfunctional conflict
• Better communication strategies
• Types of teams and teamwork
• Commitment to co-workers
• Increase knowledge and understanding of the four generations
• Enhance comprehension of how generational differences affect you
• Promote skills for effective intergenerational communication
• Expand capacity to manage diverse working styles across the generations
5. Why am I here?
I ask myself this every day
I also ask this to people I work with from time to time
7. This is where I used to workThis is where I used to work
8. Objectives
To broaden the understanding of the Platinum Rule.
To describe how to apply the Platinum Rule.
Compare the Golden and Platinum Rules.
To explore cultural aspects of nursing care.
To identify the unique challenges faced by care providers
working with diverse clients.
9. Stories
• I will use some of my experiences working in health, in
the north, and as an male nurse, often an outsider,
working in different situations.
• You are a part of the story.
11. Hierarchy is systemic.
The more vertical an organization is in its
hierarchy, the more complicated
communication becomes.
We go to school, we get a job, but nowhere
are we told that lateral violence exists, or
that we will have to deal with it, or avoid it,
or be drawn into it.
12. Communication is about listening
• My job description does not say, Greg, you will have to
listen to a lot of your co workers bitching and complaining
about each other, they will want you to fix their conflicts,
and will want you to keep it a secret and tell no one.
• This will happen on a very regular basis, consider this
‘duties as assigned’
13. LateralViolence
“Exists on a spectrum, from seemingly ordinary
behaviour such as gossiping or criticism, to
intimidation, racism and outright physical
intimidation or harm.”
Linda Rabyj, 2005
14. LateralViolence
LateralViolence (LV), also called Horizontal
violence, [bullying], incivility, and disruptive
behaviours, creates an unpleasant work
environment and has harmful effects on individual
nurses, patient safety, and health care
organizations.
Johnson, 2009 & Dimarino, 2011
15. The absence of one thing does not mean
there will be more of the other thing…
“What you see you do not see” – Archi Weenie
16. What to do?
• Awareness
• Education
• Dialogue
• Zero tolerance policy
• Be confident
• Develop effective coping mechanisms
• Confront the situation
• Rehearsal
• Enact policy and procedure
• Code of conduct
• Don’t accept it!
17. Hurt People Hurt People
When another person makes you suffer, it is because he
suffers deeply within himself, and his suffering is spilling
over.
He does not need punishment;
He needs help.
Tich Naht Hanh
18. Hurt People Hurt People
Hurt people hurt people.That’s how pain patterns get
passed on, generation after generation after generation.
Break the chain today.
Meet anger with sympathy, contempt with compassion,
cruelty with kindness.
Greet grimaces with smiles.
When you forget about the fault, there is nothing to forgive.
Love is the weapon of the future
Yehuda berg
19. Who gets targeted?
Anyone who is different from the group norm on any major
characteristic
• Experience
• Education
• Race/ethnicity
• Gender
Targeted person’s gender
• 79% Female
• 21% Male
20. Who gets targeted?
Anyone who is different from the group norm on any major
characteristic
• Experience
• Education
• Race/ethnicity
• Gender
Targeted person’s gender
• 79% Female
• 21% Male
Basically if you are different
you may be a potential target!
21. We communicate/bully differently.
2009 survey byWorkplace Bullying Institute:
- Main perpetrator’s gender
• 65% Female
• 35% Male
2009WBI survey sited in NewYorkTimes:
- Men target men and women equally
-Women target women 70% of the time
22. Conflict It’s not all Bad
Functional Conflict is considered positive, as it can increase
performance, support change, and identify weaknesses or
areas that need to be supported.
Dysfunctional Conflict is harmful to people and the
organization.This type of confrontation does nothing to
support goals or objectives.
24. Back to nursing, Do Nurses eat their
young – and each other…
This old adage should not be the price the next generation
has to pay to join the nursing profession.
25. Why?
In my profession, nurses practice in a historically patriarchal
environment.
• Oppression leads to low-self esteem.
• Nurses exert power over one another through lateral violence.
Lateral violence is perpetuated through the culture of nursing (new
nurses, curriculum, etc).
• “Nurses eat their own”
• “See one do one teach one”
We now work with four different generations in the workforce,
adding to the complexities of effective communication.
26. The Four Generations
• The Traditionalists
• The Boomers
• Generation X’ers
• Millennials
• 1922–1943/46
• 1943–1960/1946-1964
• 1960-1980/1964-1980
• 1980-2000
27. Traditionalist Values
• Dedication/sacrifice
• Law and order
• Strong work ethic
• Risk averse
• Respect for authority
• Patience
• Delayed reward
• Duty, honor, country
• Loyalty to the organization
28. Boomer Values
• Optimism
• Team work
• Personal gratification
• Health and wellness
• Promotion and recognition
• Youth
• Work
• Volunteerism
29. Gen X Values
• Diversity
• Thinking globally
• Balance in life
• Computer literacy
• Personal development
• Fun
• Informality
• Independence
• Initiative
33. Why does this happen in theWorkplace?
• Isolated from the public and other staff
• High-stress environment
• Limited autonomy in practice
• High-paced environment
• Lack of experienced staff
• Cliques or closely bonded groups
• Hierarchical climate
• Gender imbalance
• Attitudes to training
• Non acceptance of difference
34. Mobbing
A group of coworkers gang up on another
• often with the intent to force them to leave the work group
Five phases of Mobbing
1. Conflict
2.Aggressive acts
3.Management/Faculty Involvement
4.Branding as Difficult or Mentally ill
5.Expulsion
35. Risk
We often face a risk acting
We also face a risk when we do not act.
36. “We Don’t SeeThings AsThey Are,
We SeeThem As We Are”
“It has been well said that we do not see things as they are,
but as we are ourselves. Every man looks through the eyes
of his prejudices, of his preconceived notions. Hence, it is
the most difficult thing in the world to broaden a man so
that he will realize truth as other men see it.”
38. In Conflict who are you: Victim, Villain, Hero or
Resolutionary?
In conflict, each person
feels hit first.
The size of the villain
determines the size of the
hero.
“Without goliath, David is
just some punk, throwing
rocks.”
Billy Crystal, My Giant
41. Our Culture needs to change
• We do not accept bullying in our schools or other
workplaces so why is it ok in the workplace?
• In Nursing, this is the culture that was learnt by nurses 30
years ago and has propitiously been taught to new
nurses.
49. ZeroTolerance Policies
The Joint Commission and the American Association of Critical Care Nurses
(AACN).
•2008: mandate the development and implementation of
processes to offset LV that enforce a code of conduct, teach
employees communication skills, and supporting staff.
•2009: advocates that communication skills should be as
proficient as clinical skills.
50. Culture of Silence
• “Because we set ourselves up to be healers, this kind of
behaviour is in the shadows.We don’t know what to do about
it, so we try to disown it.”
• In practice, this means we can’t stay silent when another
person’s actions “makes us cringe”.
• Having the conversation is what matters . . . it shows that both
professionals share responsibility for behaviour affecting staff
and patients.
• Monica Branigan, 2009
51. Impact is on all staff
•Physical
•Psychological
•Social
52. Lateral Silence
• It is part of the culture.
• Everybody knows about it
• Everybody does it
• No body talks about it
53.
54. Why Don’tWe Stop LateralViolence?
“It’s not a problem in our work area”
“Everybody does it – just get used to it”
“If I say anything, I’ll be the next target”
“We have policies but they aren’t enforced”
“She sets herself up for getting picked on”
55. Using the ACORN Approach
•Accommodate employee differences.
•Create workplace choices.
•Operate from a flexible
management style.
•Respect competence and initiative.
•Nourish retention.
Source: Generations At Work, Ron Zemke, Claire Raines, and Bob Filipczak
56. Statement of Commitment to Co-workers
As your co-worker with a shared goal of providing excellent service to people
and families, I commit the following:
I will accept responsibility for establishing and maintaining healthy
interpersonal relationships with you and every member of this staff.
I will talk to you promptly if I am having a problem with you. The only
time I will discuss it with another person is when I need advice or help
in deciding how to communicate with you appropriately.
I will establish & maintain a relationship of functional trust with you and
every member of this staff. My relationships with each of you
will be equally respectful, regardless of job titles or levels of educational preparation.
I will not engage in the '3B's (bickering, back-biting and bitching) &
will ask you not to as well.
I will not complain about another team member & ask you not to as well.
If I hear you doing so, I will ask you to talk to that person.
I will accept you as you are today, forgiving past problems,
& ask you to do the same with me.
I will be committed to finding solutions to problems rather than
complaining about them or blaming someone, & ask you to do the same.
I will affirm your contribution to quality service.
I will remember that neither of us is perfect, & that human errors
are opportunities not for shame or guilt, but for forgiveness and growth.
(Adapted from Marie Manthey, President of Creative Nursing Management in Caroline Flint's Midwifery Teams and Caseloads 1993; p. 138)
57. Lateral Kindness
• Please be kind to each other
• Respectful and responsible relationships, there are no
apps for that.
• Be Grateful
• Be Great!
61. Three types of BULLIES
Sydney based clinical psychologist and workplace bullying
specialist Keryl Egan has formulated three workplace bully
profiles:
1.Accidental bully
2.Narcissistic bully
3.Serial bully
62. Accidental bully
This person is task orientated and just wants to get things
done, tends to panic when things are not getting done, and
goes into a rage about it.This person is basically decent,
they don’t really think about the impact of what’s
happening or what they have done.
They are responding to stress and it is believed that they
can be coached out of this behavior.
63. Narcissistic Bully
They are grandiose and have dreams of breath taking
achievement.They feel they deserve power and position.
They can fly into a rage when reality confronts them.This
person is very destructive and manipulative, they don’t set
out in a callous way to annihilate any person – it is purely an
expression of their superiority.
64. Serial Bully
Has a sociopathic and psychopathic personality.This type of bully is intentional,
systematic and organized and is often relentless.They usually get things done in
terms of self-interest.
They employ subtle techniques that are difficult to detect or prove. Coaching is often
ineffective.
They exhibit the following:
•Grandiose, but charming
•Authoritative, aggressive and dominating
•Fearless and shameless
•Devoid of empathy or remorse
•Manipulative and deceptive
•Impulsive, chaotic or stimulus seeking
•Master of imitation or mimicry
65. What can you do?
• Dialogue is ultimately far more effective than pointing
fingers
• Cognitive RehearsalTechniques
• Health care professionals across the spectrum working
together more effectively and patients receiving better
care.
66. DESC COMMUNICATION MODEL
Describe – the behavior
Explain – the effect the behavior has on you,
coworkers, patient care
State – the desired outcome
Consequences – what will happen if the behavior
continues?
67. Rehearsal
Research has demonstrated the benefit of rehearsal for new
employees.
i.e.
When a staff member makes a facial gesture (raising an
eyebrow) the participant was instructed to say “I see
from your facial expression that there may be something
you wanted to say to me. It’s ok to speak directly to me”.
Griffin, 2004
68. Teamwork and Communication
• Involve everyone in solving problems related to these
issues.
• Develop a set of “RIGHTS” for everyone.
• Effective anti-bullying practices must include a statement
of exactly what constitutes bullying.
• Communication needs to be a part of culture.
Notas del editor
What is lateral violence
What causes lateral violence
What are the effects of lateral violence
Who gets targeted
Types of bullies
Hierarchy
Mobbing
Identify terms used to describe negative coworker behavior
Describe an experience with negative coworker behavior
Discuss strategies to manage negative coworker behavior
Cultural competence and culture
Zero tolerance policies
Functional versus dysfunctional conflict
Better communication strategies
Types of teams and teamwork
Commitment to co-workers
Increase knowledge and understanding of the four generations
Enhance comprehension of how generational differences affect you
Promote skills for effective intergenerational communication
Expand capacity to manage diverse working styles across the generations
Prisoners Vacationers Keeners and Experts
Last night I gave a talk on illicit drugs and safer sex.
Fond du lac SK
The Golden Rule “do unto other as you would have them do unto you” or treat others how we would like to be treated, is a value many people learn growing up. Nursing education reinforces this adage and supports nurses to treat clients with similar conditions in similar ways. But, the Golden Rule does not support holistic care of addressing physical, mental, spiritual, or emotional needs of the client who may be culturally, ethnically, or spiritually different from the person or group providing care. For social justice to support inclusivity there needs to be a shift to the Platinum Rule, “do unto other as they want do unto them” or treat others how they want to be treated. The challenge implementing the Platinum Rule is evident in practice and occurs when providers work with clients who are culturally, ethnically, or socially different from themselves or with clients who actively engaging in risky behaviours or unhealthy choices.
The Golden Rule supports healthcare provider morals and personal values; the Platinum Rule supports clients’ values and realizes that all humans have certain rights, even the right to make “bad” choices. In nursing, we should not treat everyone the same; we are all different. Patients, families, groups, and communities possess the knowledge to be active consumers and partners in health programming. Acceptance of all clients, with a focus on genuine empathy, regardless of lifestyles, behaviours, and choices, is required to deliver optimal client-first health care. This presentation is about the Platinum Rule and you.
Someone is always watching you,
I saw you talking about me…
New nurses finding that to survive and succeed one needs to be able to throw one’s weight around in this fashion may constitute a pool of new recruits to the culture. Many more, however, are deciding that this is not for them. Health care facilities cannot afford this loss.
Often, experienced nurses have firm views on the necessity for younger nurses to endure what they themselves had to endure in their "training" for the profession.
http://www.reseaufranco.com/en/best_of_crosscurrents/bullying_in_nursing.html Building a culture of respect combats lateral violence
Tackling the nursing shortage and addressing retention and recruitment requires action.
It is not enough to train RNs and LPNs with skills and competencies.
We need to make it easier for them to stay and be a part of the team.
Many senior nurses expect graduates to hit the ground running," says Judith Tompkins, chief of Nursing Practice and Professional Services and executive vice-president of Programs at the Centre for Addiction and Mental Health (CAMH) in Toronto.
"When there is a lack of collegiality and mentoring from peers, young nurses are thrown into the workforce and are left feeling unsupported."
What to do?
When nurses don't have control but must be accountable, you can see where they might not be happy with one another.
Other unhealthy coping strategies include taking up smoking, using alcohol excessively and abusing prescription medication.
Anti-harassment and diversity initiatives can make a big difference.
Women were more often the perpetrator – 65%
Men target men and women equally
Women target other women 70% of the time
Hierarchy makes us different
Women were more often the perpetrator – 65%
Men target men and women equally
Women target other women 70% of the time
Hierarchy makes us different
Image http://www.homebirth.net.au/2010/03/bullying-culture-of-midwifery.html
To effectively intervene in situations where toxic work environments lead nurses to exit the profession, understanding the dynamics of relational aggression (RA) can be helpful.
Females and males express negative feelings differently across different ages and stages of development. This is relevant to female-dominated professions like nursing.
http://nursing.advanceweb.com/Features/Articles/Why-Nurses-Bully-What-You-Can-Do-About-It.aspx
Image http://nursing.advanceweb.com/Features/Articles/Why-Nurses-Bully-What-You-Can-Do-About-It.aspx
Hierarchy versus the medicine wheel
Emotional abuse committed directly or indirectly by a group.
This is when people come and talk to me about their issues, time for a story.
http://quoteinvestigator.com/2014/03/09/as-we-are/ Anaïs Nin? Babylonian Talmud? Immanuel Kant? G. T. W. Patrick? H. M. Tomlinson? Steven Covey? Anonymous?
1891, The Province of Expression: A Search for Principles Underlying Adequate Methods of Developing Dramatic and Oratoric Delivery by S. S. Curry (Samuel Silas Curry) (Dean, School of Expression: Instructor of Elocution, Harvard College), Quote Page 392, Published by School of Expression, Boston, Massachusetts. (Google Books Full View) link ↩
This meeting only took place after both sides had waited for 40 days.
Are you facing a big problem? Do you know what you are facing?
roles focus on problems, feed on each other, generate anxiety and perpetuate the toxic interplay between the people within the drama. Sometimes you switch back and forth between these roles so fast you can't keep it all straight.
Drama Triangle Gary Harper
http://www.reseaufranco.com/en/best_of_crosscurrents/bullying_in_nursing.html Building a culture of respect combats lateral violence
We often personalize our experiences and assume they are unique to ourselves.
"Our program empowered nurses to advocate for themselves. As it liberated them, retention rates improved. We attribute this to recognition of lateral violence. Newer nurses can learn from those who've gone before.“
Dr. Martha Griffin, 2005
http://theprospectorsite.com/blog/?p=2753
http://www.forbes.com/sites/afontevecchia/2011/11/15/is-gld-really-as-good-as-gold/
http://bizmology.hoovers.com/2012/02/22/anglo-american-reviewing-platinum-business-despite-record-2011/stacks-of-platinum-bars/
Bronze rule - Do unto others as they have done unto you
Silver – negative form of the golden rule - what you do not want done to yourself, do not do to others Confucius or One should not treat others in ways that one would not like to be treated
Gold – do unto others as you would have them do unto you.
Platinum – do unto others as they want done unto them, basically treat other people how they want to be treated. This is really what we are trying to do with all people.
Unfortunately this is often how nursing is, we had to endure certain hardships as new nurses, and many feel the need to see one, do one, and teach one in the same manner, putting new graduate nurses through the same hardships they endured.
Confucius or One should not treat others in ways that one would not like to be treated
This is really what we are trying to do with all people. Basically treat other people how they want to be treated.
The Platinum Rule meets people where they are at, it is a balanced approach that gives power to the client. Just like all areas of the medicine wheel need to be balanced for (w)holistic health for the client, where the client is the person, family, group, or community. Indigenous teachings support addressing all areas of the person to achieve balance.
The culture of Western medicine places diagnosis as a central goal
Aboriginal medicine, see diagnosis as less central and pay more attention to finding a safe environment in which the patient may recover.
We all know the Golden Rule “do unto others…” but in health care, this does not work all the time for all people receiving or providing care. The Platinum Rule supports acceptance of all and avoids value and moral judgments to support care. Learn about the Platinum Rule and you.
Physical
Fatigue or insomnia
Stress
GI distress
Headaches, depression
Increased blood pressure
Psychological
Shame or guilt
Prolonged duress stress disorder or post traumatic stress disorder
Substance abuse.
Increased stress, anxiety, irritability
Poor concentration, feeling overwhelmed
Inability to concentrate
Social
Isolation
Loss of libido
Loss of self confidence, decreased self esteem
Avoidance and withdrawal behaviors, disconnection from others
Increased use of tobacco, alcohol, and other substances
Griffin, m. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. Journal of continuing nursing. 2004; 35(6): 257-263.
Cortina & Magley, 2003; Gilmour & Hamlin, 2003; Longo & Sherman, 2007; Normandale & Davies, 2002
May also be PTSD and suicidal ideation
Individual factors:
Type A personality
Emotional state – anger, burnout
Inadequate conflict management skills
Beliefs and expectations
No time for reflection
No acknowledgement of the emotional work required
Kathleen Bartholomew quote
Exercise, listening,
Denial that behavior is a problem
Manager condones the behavior
Manager exhibits the behavior
Negative behavior is accepted as the norm
Information about negative behaviors is suppressed
Manager protecting someone with good clinical skills
Employee fear of retaliation causes ‘silencing of voice’
Policies are in place but not enforced
Manager lacks confrontation skills
Time pressure used as an excuse not to confront perpetrators
Human resources department not consulted or not helpful
Blame is shifted to the victim
Cognitive Rehearsal Techniques
Introduced by Dr. Martha Griffin in her study with new graduate nurses
Taught nurses about the behaviors
Provided suggestions for what to say in response to each behavior
Provided laminated cards with the information that nurse could put behind her ID badge
Gave nurses the opportunity to practice responding to lateral violence behaviors
Image http://nursing.advanceweb.com/features/articles/no-tolerance-for-bullying.aspx
“I feel (state a feeling) when you (describe the behavior). I
would really like to do something about this situation so
that it will not happen again. I’m wondering if you have
any ideas about possible solutions. Here are some of my
ideas. (State alternative solutions and come to an
agreement on one of them.) Now, since this problem has
come up before, I want some assurance that the problem
will work this time. (Negotiate positive and/or negative
consequences.) I feel much better now that we’ve spoken
about this issue. I appreciate your willingness to work this
out with me.”
2. What do you say after you hear that someone has been backstabbing you?
D “I’d like to talk with you in private. I heard from another nurse that you said I didn’t
know what I was doing, that I am a terrible nurse.”
E “When I hear that someone has been saying things about me and I don’t know why, or
even what situation it pertains to, I feel sabotaged and set up to fail.”
S “I want to be a good nurse, and I can’t do that without your honest feedback and support.
Can you say what you feel and think directly to me in private?”
C “Without that support, I am sure to fail. I will have to find another place to work, even
though this is the specialty I had chosen.” (Bartholomew 2007)
Issues such as this, within both organizations and professions, need to be brought out into the open in a non-blaming way with a focus on the future
Policy documents on bullying and intimidation was developed.
Specify the sorts of behavior that would not be tolerated, and instead the policy referred to the general "rights" of individuals to be treated fairly and with respect.