Slides from the University of Michigan Investing in Ability 2015 series of events. The presenter is from Wayne State, and we are hosting the slides here for the convenience of our audience.
1. Bullying in the workplace:
Causes, consequences and
actions
Loraleigh Keashly
Dept of Communication, Wayne
State U
October 9 2015
l.keashly@wayne.edu
UMich Abilities Week 1
2. Healthcare Environment
• Everyone needs healthcare - high
demand
• Fastest growing industry – regulations
• Spiraling costs
• Multiple providers – competition; mergers
• Operating in a political and legalistic env’t
• New technologies
3. Healthcare Environment
Mitchell et al 2012; Longo & Hain 2014)
• Challenging health issues
• Sophisticated and increasingly complex
• Requires a multi-professional team-based
approach (Mitchell et al 2012)
• Goal: Providing quality care and protect patient
safety
• Requires skills in collaboration & coordination;
• Grounded in mutual trust and professional
respect
• Critical importance of communication and
clear expectations
4. Culture of Safety & Health
https://www.osha.gov/SLTC/etools/safetyhealth/mod2_culture.html
Basic elements (OSHA)
• All individuals within the organization
believe they have a right to a safe and
healthy workplace
• Each person accepts personal
responsibility for ensuring his or her own
safety and health.
• Everyone believes he or she has a duty to
protect the safety and health of others.
4
In essence, this is about relationships and necessity
of connection and coordination
5. Quality work environment
• What does a constructive and
productive work environment:
• Feel like?
• Look like? Behaviors?
6. Scenario
You observe a nurse in your unit, Sam, respond to
the actions of a tech, Chris, in a hostile manner.
Chris questioned Sam about an order and Sam
stated “what an unbelievably stupid question…you
should know to just do what’s ordered.” With that,
Sam turned away from Chris, threw hands up, and
strode away. Chris was clearly embarrassed in
front of all the others in the unit. Not long
afterwards you learn that Chris has gone home
early due to “not feeling well.”
6
7. Definition of Disruptive Behavior
• Behavior that interferes with work or creates a
hostile environment, e.g.:
– verbal abuse, sexual harassment, yelling, profanity, vulgarity,
threatening words/actions;
– unwelcome physical contact; threats of harm; behavior
reasonably interpreted as intimidating;
– passive aggressive behaviors: e.g., sabotage and bad-mouthing
colleagues or organization
• Behavior that creates stressful environments and
interferes with others’ effective functioning, impacts
ability of the team to achieve the intended outcome
• Chronic or patterns of disruptive behavior are costly
– Bullying, mobbing, lateral violence
Vanderbilt University and Medical Center Policy #HR-027 ; Center for Patient and Professional Advocacy acpe.org
at Vanderbilt
7
9. Incivility
Low-intensity deviant behavior with
ambiguous intent to harm the target,
in violation of workplace norms for
mutual respect. Uncivil behaviors are
characteristically rude and discourteous,
displaying a lack of regard for others.
(Andersson & Pearson 1999)
10. Bully
Frequent and
Prolonged
Mobbing Victim
Frequent and
Prolonged
Bullying
• Repeated, persistent, patterned,
and enduring acts of aggression.
• Unwanted by the victim.
• Done deliberately or unconsciously
• Cause humiliation, offence, distress.
• Creates unpleasant work
environment, interfere with job
performance and health harming
consequences for targets and
bystanders.
• Power imbalance impacts ability to
defend(Einarsen 1999)
Mobbing
• Malicious attempt to force a
person out of the workplace
through unjustified accusations,
harassment, and emotional
abuse.
• Involves rallying others into
systematic and frequent “mob-
like” behavior against target.
• “ganging up” (Davenport et al
1999)
11. Scenario
A physician demanded a nurse be drug
tested because the nurse questioned an
order. The order would have placed the
patient at risk. The physician then
demanded the nurse be fired because the
nurse ‘evidently wasn’t competent to care for
a slug.’ The physician also called the nurse
names and cursed at the nurse in front of
staff and family members.
11
12. Distinguishing features
• Negative behaviors
• Persistent/Repeated
• Frequency
• Single episode?
• Enduring - occurs over a period of time – how
long?
• Patterned – variety and sequencing/
progression
• Critical consideration
• Micro-aggressions and micro-inequities
• Focused on the identity & character of
another
• Unwelcome & unsolicited
13. Distinguishing features
• Violations of a standard of appropriate
conduct towards others
• Self-regulating profession
• Exposure causes harm
• Power imbalance (formal v. informal)
• Ability to defend oneself – Key distinction re
conflict
• Multiple sources of power – not just organizational
power
• Use/abuse of power
14. Not bullying
• People not getting along
• Expression of conflicting opinions
• Direct communication
• High performance standards
• Constructive feedback, guidance
or advice about work-related
behavior and performance;
corrective feedback
15. Categories of behavior
Rodriguez-Carballeira et al 2010
• Isolation – restricting interaction with others and/or
seeking physically separating from others, seeking to
marginalize or exclude
• Control and manipulation of information –
selecting and manipulating info, lying, interfering with
info transmission
• Emotional abuse – offensive actions and
expressions aimed at attacking, injuring and sneering
at worker feelings and emotions
• Intimidation and threats
• Disrespect, humiliation and rejection of the person
16. Categories of behavior
Rodriguez-Carballeira et al 2010
• Control- abuse of working conditions – intervening
or acting negligently in work env’t and work
conditions in order to upset worker as they attempt to
perform tasks or put their health at risk
• Obstructionism
• Dangerous work
• Professional discredit and denigration –
discrediting and denigrating worker’s professional
reputation and standing, belittling his or her
knowledge, experience, efforts, performance etc..
17. Categories of behavior
Rodriguez-Carballeira et al 2010
• Devaluation of the role in the workplace –
undervaluing the importance of the role of the worker,
unjustifiably relieving the worker of their
responsibilities or assigning useless, impossible or
clearly inferior task to person’s category in the
organization.
18. • Escalatory sequence
1. Aggressive behavior – subtle, indirect to direct,
overt
2. Bullying – frequency and having difficulty defending
self
! Target becomes increasingly disabled in responding; more
ineffective responses
3. Stigmatization – when unable to defend becomes
stressed, which may lead to performance issues.
• Focus now on job performance of the target;
acceptance of “offender’s” interpretation.
• Others join in – spirals, mobbing
4. Severe trauma – if not address without further
victimization.
Process of bullying
(Einarsen 1999)
19. In Healthcare
• Active research area since the 1980’s
• Early attention to nurses’ and medical
students’ experiences of abusive treatment
(e.g., Cox 1991; Rosenberg & Silver 1984; Lanza 2006)
• High rates of verbally abusive behavior
(50-97%,); Bullying 27% (e.g.,Johnson & Rea 2009; Solfield
& Salmond 2003 )
• Witnessing – 77% Physicians, 65% Nurses
(Rosenstein & O’Daniel 2008)
• “kick down” kind of treatment – those higher
up mistreat those lower down.
• Horizontal and interdisciplinary (Keashly, 1998)
20. Immediate effects of disruptive behavior
(Rosenstein & O’Daniel 2005)
• Stress
• Frustration
• Loss of concentration
• Reduced team collaboration
• Reduced information transfer
• Reduced communication
• Impaired professional relationship
21. Broader implications of exposure
(Rosenstein, 2011)
• Negative staff satisfaction and morale
• Staff turnover
• Compromises in patient safety – medical
error, adverse events
• Joint Commission noncompliance
• Negative hospital reputation
• Decreased patient satisfaction
• Increased liability and malpractice exposure
• Increase cost of care
22. Some reasons why
(Baillien et al 2009; Salin 2003)
• Intra/interpersonal influences
• Poor or miscommunication
• Poorly managed conflict
• Poorly managed stress
• Group/Org’l influences
• Low perceived costs/risks for behavior
• Lack of normative guidance re behaviors
• Competition for scarce resources
• People perceived as “different” – conformity
• Threats to perceived status
• Env’t – rigid hierarchy, uncertainty, lots of change,
productivity demands, role state stressors
23. Why so hesitant to act?
(Hickson et al 2007; Rosenstein 2011)
• Power differential – impact on responding
• Lack of awareness of impact (risk)
• Lack of effective policies
• Leaders do not act consistently
– Tie to “idiosyncrasy credits”
– Fear of no organizational backup
• History of tolerance & code of silence
• Lack of training on how to deal with
disruptive behaviors 23
24. Just as disruptive behavior is multi-
determined, addressing it must be
multi-layered:
- individually
- team/unit
- institutionally
Multi layered approach
25. What if it is happening to you?
Getting clear and taking care
(Dutton, 2003)
• Label what is happening to you (Naming)
– Conflict, incivility, bullying?
• Enlist support from other coworkers
– If possible, reduce dependence on other (Bound &
Buffer)
• Enlist support from family and friends
• Engage in outside activities that build self
esteem (Buttress & Strengthen)
26. Deciding what to do
(Target & transform)
• Clarify own needs
• Get information about the other’s needs
• Think through alternatives
• Sources of power and influence you have and
the other has:
– Positional - reward, coercion, legitimate
– Personal - expert, referent, informational
– BATNA - Best alternative to a negotiated
agreement
27. Happening to you
Confronting the actor:
• high risk of becoming more isolated or
losing job
• positive move if done early in the process
when bullying/intimidation has not become
established part of working relationship.
• when no threat to physical safety
• assertion and conflict management
• Crucial conversations model – Grenny
2009
Do not retaliate!
28. Happening to you
• Keep factual log of events
• Look for internal bullying/harassment
policies in personnel handbook or
mission statement
• Look for violation of discrimination laws
• Keep copies of letters, memos and
emails
29. Happening to you
• Report disruptive behavior to person
identified in workplace policy, supervisor
or HR
• Consider outside consultation with a
union representative or an employment
lawyer
• Leaving the job may be the only option
in light of significant health risks.
31. What if you see it?
Two decisions you need to make:
1. Level of involvement - willingness to take
action; how much involve self publicly
• Range from noninvolvement
• High - put self into episode
• Low - involve but outside public eye
2. Immediacy - in current situation or later
• High - interrupt specific incident
• Low - efforts to prevent future incidents
(Bowes-Sperry & O’Leary-Kelly 2005)
32. Choices in responding
Low Immed-High Involvement
• Report actor to Administration
• Accompany target when reports it
• Talk to target about experience
• Confront actor after incident
• Work to develop/implement policies
• Build the business case
High Immed-High Involvement
•Tell actor to stop conduct
• Name or acknowledge offense
• Publicly encourage target to
report conduct
• Get others to publicly denounce
conduct
Low Immed-Low Involvement
• Privately advise target to avoid
actor
• Covertly keep actor away from
target
• Advise target to report incident
• Refuse to share gossip/rumors
Hi Immed-Low Involvement
• Redirect actor from situation
• Remove target from situation
• Interrupt the incident
• Affirm the target
• Use body language to show
disapproval, e.g., silent stare
Immediacy
Involvement
34. Accused?
Take it seriously
• Listen carefully
• Don’t be defensive
• Take time to reflect
• Use of silent witness (another set of eyes & ears)
• Consider accusations rationally
• Ask what behavior prefer
• Apologize for offense
• Request a third party to help with conversation
If false, take to higher up
(Rayner, Hoel, & Cooper 2002)
35. Questions we should all ask…
• Am I aware of how I come across to staff,
colleagues and boss/supervisor?
• Do I ask for feedback on the way I behave?
• Do I pay attention to my own emotions while
at work?
• Is my body language in tune with what I am
saying?
• Do I join in when jokes are made at someone
else’s expense?
(Rayner, Hoel, & Cooper 2002)
36. Unit/team level action
• Graduated Intervention model
• Development of a communication protocol
• Cues for rising “temperature” - “Tempo”
• CREW – VHA initiative
• Fostering and affirming exemplary behavior
36
37. Responding to disruptive
behavior
(Hickson et al 2007; Pritchert et al 2013)
• Model of graduated intervention
• Premised on idea of self-regulation and
professionalism
• Evidence-based – providing information on
impact of behaviors (risk)
– Patient At Risk Score (PARS Risk), patient
complaints, surveillance
• Engaging “peer messengers”
– informal cup of coffee conversation
37
38. Apparent
pattern
Single
“unprofessional"
incidents (merit?)
When action needed: Graduated
intervention model
"Informal" Cup of
Coffee Intervention
Level 1 "Awareness"
Intervention
Level 2 “Guided"
Intervention by Authority
Level 3 "Disciplinary"
Intervention
Pattern
persists
No
∆
Vast majority of professionals - no
issues - provide feedback on progress
Adapted from
Hickson GB, Pichert
JW, Webb LE,
Gabbe SG, Acad
Med, Nov, 2007
Mandated Reviews
Mandated
39. Guide to graduated intervention
(see Vanderbilt CPPA Toolkit Sept 2013)
Single unprofessional incident " Informal “cup
of coffee conversation” (collegial)
• raise the issues/incident
• actor’s experience/explanation is sought
• highlighting the cost of the incident to those
involved
• request and discussion of different ways of
responding and future action
# Espresso conversation: involve a respected
higher up
39
40. Guide to graduated intervention
Apparent pattern " Level 1 – “Awareness”
intervention – more formal discussion with higher up
• note the pattern
• the costs
• the behavior must change – specific outcomes
required;
Pattern persists " Level 2 – “Guided” intervention
by authority
• Review prior interventions/discussions
• Note persistence and unacceptability of behavior
• consequences for not changing – what would be
the discipline?
No change " Level 3 – “Disciplinary” intervention
41. Responding?
• Early!
• Assessment is critical
• Focus on situation, issues or behaviors, not the
person (See Westhues, 2012)
• Get both sides plus witnesses
• Gather information; test out hypotheses
• Be cognizant of your own biases, perspective
and experiences
• Identifying resources
• Sequencing of actions
42. Developing shared norms:
Communication protocol
Hoover (2003)
• Provides a set of agreed upon procedures
that a department, team or unit creates to
promote productive outcomes to conflicts or
complaints that arise between and among
members of the group
• Promotes informal problem-solving between
people; not close doors to usual system
resources and policies
• May include guidelines for decision-making,
based on the culture and norms of the
department or unit
43. Communication Protocol: Prompts
Sebok 2014
• If you have a concern or complaint that you would
like to address with another member of your group,
what will you agree to do?
• If you are the receiver of a complaint, what will you
agree to do?
• If both parties make a good faith effort to resolve
the problem but are unable to do so, what are the
options?
• If one party initiates a conversation with a
colleague about an issue with a third person in the
department, what should the person approached
do? What should they not do?
45. What can facilities do?
Focus on developing a healthy,
respectful work climate
It starts with having conversations;
lots of conversations
46. Knowing how we are here
• Describing climate and culture; data driven; joint
effort
• Mission and core values including quality of
care and patient safety
• Data driven; data collection
• Surveys; focus groups; case studies
• Relevant unit annual reports
• Policies and practices reviews
• Sharing and discussing information with system
members
• What it means to them; making sense of the
data
• Multiple opportunities for input and discussion
47. Knowing how we are here
• Identifying key areas of focus & action teams
• Develop actions, implement, assess
• Regular and accessible updates for campus
• Visible and meaningful action
48. Characteristics of effective policies
Leape et al (2012)
• Fairness of process for responding to
breaches
• Include all in process of development
• Consistency – responsive to all complaints
• Graded response – proportional to nature
of incident
• Restorative process – goal to change
behavior and continue as member of team
• Surveillance mechanisms
• Proactive
• Safe reporting 48
49. Code of Conduct
• Code of conduct – Develop with administration,
mgmt, staff
• Tie to mission and values; Jt. Commission core
competencies
• Acceptable and unacceptable behaviors – provide
examples
• Tie to risks to quality of care and patient safety
• Address & applies to all - employees & “non”employees
• Professional codes are valuable resources – e.g., AMA
• All team members accountable for modeling and enforcing
the code
• Reference policies or procedures re when breach of code
• Clearly delineated reporting channels- Include non-retaliatory
clauses
• Review process of information and facts
• If infraction, intervention – coaching, mentoring;
• If ineffective, disciplinary action - When and how
Good example of the
process: Capitulo
2009
50. Policy relies on reporting:
Challenges
• Higher up or others may trivialize complaints
• Feel ashamed not able to handle situation
• Not want to be labeled a “troublemaker” or
not collegial
• Fear of retaliation (work and social forms)
• Unaware of policies or view as ineffective
• Investigation biased if actor is more senior or
tenured or better connected
• Covert, indirect, and often passive nature of
behaviors hard to describe and to assess.
51. Educational initiatives
1. Appropriate professional behaviors
2. Introducing policies regarding disruptive behaviors
• People’s responsibilities
3. Building communication and conflict mgmt skills;
working in multi-professional teams
4. Responding to disruptive behaviors; Fostering and
affirming exemplary behaviors
52. Leader role and responsibilities…
Adapted from : http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/
RespectfulCampus/index.htm#whatisrespect
• see prevention as your own responsibility
• ensure others know you are open to listening
and dealing with situations
• identify behaviors that can be considered
disruptive, intimidating, bullying, unprofessional
• communicate that problems/difficulties are
manageable
• promote the concept that mistreatment,
intimidation, bullying or harassment of any type
will not be tolerated
53. Leader role and responsibilities…
Adapted from: http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/
RespectfulCampus/index.htm#whatisrespect
• Do not wait for a complaint. Deal with
inappropriate behavior whenever you see it
• encourage co-workers to identify and address
inappropriate, unprofessional behavior
• recognize the danger signals. Take the initiative
to talk with someone if it looks like they are
under stress
• make a habit of positive feedback; affirming
exemplary behavior
• deal with retaliation
54. Leader role and responsibilities…
http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/
RespectfulCampus/index.htm#whatisrespect
• be supportive
• role model respectful and constructive
behaviour
• discuss facility's policies and procedures
related to disruptive, unprofessional
behavior
55. References
Andersson, L.M., & Pearson, C.M. (1999). Tit for tat? The spiraling effect of incivility in
the workplace. Academy of Management Review, 24, 452-471.
Baillen, E., Neyens, I., De Witte, H., & Cuyper, N. (2009). A qualitative study on the
development of workplace bullying: Towards a three way model. Journal of
Community and Applied Social Psychology, 19, 1-16
Bowes-Sperry, L., & O’Leary-Kelly, A. M. (2005). To act or not to act: The dilemma
faced by sexual harassment observers. Academy of Management Review, 30, 288–
306.
Capitulo, K. L. (2009). Addressing disruptive behavior by implementing a code of
professionalism to transform hospital culture. Nurse Leader, 7(2), 38-43.
Cox, H. (1991). Verbal abuse nationwide, Part I: Oppressed group behavior. Nursing
Management, 22(2), 32-35.
Davenport, N., Schwartz, R.D., and Elliott, G.P. (1999). Mobbing: Emotional abuse in
the American workplace. Civil Society Pub.
55
56. References
Dutton, J. (2003). Energizing your workplace. University of Michigan.
Einarsen, S. & Nielsen, M.B. (2014). Workplace bullying as an antecedent of mental
health problems. A five-year prospective and representative study. International
Archives of Occupational and Environmental Health, DOI 10.1007/s00420-014-0944-7
Grenny, J. (2009). Crucial conversations; The most potent force for eliminating
disruptive behavior. The Health Care Manager, 28(30, 240-245.
Hickson, G.B., Pichert, J.W., Webb, L.E. & Gabbe, S.G. (2007). A complementary
approach to promoting professionalism: Identifying, measuring and addressing
unprofessional behaviors. Academic Medicine, 82(11), 1040-1048.
Hicks, D & Tutu, D.. (2011). Dignity: Its essential role in resolving conflict. Yale
University Press.
Hodgson, M., Reed, R., Craig, T., Belton, L., Lehman, L., & Warren, N. (2004).
Violence in healthcare facilities: Lessons from VHA. Journal of Occupational
Environmental Medicine, 46, 1158-1165
56
57. References
Larry Hoover, University of California-Davis, “Developing Departmental
Communication Protocols” in the Conflict Management in Higher Education Report,
October 2003, Volume 4, Number 1, (
http://www.campus-adr.org/cmher/ReportArticles/Edition4_1/hoover4_1a.html)
Johnson, S.L. & Rea, R.E. (2009). Workplace bullying: concerns for nurse leaders.
Journal of Nursing Administration, 35, 84-90
Joint Commission, Behaviors that undermine a culture of safety. Sentinel Event Alert,
July 09, 2008.
Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect.
Academic Medicine, 87(7), 853-858.
Keashly, L. (1998). Emotional abuse at work: Conceptual and empirical issues.
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Keashly, L & Neuman, J.H. (2009). Building constructive communication climate: The
U.S. Department of Veterans Affairs Workplace Stress and Aggression Project. In P.
Lutgen-Sandvik & B.D. Sypher (eds). Destructive organizational communication:
Processes, consequences and constructive ways of organizing. Routledge/LEA 57
58. References
Keashly, L. & Jagatic, K (2010). North American perspectives on workplace
hostility and bullying. Chapter in S. Einarsen, H. Hoel, & D. Zapf. Workplace
bullying: Developments in theory, research and practice. London, UK: Taylor
Francis
Lanza, M. (2006). Violence in nursing. In E.K. Kelloway, J. Barling & J. Furrell
(eds). Handbook of Workplace Violence; Thousand Oaks: Sage Publications.
Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect.
Academic Medicine, 87(7), 853-858.
Leiter, M. (2013). Analyzing and theorizing the dynamics of the incivility crisis.
Spring Briefs in Psychology.
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Healthy Work Environment" OJIN: The Online Journal of Issues in Nursing Vol.
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Nephrology Nursing Journal, 41(2), 193-199.
58
59. References
Mitchell, P., Wynia, )M., Golden, R., McNellis,B., Okun, S., Webb, C.E.,
Rohrbach,R. & Von Kohorn.I (2012. Core principles & values of effective
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DC. www.iom.edu/tbc. .
Osatuke, K., Moore, S.C., Ward, C. Dyrenforth, S.R. & Belton, L. (2009).
Civility, respect, engagement in the workforce (CREW): Nationwide
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Pichert J.W., Moore I.N., Karrass J, et al. (2013). An intervention that promotes
accountability: Peer messengers and patient/family complaints. Jt Comm J
Qual Patient Saf; 39(10):435–446.
Rau-Foster, M (2004). Workplace civility and staff retention. Nephrology
Nursing Journal, 31(6), 702.
Rayner, C., Hoel, H., & Cooper, G.L. (2002). Bullying at work: What we know,
who is to blame and what can we do? London: Taylor & Francis
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60. References
Rosenberg, D. A., & Silver, H. K. (1984). Medical student abuse: An
unnecessary and preventable cause of stress. JAMA, 251(6), 739-742.
Rosenstein, A. (2011). The quality and economic impact of disruptive behaviors
on clinical outcomes of patient care. American Journal of Medical Quality, http://
ajm.sagepub.com/content/early/2011/04/21/1062860611400592
Rosenstein, A. & O’Daniel, M (2005). Disruptive behavior and clinical
outcomes: Perceptions of nurses and physicians. American Journal of Nursing,
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communication defects on patient safety. Jt Comm J Qual Patient Saf ;34(8):
464-71.
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61. References
Sebok, T. (2014). Promoting a respectful working environment. Workshop
presented at the Annual International Ombudsman Association Conference,
Denver, CO, April.
Sofield, L. & Salmond, S.W. (2003). Workplace violence: A focus on verbal
abuse and intent to leave organization. Orthopaedic Nursing, 22, 274-283.
Excellent web resources:
www.workplacebullying.org (Gary and Ruth Namie – rich with resources)
www.centerforamericannurses.org/displaycommon.cfm?
an=1&subarticlenbr=195
• 10 tips for addressing disruptive behavior:
61
Editor's Notes
The context for our conversation about workplace bullying in healthcare settings. The industry is rapidly changing with pressures of high demand, external regulation, and cost management.
Health and managing it is increasingly sophisticated and complex. Thus, it requires health professions to work together to provide quality care and protect patient safety. While the people in the team are subject matter experts, they also require additional skills and experience in working collaboratively. They need to appreciate each other’s knowledge and contributions and develop trust in the team’s capabilities.
An activity to map out what the constructive and productive work environments look and feel like. This can be a very useful activity for a unit or team to do as well. Having discussion about what makes an env’t productive and constructive can reveal places of shared expectations and places where they diverge.
An example of such an approach is the CREW initiative (Civility, Respect, and Engagement in the Workforce) by the Veteran’s Health Administration. This approach recognizes that definitions of respectful engagement need to be surfaced and explicitly discussed in any unit or workplace.
Thoughts on this situation? How does what happened here map on to what you have identified as a productive and constructive work environment? What are the implications of this interaction if left as is for Chris, Sam, and others in the unit? Alternative ways to handle this situation? Who is responsible for addressing this?
The Joint Commission Sentinel Event Alert, July 09, 2008.
What the key accrediting body has to say about what is considered disruptive behavior.
This diagram depicts the handling of challenges and conversations with each other from constructive and lively engagements to uncivil, misconduct (counterproductive, demeaning, destructive) to conduct that breaches laws and to criminal activity.
9/26/13
What is problematic here? What is the impact/implications?
What distinguishes bullying tactics fromnconflict and similar forms of healthy aggression, such as productive competition and collegial argumentativeness, is that the acts of the aggressor attack the character or identity of an individual, are unwelcome by the recipient, and are repeated over time.
Heinz Leymann , the first scholar-practitioner to identify these interactions as problematic and traumatic, has argued that it is less the specific nature of the behavior and more its frequency, patterned nature and enduring quality that are responsible for the nature and extent of negative impact.
It is important when talking about what bullying is to also distinguish it from other challenging and often difficult interactions. This list comes from Mary Chavez Rudolph and Tom Sebok who were part of a 4-part webinar in 2011 sponsored by the International Ombuds Association.
Direct communication here refers to the blunt no frills style of delivering feedback and information. This can feel challenging.
I have heard ALL of them said AND . . .
Some people may honestly think of these as “bullying” BUT
Often: I suspect these things are said:
By someone engaging in bullying to minimize the real problem
Help conflict-avoidant supervisors avoid confronting bullying
By employees seeking to avoid discussion of performance problems
So it is important to do a full assessment of the situation using the defining elements as guides for discerning whether bullying or not.
“It is the accumulated number of acts over time, and the summarized pattern of behaviors, and not the particular and individual acts involved, that constitutes the menace. As isolated acts of aggression, such incidents may be mildly offensive and even tolerable. However, when accumulated over time, these acts will be highly destabilizing and a distressing situation to those exposed. Following from this notion, bullying does not seem to be an either-or phenomenon, but rather a slowly escalating process with increasingly more harsh treatment of the target.”
(Einarsen & Nielsen 2014, pg. 2)
Implications for assessment
- Theiss – identify where are in the process as that highlights the most immediate needs.
So what is the situation in healthcare regarding workplace bullying (disruptive behavior)?
Compromises culture of safety and health
So knowing workplace bullying exists and it harms, it is important to determine the reasons why it is occurring. Such assessment needs to consider individual, group, intergroup and institutional level influences. Understanding why has implications for the focus and nature of action to address.
Reward power refers to ability to control resources or other things that another values; Coercive power is the ability to punish another; Expert power comes from having specialized knowledge and experience that others do not have but they need; Referent power comes from relationships you have with others in the system, more specifically how well liked and respected you are by others. Informational power captures the influence you have when you have information critical to others achieving their goals. BATNA is a term from negotiation. You are in your strongest position to negotiation, i.e., influence others to get what you need when you have a strong and viable alternative (Plan B), should the other not want to negotiate or you are unable to get what you needed from themm.
The success of confronting (speaking directly to) the actor depends upon timing and your own sources of power. If this is one early on (i.e., the not-yet-bullied phase), then you have the resources and strength to take them on. The Crucial conversations model is a thoughtful approach for addressing inappropriate behaviors with someone early on. However, if bullying has become established, your power and ability to respond have been undermined, and you would be vulnerable to them utilizing the conversation to continue to undermine and demean you.
It is vital that you do not retaliate. To the extent that others are not aware of what is going on, your retaliation is often the first time they are aware and you can get labelled as the problem. Also, by retaliating, you can fuel an escalatory spiral that will consume your energy and you in the process. Sometimes, we need to get others to help us.
Record date, time and what happened; witnesses and outcome of event. Remember number of behaviors/events, frequency and and patterning can reveal bullying. This is important affirmation for you for your experience and it will be useful information should you decide to take the situation to others.
If the people you take it to, do not take action then proceed to next level of management if concerns minimized.
Bystander intervention is about recognizing the powerful influence of peers in the workplace. I believe this to be particularly true for faculty. It is faculty colleagues who are present, who have the relationships with each other, who are important in the overall culture and climate and thus, need to be mindful and intentional in taking action to influence more constructive interactions.
The Literature on coworker influence supports the power of the peer:
Work stress literature – coworkers (ppers) are incredible sources of support – they can energize, support, buffer and protect.
Coworker influences regarding hostility
Witnessing rates – 13-50%
Targets talk to coworkers about experience (92.1% in 2008 university study) – Peers know what is going on!
Mobbing – peers joining in
Creative responding - Code White/Pink (Nurses responding to abusive behaviors by physicians), Gatekeeper e.g., the secretary who lets you know whether the boss is in a “good” mood or “bad” mood today. – examples of how coworkers have banded together to provide buffering to targets or to communicate unacceptability of behavior…often to a higher power actor.
Immediacy – intervene to de-escalate early on; peers are typically present or aware of what is going on…more on the scene so more able to intervene quickly if needed.
Credibility – bystanders/witnesses are more likely be perceived as credible than are targets.
Observers(bystanders) to problematic behavior are faced with a couple of decisions in deciding on action. They are decided how involved they will get (in essence, how publicly they will be in their involvement) and whether they will take action now or after the incident/situation.
Here are some examples of different kinds of actions that can be utilized by observers/witnesses/bystanders. There are a range of possible actions that vary in degree of risk to the bystander. The choices will also be influenced by the goals you wish to achieve, i.e., is it important to get the interaction to stop immediately before further harm is done? Then options under high immediate opens up possibilities such as telling the person to stop or if you feel that is too risky, then distracting/redirecting the actor from the situation or removing the target…this stops the immediate interaction and creates time and space to think of other actions to prevent recurrence.
Much attention has been paid in the healthcare literature to addressing what they term “disruptive practitioner behavior”. This was facilitated by rigorous and empirical data that such behaviors on the part of healthcare professionals were costly to the quality of patient and the culture of safety. It was these data that resulted in the Joint Commission, which accredits almost all the healthcare systems in the US, requiring that it was important for systems to have policies and procedures in place to address disruptive behavior. Gerry Hickson of Vanderbilt Medical Center has developed and tested a model of graduated intervention that has been very effective in managing physician behavior. Thus, I think it is useful to share this with administrators, faculty and staff as a way of thinking about graduated/coordinated strategy for managing problematic behavior.
This is a model for “progressive discipline” or as it is used here re responding to physician disruptive behavior “graduated intervention”. This is framed within the broader notion of feedback for development. This is from the work of Gerry Hickson and his colleagues at the Vanderbilt Medical Center. Two things to note here….the use of staged action, based on where a situation is at the time. So in the case of an initial incident that raises questions re “professionalism” (a term used here that encompasses disruptive, hostile, bullying types of behavior…viewed as unprofessional), if it is particularly egregious (e.g., slapping a nurse), then other actions come into play (assault charges). Or if it is a mandated response situation e.g., sexual harassment, then those policies and procedures are engaged. If it is outside those realms and “ambiguous” re is this something to be worried about, Hickson proposes a colleague engage the actor in an “informal” cup of coffee conversation. The issue is raised, the actor’s experience/explanation sought, highlighting of the cost of the incident to those involved, and request and discussion of different ways of responding and future actions. If behavior continues, i.e., a pattern develops, then a more formal discussion with someone higher up occurs, noting the pattern, its costs, and that behavior must change. If still persists, then more specific guidance is provided with consequences for not changing. And if it does not change, then “discipline” occurs ,e g.. suspension of hospital privileges etc. Hickson has developed a training for colleagues in the “informal cup of coffee conversation” and the data indicate it is useful in managing disruptive and unprofessional behavior.
A concise overview of key principles to your responding:
Ken Westhues (mobbingportal.ca) talks about being open when you entered an assessment phase. Gather a range of information and surface and test out various hypotheses. He suggests that in assessing a situation for workplace bullying, there are three possible hypotheses
Person is the problem – as presented by others; difficult person…bully!
Null – there is no problem
Mobbing hypothesis – others are ganging up and framing the person as a problem to be removed, i.e., the “actor” is actually a “target”
Part of this assessment is the recognition of one’s own biases. I have seen fairly stereotypical notions of physicians by nurses and other healthcare professionals and of other healthcare professionals by physicians that compromise the ability of the perceiver to assess what is happening, seeking only confirming evidence (i.e., confirmation bias). Also one’s experience does influence how one perceives and thus responds to a situation or in this case an assessment.
Knowing what resources are available (policies, practices, training, HR, labor, rewards, contingencies) and support for actions is important in choosing how to respond.
A contingency approach to third party conflict intervention (see Keashly & Nowell, 2010) recognizes that in “advanced” situations like entrenched or established bullying, a variety of actions becomes necessary and they should be sequenced. For example, a first step may be to “separate the parties” to immediately stop the harm or aggression. That will not suffice but it does provide time to consider other options based on a thorough assessment.
This is a very specific tool for either addressing conflictual climates that have developed or in an effort to establish constructive climates to reduce the likelihood of destructive confrontation and discussion. This comes from the work of Larry Hoover (2003) at University of California, Davis. Maureen Brodie, ombuds at University of California San Francisco has developed this further with a trainer’s guide for this discussion. This is an explicit discussion among members of a unit of how they want to handle challenging issues.
These are the types of questions that are explored and the results of which are utilized to structure the protocol. This specific set of questions comes from Tom Sebok, Director of the Ombudsman Office at U of Colorado – Boulder.
The CREW initiative is characterized by several features:
- Define respectful relationships here – recognition that definitions of behaviors and relationships is heavily dependent on the people around the table and the facility within which they operation. We talk about “commonsense” but in reality that is about shared expectations and norms…we should not assume these, they should be explicitly negotiated and articulated.
- Facilitate difficult conversations
- Contextualized - locally crafted
- Regular meetings/huddles of unit members
- Comprehensive Toolkit developed and provided.
- Intensive support - CREW companion NCOD
- Pre-post intervention data
Viral spread
Leiter 2013; Osatuke et al 2009
Genuinely engaging organizational members in conversations regarding the nature of the working and learning environment, the roles and needs of different groups in this environment, and ways to build and nurture constructive environments in which challenging discussions can be engaged in with passion and with respect, focused on developing solutions and actions that permit individuals and the organizations to fulfill their purpose in concert is vital.
I am a big proponent about knowing who we are as a healthcare facility, unit or office. And that means getting as accurate a picture of the climate and culture. Health care is about being “data-driven”, “evidence-based”, building arguments for our perspectives and conclusions and putting them out for review, critique and enhancement.. We need to apply this same framework and rigor to understanding how we are here. This is an effort that needs to be truly joint as understanding the facility and its climate and culture requires knowing the perspectives, experiences and expectations of its members. And when such information is developed, it needs to be shared and discussed with members. One of the frustrations of organizational members is that they are asked for their input and then never hear where it went and how it influenced what happens in the organization. Having the organizational members help “make sense of the data”, develops that sense of working together and shared understandings and appreciation for the different perspectives that exist in the organization. Those understandings of the data should then drive the choice and development of actions to address what have been identified as issues from the data gathered. Implementation and evaluation of actions needs to feed back into this process. The very act of working together across group lines to identify issues and address them is a real life illustration of a constructive working climate.
Our work with Veterans Administration on a 5 year project on workplace stress and aggression demonstrated the value of such processes. Keashly & Neuman (2009)
An important organizational tool are policies and procedures. They capture the values and goals of the facility and articulate processes and procedures by which we operate together to reflect those values and to achieve those goals. Policies are explicity articulation of expectations.
ACGME/Joint Commission six core competencies:
Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism (peer and coworker relationships) systems-based practice
Longo, J., (2010) "Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 5.
American Medical Association: www.ama-assn.org/ama/pub/about-ama/our-people/membergroups-sections/organized-medical-staff-section/helpful-resources/disruptivebehavior.
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HC Pro: www.strategiesfornursemanagers.com/ce_detail/225618.cfm
Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect. Academic Medicine, 87(7), 853-858.
Why people may not report incidents or situations is a critical discussion when devising policies. This is important to understand for if these concerns are not addressed, then formal reporting mechanisms are rendered ineffective, providing incomplete information regarding the situations in a unit or facility and thus hampering everyone’s abilities to address issues effectively. Understanding these influences has implications for the development and implementation of relevant policies and procedures.
10 tips for addressing disruptive behavior: www.centerforamericannurses.org/displaycommon.cfm?an=1&subarticlenbr=195.
I have highlighted fostering and affirming exemplary behaviors because it is important we not only articulate what is NOT acceptable here, i.e., what is counterproductive and harmful, but we must also know what it is we want (see the earlier slide on what a productive and constructive work environment looks and feels like). And if we really want those behaviors, then we need to support and affirm those behaviors and the people associated with them when they occur. Thus, people need to be recognized and reinforced when they are engaging in behaviors that make the workplace productive and a great place to be.
While I believe we all have responsibility and are critical to the development and maintenance of productive and constructive work environments, leaders have a special set of roles and responsibilities and they and other organizational members need to understand what those are. I like this articulation, which comes from Mount Royal University in Calgary, AB, Canada.
As can be seen, deans and chairs are expected to manage the work env’t and thus, the interactions that occur.