Alpha Eta, STTI, UCSF
Leaders: Changing Disruptive Behavior
Mileva Saulo Lewis, EdD, RN
Professor Emerita, Samuel University Oakland
Vice-President, Center for Medical Ethics and Mediation San Diego
msaulo@samuelmerritt.edu
Welcome
Acknowledgements
• Kathy Bratcher, RN, MS, Early work in LV in practice, Palo Alto Medical Foundation
• Phyllis Kritek, RN, PhD, FAAN,– Einstein Slides
• Christina Purpora, PhD, RN, national leader in study of Lateral/horizontal violence
Getting to Know the Audience
Empowerment
 People Can’t Drive You Crazy if you Don’t Give Them the Keys (Bechtle, M. 2012)
 No one can make you feel inferior without your consent.” (Eleanor Roosevelt)
Presentation Outcomes
• Describe the dynamics underlying lateral/horizontal violence
• Recognize an incident of incivility
• Distinguish between those that can be set aside as opposed to those that must be addressed
• Use data to enhance work/group teams, reduce lateral violence, & enhance patient safety.
Overview
• Describe the dynamics underlying lateral/horizontal violence
• Recognize an incident of incivility
• Distinguish between those that can be set aside as opposed to those that must be addressed
• Use data to enhance work/group teams, reduce lateral violence, & enhance patient safety.
Health Care Environment
• Capitated Payment
• Nursing Shortage
• IHI – Triple Aim
• HCAHPS
• Patient/Family Centered Care
• Relationship Based Nursing
• IOM Future of Nursing
• Opportunity!!!
Our Honorable Foundation – The ANA Code of Ethics for Nurses (2015)
• The Profession’s Non-negotiable standards
• Provision 1-3:Essential values and commitments
• 1.5: Relationships with Colleagues & others
• 2.3:
Collaboration
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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3.4: Professional responsibility in promoting a culture of safety
3.5:Protection of patient health and safety by action on questionable practice
3.6:
Patient Protection and impaired practice
• Lachman, 2014; American Nurses Association (2015). Code of ethics for nurses with
interpretive statements. Silver Spring, MD: Author
The International Council of Nurses Code of Ethics
• The nurse demonstrates professional values such as respectfulness, responsiveness, compassion,
trustworthiness and integrity.
• The nurse at all times maintains standards of personal conduct, which reflect well on the profession and
enhance its image and public confidence.
• The nurse strives to foster and maintain a practice culture promoting ethical behavior and open
dialogue.
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The nurse sustains a collaborative and respectful relationship with co-workers in nursing and other
fields.
The nurse takes appropriate action to safeguard individuals, families, and communities when their health is
endangered by a co-worker or any other person.
The nurse takes appropriate action to support and guide co-workers to advance ethical conduct.
• International Council of Nurses, (2012). The ICN Code of Ethics for Nurses (ISBN: 978-92-95-495-6).
International Phenomenon
• United States
• ANA, 2015
• Canada
• Croft & Cash, 2012
• Italy,
• Bambi, et.al., 2014
Suggested Origins
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Oppressed Group Theory
Origin in Africa, South America
Dominant devalue the other
Succeed by adopting behavior of dominant
Can’t fight the dominant so they fight each other
• Roberts, Demarco, & Griffin,2009; Matheson & Bobay, 2007.
Oppressed Individual
•
• Purpora, Blegen, & Stotts, 2012
Learned Behavior
Self-esteem issues
Lack of self-care
Hierarchical relationships
Organizational structures
• Embree & White, 2010
Contributing Factors
• Economy & Workload
• Lack of interpersonal skills
• Lack of management skills
• Hierarchical nature of the nursing work
• Croft & Cash, 2012
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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The Cycle of Lateral Violence
courtesy: Kathy Bratcher, RN, MS
Palo Alto Medical Foundation

Begins with nurses training nurses  New nurses in workplace - New nurses
become experienced nurses
The Continuum of Incivility
Equal Opportunity Problem
Female Nurses
• Woman-dominated profession
• Women trained to be “passive aggressive”
• Nursing seen as “women’s work”
• Women bullies target other women 84% of the time
75% of female nurses say they have been undermined by another female
Male Nurses
• Male nurses also experience frequent verbal attacks from coworkers
• Also make disparaging remarks about coworkers
• 30% of targets are male
Purpora, C., Blegen, M.A. 2012
Ten most frequent forms
• Non verbal innuendo
• Verbal affront
• Undermining activities
• Withholding information
• Sabotage
• Infighting
• Scapegoating
• Backstabbing
• Failure to respect privacy
• Broken confidences
•
Griffin, 2004
Top 12 consequences
• Severe anxiety (94%)
• Sleep disruption (84%)
• Loss of concentration (82%)
• Feeling edgy, easily startled (80%)
• Obsession over bully’s motives and tactics (76%)
• Stress headaches (64%)
• Avoidance of feelings, places (49%)
• Shame or embarrassment (49%)
• Racing heart rate (46%)
• Recurrent memories (46%)
• New body aches – muscle or joints (43%)
• Diagnosed depression (41%)
•
Longo, J. (2010).
Incivility in Nursing Education
• Dramatic incidents
• Faculty/Student; Student/Student; Faculty/Faculty
• Forms
• Incivility
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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• Bullying
• Academic Dishonesty
Limited instruments, research, interventions
• Gallo, V.J. (2012). Incivility in nursing education: a review of the literature.
Teaching and Learning in Nursing, 7, 62-66, doi: 10.1016/j.tein.2011.11.006.
Impact on Social Relations
• Isolation because of fear
• Co-worker resentment, attempts to silence
• Wavering support from family
• Spouse questions your role in dispute with bully
• Abandonment/betrayal by co-workers
• Longo, 2010
The Speck and the Log – Take the log out of your own eye before you attempt to take the log out of the other.
Do I…..
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Blame or criticize someone without having all of the evidence, that is, assume the worst?
Not acknowledge the good work that a colleague has done?
Belittle someone’s work when talking to others?
Make sarcastic or insulting remarks to, or about, a co-worker?
Ignore another staff member or exclude them from conversation?
Bratcher, K, nd
The Abilene Paradox – All saying “yes” when you really mean, but do not say, “no.”
Changing the Pattern
Shift one’s behavior; Moving from Incivility to Civility. Do I …
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Say thank you whenever a colleague is helpful?
Praise colleagues when I think they have done a good job?
Make sure that no one is left out of informal discussions or social occasions?
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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Regularly offer to help others when they are overworked or having some difficulty?
•
Griffin, 2004
Am I a professional?
• Accept one’s fair share of the workload
• Respect the privacy of others
• Cooperate with regard to the shared physical working conditions
• Keep confidences
• Work cooperatively despite feelings of dislike
• Address coworkers by their first name, ask for help and advice when necessary
• Look coworkers in the eye when having a conversation
• Repay debts, favors, and compliments, no matter how small
• Stand up for the “absent member” in a conversation when he/she is not present
• Griffin, 2004
•
Commitment to my Coworkers®
http://shop.chcm.com/store/c/24-Commitment-to-My-Co-Workers.aspx
Margaret Mead quote:
Ghandi quote:
Complexity Science and Adaptive Systems- The Butterfly Effect
 Seemingly small changes large effect on the results
 Groundwork for the mapping of chaos mathematically.
 Small changes in the initial characteristics of an active system can dramatically affect the long-term
behaviour of that system.
 Referred to as the ‘butterfly effect’.
 If a butterfly flaps its wings somewhere in the world today, there will be a hurricane somewhere else
at some future point
 Holden, L.M. (2005). Complex adaptive systems: concept analysis. Journal of
Advanced Nursing, 52(6), 651-657
JCO – Sentinel Behaviors that undermine a culture of safety
• All intimidating and disruptive behaviors are unprofessional and should not be tolerated
• Overt and passive behaviors undermine team effectiveness and can compromise the safety of
patients.(7, 8, 11)
• Code of Conduct; accountable, enforceable
• Emphasize respect
• Business etiquette
• The Joint Commission. (2008). Behaviors that undermine a culture of safety.
Sentinel event alert, issue 40. Retrieved from
http://www.jointcommission.org/assets/1 /18/SEA_40.pdf
ANA Responds National Task Force - Incivility, Bullying, and Workplace Violence
• Experts
• Position Statement – All of health care
• Background; Detrimental effects
• Responsibilities RNs & Employers
• Recommended Interventions
• Resources
• Primary, Secondary & Tertiary Prevention
• Relevant publications and references
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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http://nursingworld.org/MainMenuCategories/WorkplaceSafety/HealthyNurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html
American Nurses Association
• Students can join ANA FREE to students, and have access to invaluable information and
resources such as Career Center, Position Papers, Job Search hints, to name a few.
• http://www.nursingworld.org/EspeciallyForYou/Student-Nurses
•
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/HealthyNurse/bullyingworkplaceviolence
Peer Relationships are Critical
• HV predictor of RN job satisfaction
• Peer relationships a job satisfier
• Study of RNs in California
• Peer relationships diminish negative impact of HV
• Purpora & Blegen, 2015
Nurse Manager is Key
• Transformational Leadership
• Treats all with respect
• Promotes team work
• Constructive conflict management
• Barrett, 2009; Longo (2010); Roberts, DeMarco & Griffin, 2009
Interventions
• Zero Tolerance including enforcement
• Codes of Conduct
• Skill Development
• Communication
• Cognitive Rehearsal
• Empowerment
• Inter-professional education
• Longo,2010; Lachman 2014; Coursey, Rodriquez, & Dieckmann,2013
Organizational Interventions
• Administrative Support
• Team Building/Quality Improvement Processes; Empowerment
• Zero Tolerance , Codes of Conduct + Oversight
• Skill Development: Communication, Assertiveness, Conflict Resolution
• Facilitators
• Train the Trainers
• Multiple interventions simultaneously
• Barrett, et al., 2009; Ceravolo, et al, 2012; Coursey, Rodriquez, & Dieckmann, 2013, DiMeglio,
et al. 2005; Roberts, Demarco & Griffin, 2009
Professional Organizations Respond
• Nurse Professional Associations: ANA, AACN (Critical Care) AONE, AORN,ENA
• Physician Professional Associations
• AMA and Ottawa, Canada MDs
• State Nurses Associations
• Nevada
• South Carolina
• Alabama
• Massachusetts
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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Medicine Responds
Ottawa Physicians American Medical Association - Opinion 9.045 - Physicians with Disruptive Behavior
• Personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively
affect patient care constitutes disruptive behavior. (This includes but is not limited to conduct that
interferes with one’s ability to work with other members of the health care team.)
• Policies
• Behaviors
• Enforcement
AMA, 2000
Inter-Professional Education
• Definitions vary; Complex, structural constraints
• Requires an investment of time and energy
• Address professional identity and power differential
• Create a level playing field
• Understand each other’s roles
• Model respect
• Know each other as human beings
•
Meleis, A.I. (2016). Interprofessional education: a summary of reports and barriers to
recommendations. Journal of Nursing Scholarship, 48(1), 106-112.
Conclusion
• Our work is valuable
• We need to own the power of our profession
• Knowledge is power
• Change our attitude; Action follows
• We are not victims
• Each of us is an agent for change
• Stand Up and Speak Out
References
References
Leaders: Changing Disruptive Behavior – Alpha Eta Chapter, STTI, 10 February 2016
Courtesy Dr. Mileva Saulo Lewis, msaulo@samuelmerritt.edu
American Medical Association. (2000). Opinion 9.045 - Physicians with Disruptive Behavior.
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9045.page
American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD:
Author
American Nurses Association (2015). American Nurses Association position statement on Incivility, bulling, and
workplace violence.
http://nursingworld.org/MainMenuCategories/WorkplaceSafety/HealthyNurse/bullyingworkplaceviolence/Incivility- Bullyingand-Workplace-Violence.html
Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved
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Figure citation:
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model. Nursing Research and Practice, 2012, Article ID 306948. Doi:10.1155/2012/306948.
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oppressed self or oppressed group. Journal of Professional Nursing, 28(5), 306-314.
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Leaders: Dealing with Disruptive Behavior; Dr. Mileva Saulo Lewis – All rights reserved