Creating A New Story

Part IICreating Healthy Worplaces

Kathleen Bartholomew, RN, MN

Summary

• History of powerlessness• Lack of time for reflection• Decreased social capital• Human Adaptability

The work is compressed and complex – we have adapted to an increased pace• Inadequate confrontation skills

How do we end horizontal hostility and create a

healthy work enviornment?

Action Plan !

Depends entirely on three things:

• Awareness

• Communication

• Response

Awareness

Indications of Horizontal Hostility

Poor employee satisfaction scoresHigh Turnover ratesDueling shifts or unitsPresence of cliquesIncident report increaseAbsenteeismBehavior Clues

Response: Strategies and Tools

1. Decrease negativity, gossip and a culture of blame by maintaining a zero tolerance for any communication

that is unhealthy

2. Increase a climate of safety and healthy communication by role modeling and utilizing opportunities to teach interpersonal and confrontation

skills.

Any intervention that…

1. Flattens the hierarchical structure2. Empowers staff, increases “voice”3. Builds self esteem4. Raises awareness of the problem5. Provides opportunities for networking6. Supports reflective practice7. Illuminates the problem by showing the

consequences

…will decrease horizontal hostility

To thrive horizontal hostility needs:

secrecyshamesilent witness

“Our lives begin to end the day we become silent about things that matter”

M. L. King

Why don’t you speak your truth?

• Fear of retaliation• Fear of hurting the relationship/feelings• Fear of gossip, scapegoating,• No time• Why bother? Nothing will change• Fear of being isolated from the group

(Bartholomew, 09)

DESC Communication Model

• Describe - Lead with the facts• Explain – Let them know the impact (pause, pause, pause)• State – What you want. Be descriptive• Consequences – Describe the impact

(individual, social and work env.)

What do you say when you hear

someone talking about you?

DESC Communication Model

D - When…

E - I feel…because

S - Therefore, I want (I need)

C - So that…

How do I approach experienced staff when she makes it obvious in many ways that she has no time patience or empathy for my concerns?

D

E

S

C

D – I noticed today you felt bothered by my questions and I felt in the way

E - I understand your workload is heavy, but when you ignore me, I feel unimportant and get the message that you wish I wasn’t here

S - I need to find some way or some time to connect with you. I really want to learn and be the best nurse I can be.

C - If you continue to ignore me, I can’t learn and I won’t stay

What do I do when I walk into my boss’s office and I can tell by his tone and expression that he has already jumped to a conclusion?

D

E

S

C

D – As soon as I walked into your office I noticed that your jaw is set and your face looks stern

E - This makes me feel defensive, anxious and afraid that the open dialogue that I wanted to have with you just isn’t going to happen

S - What I need is for you to listen to me before you make up your mind because I need your support and understanding. Ask me questions instead of jumping to any conclusions

C - So that I can tell you what I know and together we can solve this issue

Sample Questionnaire

I am respected by my peers 1 2 3 4 5

I feel supported by my peers 1 2 3 4 5

I can safely express my opinions 1 2 3 4 5

What I like the most about my team is_____________

What I need more from this team is ______________

The Grey Zone

Nurturing Our Young

“ The profession of nursing has an obligation to reduce lateral violence...

Griffin 2004

Professional Behaviors

• Accept one’s fair share of the workload• Keep confidences• Work cooperatively, despite feelings of dislike• Always look co-workers in the eye• Don’t engage in conversation about a coworker• Stand up for an “absent member” in

conversations• Don’t criticize publicly• Don’t be overly inquisitive about each other’s lives• Do repay debts, favors, and compliments

Responding to to Horizontal Hostility

Non-verbal inuendos (raising eyebrows or making faces)

“I see from your facial expression that there may be something you wanted to say to me. It’s ok to speak to me directly”

Sabotage (deliberately setting up a negative situation)

“There is more to this situation than meets the eye. Could you and I (or whoever) meet in private and explore what happened?”

Verbal affront (covert or overt snide remarks, lack of openness or abrupt responses)

“Can I talk to you in private? When you____ I got the feeling that you______. Is that the case?”

Undermining activities (turning away or being unavailable)

“Can you help me understand how this situation could have happened?”

Withholding information (practice or patient)“It is my understanding that there was more

information available regarding the situation, and I believe if I had known that, it would have affected what I did and how I learn “

M. Griffin

Infighting (bickering with peers)“This is not the time or place. Please stop” Then

physically walk away or move to a neutral spot

Backstabbing (complaining to others about an individual)

“I don’t feel right talking about him/her/the situation when I wasn’t there. Have you spoken to him/her? “

M. Griffin

Action Plan for New Nurses

1. Teach cognitive rehearsal skills in nursing school

2. Student nurse feedback to preceptor

3. Utilize a coaching model for education

4. Share a meal 1:1 in the first 2 weeks

5. Affirm individual contributions

6. Make the time for reflective practice

7. Adopt a mentorship program

8. Decrease precepting nurse’s workload

9. Share a story from your first week

RN Action Plan

1. Be aware of the signs and symptoms of HH2. Understand the many forces nurses affecting

nurses today3. Speak your truth – hold crucial conversations4. Adopt a zero tolerance unit philosophy5. Take care of yourself

Revolutionary New Nurse Beliefs

• A good nurse takes care of herself• A good nurse needs the help and support of

her peers• A good nurse seizes the details of a mistake

and shares them to improve practice• A good nurse speaks her truth at all times• A good nurse nurtures and feeds new nurses• A good nurse demonstrates professionalism

6. Evaluate your belief system7. Take the time to reflect on your practice8. Education

- Assertiveness training - Confrontation skills – DESC model

- Crucial Conversation skills- Non-violent communication

8. Compliment each other – often!9. Provide opportunities for socialization10. Never be a “silent witness”11. Ask for feedback – peer review

Faculty

Integrate into Nursing School curriculum -

1. Norms and culture of Nursing2. Cognitive Rehearsal – role play3. Assertive communication models4. Professional image of Nursing

1. Survey both Faculty and Students on current culture

“By continuing to conceptualize workplace bullying as an inherent feature of nursing, we risk passive acceptance that bullying is a feature of nursing, rather than what it is – an abusive and harmful activity perpetuated within organizations.”

(Hutchinson, Vickers, Wilkes, Nursing Inquiry 2006 13(2).

Organizational Level

Major concepts….

• Flatten the hierarchy• Focus on Language and Behavior• Zero Tolerance Policy - 100% compliance

• “Chase ZERO” • Lead Physicians to critical mass

Strategies and Tactics:

• Follow “Roadmap” for professional behavior• Educate and empower front line leadership• Provide skills in confrontation training• Adopt structures as forcing MD/RN functions• Adopt a “Just Culture” Model• Adopt Senior Leadership Rounding• Vision and values – “If that were…”• TCAB at the bedside - then share

“The future …materializes from the actions, values and beliefs we’re practicing now.

We are creating the future every day by what we choose to do…

…If we want a different future

we have to take responsibility for what we are doing

in the present.”

Wheatley 2002

Thank you!

• Kathleen Bartholomew• kathleenbart@msn.com• 206-356-2599• www.kathleenbartholomew.com• To Purchase books at 40% off

800 650-6787 code# MB90008A