October 27, 2020

Episode 38: Addressing bullying and incivility in nursing

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Podcast

Description

One of the things that many people are surprised to learn about nursing is how strong the culture of bullying can be. It’s an issue that Dr. Nurse Dan feels passionately about addressing, and in this episode he goes deep with Dr. Renee Thompson on this issue and some of the root causes behind it. 

Renee is the CEO and founder of The Healthy Workforce Institute, a training and consulting company dedicated to helping healthcare organizations create a healthy workforce by eradicating bullying and incivility. 

In her conversation with Dan, Renee shares advice on the behaviors that nurse leaders should look out for among their staff as well as key confronting strategies. She explains why confronting is actually much easier than you might think. Renee also shares where she sees the most bad behavior happening and the role of self-care in creating a healthy workplace. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Renee, welcome to the show.

Renee:
Well, thank you, Dan, for having me here to talk about, unfortunately, my favorite topic. Hoping at some point, I won't have to actually talk about this because my goal is to actually do something to help leaders to eliminate bullying and incivility in healthcare. But until then, we'll keep talking.

Dan:
Yeah, I think you and I are both on the same page and same mission there. I've experienced it several times, and it's demoralizing, it is life-altering. And it's so fascinating that a profession that is founded on caring has bullying and incivility as almost a core piece of its culture. Why do you think that is?

Renee:
Yeah, you're absolutely right. When people who don't work in healthcare find out that this is actually happening, where we can be so caring and compassionate to our patients but so cruel to each other. They're shocked by it. But if you look at it, we see more disruptive behaviors in healthcare than any other industry in the world. And when you look at why that might be, okay, let's face it, people who work in healthcare is one of the most stressful jobs you can have. Think about the last six, seven months. There is more stress than I think we've ever experienced in, at least our lifetime. And we see life and death situations every day. The unpredictability of just patient care. You come into work, and the patient that you thought was stable is a patient who crashes on you, and the patient you've been worried about, hovering over the whole shift is fine.

Renee:
And so when you look at the high stress environment, when people are under a lot of stress, they don't always behave as their best. And we're seeing more and more of that showing up, especially right now in healthcare. And then the other reason, Dan, is because, well, we've accept bad behavior as the norm. We've actually normalized deviant behaviors because of how clinically excellent someone is. I mean, we've all heard it, "Oh, she's a really great nurse, but okay, don't get on her bad side." Or my favorite is, "Oh if you have any questions, don't go to him. He doesn't like people very much, but he's really good at what he does." How can you work in healthcare and not like people? We've seen this time and time again, where you have a physician who is brilliant, and people just do workarounds they justify someone's bad behavior because of how good they are. So we don't even recognize these behaviors as abnormal anymore, and so they just continue.

Dan:
Yeah, it's fascinating me because you have a nurse or a physician, and let's say a medication error happens, and the whole system goes into root cause analysis. They dive in to figure out what went wrong, what the system was, what the process was, what the person did? And then on the other side, when you have deviant behavior, toxic leadership, incivility, it's like, "Oh, well, that's just how they are." And we chalk it up and there's no deep dive, and it's fascinating. And you know this, and I'd love you to tell me more about it, but the data shows that that directly impacts people's ability to care for patients. Morbidity, mortality increases. People burn out. It's just I don't know why we accept it.

Renee:
Yeah, 100% accurate. We have study after study that shows a negative impact disruptive behaviors have on employees and patient outcomes. One of my favorite studies is one that came out from Johns Hopkins a couple of years ago that showed 71% of physicians and nurses have linked incivility to medical error. 27% of them said it led to a patient's death, but yet here we are. We have all of these studies showing that the way we treat each other is just as important as the care that we provide. Yet we turn a blind eye for a variety of reasons, somebody's tenured or somebody's contribution to the organization. Sometimes that's in a financial way. Because of how good somebody is at what they do, we turned a blind eye and then wonder why we have the problems that we have. It's a huge problem.

Dan:
Let's dive into where this occurs. I mean, I know it occurs at every level. I think the most common thing is nurses eat their young, and that's how nursing students get acclimated to the profession on day one outside of nursing school. Which I think starts the whole process of normalizing this behavior, but throughout your experience with working with hundreds of people related to this, where do you see the most bullying happen? Is it really in that staff nurse manager realm, or is it higher up? Is it lower down? Where's the most prevalent?

Renee:
There are a couple of different things that I think your listeners would find interesting. If you look at departments, we see patterns. When people reach out to us within a hospital setting, and they say, "Okay, we'd like your help to fix this problem." Three departments are always at the top of the list. The number one department, Dan is surgical services. We see more disruptive behaviors in surgical services. The second is usually some type of mother, baby department, women's and children. So we see a lot of labor and delivery. We see the NICUs, maternity, and then we see critical care as another one that we see these types of disruptive behaviors. And there are a variety of reasons why. But then if you take it from a different perspective and you look at who's bullying whom. Well, it depends because if you look at, say, surgical services or some of these other types of departments where you have a lot of technicians, sometimes it's the technicians who are bullying the nurses.

Renee:
And obviously vice versa, we talk about nurses eat their young. Well, now some of the new nurses are eating the old, and I'm often heard saying, we eat our young, we eat our old, and we eat everything in between.

Dan:
It's just a buffet.

Renee:
It's a buffet. And something else that I ended up finding out that the administrators, who are also sometimes part of the problem, I'm just going to put it out there. The leaders are often part of the problem too. It can't just be the staff. What I find that is sometimes shocking to them is a lot of times where the disruptive behaviors are showing up are in roles like the assistant manager, the night supervisors, the charge nurses, and especially that charge role. I can't tell you how many times we figured out that there are some major issues happening with some of the charge nurses who were the informal leaders but were really ruling the roost. And we put people into these roles without fully equipping them and then we don't pay attention to them because we're making an assumption that they're conducting themselves in a professional manner. And let me tell you the stories I could share about people in some of these roles, especially if somebody is responsible for the schedule for the assignment. So it can come up in a variety of ways.

Dan:
What are some of the core behaviors that are associated with bullying and incivility that you would say, let's say I'm a nurse manager? What should I be looking out for, or a chief nurse, what should I be looking out for in my team? What are those behaviors that are red flags, telltale signs, that something's wrong?

Renee:
What we've done, we have a validated tool. We do a lot of assessments. We really want to find out how are disruptive behaviors showing up? What are the most common types of behaviors that we're seeing in healthcare? And when I give this one piece of information, I often get the look like, why is this a big deal? Believe it or not, Dan things like mocking talking about somebody behind their back, being nice to their face but mocking them behind their back. Eye rolling is a big one. And you might say, that's not that big of a deal. And in a sense, it's worse than somebody yelling, cursing, criticizing somebody openly in front of other people because when people are treating themselves in this way, it erodes the team. It makes somebody feel devalued. And when you have a team of healthcare professionals who don't feel valued by their coworkers don't feel comfortable communicating with their coworkers, it stops the flow of information.

Renee:
And when we stop the flow of information, that affects someone's mom, someone's dad, someone's child, someone's partner. However, one of the behaviors that's also equally common that I think is a huge red flag for patient safety is when we ignore or give people the silent treatment. And that shows up as one of our top four ways disruptive behaviors show up. Now as the chief nurse, how are you going to know this? Seriously, how do that this is happening in your ICU at 2:00 AM? You're not, but your frontline leaders should, and that's where we focus, is making sure those frontline leaders are equipped with the ability to be, as I always say, check the temperature of your department, dip your toe in the water. You need to figure out what's happening, and there are a variety of ways we do that.

Dan:
Yeah, no, that's great a point. And I think you hit it on the head. It's all about information flow, which is the currency of nursing and healthcare, is sharing that pertinent information back and forth to make sure that care gets delivered or teams are on the same page. And as soon as that gets disrupted, you've automatically created an unsafe environment. That's the pattern you're looking for, is where's the breakdown in information sharing? And that might give you insight into where there might be some struggling relationships.

Renee:
Sure. I mean, if any of us don't feel comfortable and I try to get people to understand, it's okay to be uncomfortable, speak up anyways. And that's creating a culture of psychological safety, is that I'm willing to speak up to you even though I'm not comfortable. That's the goal, but if any of us are not comfortable, willing to communicate with anyone on the healthcare team, that's the breakdown. That's where you have the concern, that the risk for patient safety.

Dan:
So what do we do about it? You see someone eye-rolling in a meeting, crossing their arms, huffing and puffing, what's the first plan of attack to stop that?

Renee:
It's easier than you think. Okay. I'll just tell you that. I have a couple of key confronting strategies that I always share, and it doesn't matter what role you have. Whether you're an executive, you're a physician, you're a staff nurse, you're brand new, you've been there for decades, you're support staff, doesn't matter. Get crystal clear on what the behavior is, first. So you mentioned eye-rolling, super easy. If I'm talking to you, Dan, and I say, "Oh my gosh, I just listened to this great podcast that was on Dan's show. And they were talking about all these things. And I think we should talk about this in our department." And you roll your eyes at me. All I need to do is look at you and say, "You just rolled your eyes at me."

Renee:
It's, name the behavior. If somebody is yelling, you're yelling at me. If somebody says something really rude to you, it's, you just called me an idiot in front of people, or I just saw you roll your eyes at her. You're huffing and puffing and stomping down the hallway, it's, get clear on what the behavior is, and then just name it. And you have to name it in the moment. And this actually, I know you have a lot of leaders that listen to your podcast, Dan, this is something that I think is critically important for leaders. I hear all the time that, let's say there were in huddle and one of their nurses was extremely disrespectful. Maybe even yelled or criticized or said something really rude. That leader doesn't say anything in the moment because that leader doesn't want to embarrass that nurse.

Renee:
So that leader will say, you know what? I'm going to talk to her later about it. The problem with that is the rest of the people who are standing there witnessing it, they're not mind readers. They don't know that you plan to talk to her. And what you've just done is let everybody else know that that behavior is acceptable. So it's in the moment say, you're yelling, or you could say, the way you're behaving right now is incredibly unprofessional, and you need to stop. And then, later on, go and talk to that person about it. But it's naming the behavior in the moment. It's a simple strategy.

Dan:
Yeah, I get that question a lot, and I wrote a chapter in our latest book around toxic leadership, which is right in this vein. And people ask, "How do you stop that person who, in a staff meeting stands up and starts ranting or yelling or making a scene or whatever?" And I give the advice, and they're like, "Well, that's simple, but it's hard to, it's hard to do." So to address somebody in the room, you put yourself out there, you have that thought of embarrassment, all that stuff, but at the end of the day, you're doing the right thing. Do you have tips on getting the courage to do that; how do you get nurse managers to be okay with that and take that step out and stop that behavior in its tracks?

Renee:
Yeah. We actually have this conversation all the time. Yeah. Because, especially when I start talking to leaders about this, and we go through the gamut of different behaviors and how they show up, the, he said, the, she said, the passive-aggressive, covert, overt, all of these behaviors, and they're so overwhelmed. It's like, okay, where do I begin? I always have two general rules of thumb. First of all, especially when it comes to overt behavior. You have to make a decision ahead of time, that anytime one of your employees acts out in a very aggressive manner that would include yelling, cursing, stomping down the hallway, anything that's overt and aggressive, you have to, immediately interrupt that behavior. Because what's happening is, if you don't everybody who hears this, who sees this, it affects their performance for the next four hours.

Renee:
Because studies show when you witness or overhear, oversee, or you see really bad behavior, your body sees it as a threat, and it elicits your fight or flight response which takes away from your thinking brain. So you have to interrupt that behavior. So that's, all right, from now on anytime any of my employees or anybody in my department acts out in a way that's very aggressive, I'm going to stop them in the moment by saying, "Timeout, you need to stop right now." I'll maybe name the behavior, you're yelling, you need to stop. Okay? So that's overt. Everything else, this is what I always say, pick a couple of people that you actually have a pretty good relationship with and start practicing with them. If you're a staff nurse, don't go after the queen bully who's been there for decades. That every time you see, you have to give a report to them, you have to run to the bathroom per se, but start small. Start with somebody you already have a good relationship with, that you can just say, "Hey, can we talk about what happened yesterday? The way you treated me during shift report, you came across as very intimidating and a little condescending. Can we talk about this?" So start small.

Dan:
Yeah, that's good advice, and I think at the end of the day, your role as a leader is to protect your patients and your team. And so you have to see it like that. You would call out a family member or a patient that was acting that way, and as a leader, it's the same with your nurses. They're your patients now, right, basically. So you use those same tactics that you have to have difficult conversations with patients, with your team.

Renee:
Exactly.

Dan:
This is stressful for managers, and leaders, and staff nurses. We have to address this. So what's the role of self-care here? So you see this thing happen, you have four hours of just cortisone and adrenaline running through your body; how do you get rid of that or get back to your normal pattern, inward focus on yourself?

Renee:
A couple of things, because when COVID-19 hit, and there was this whole focus on supporting our healthcare, teams and everybody was shouting, they're our heroes, and we're in this together. And they really did pull together. And that was because we thought there was going to be a finish line. And then this virus moved the finish line, and it's still moving the finish line. And now we're dealing with every day you have to come in and put yourself at risk. And we're seeing obviously, more and more of this burnout. A lot of people have been even reaching out to me, asking for help with this because as I mentioned earlier, when people are burned out, when they're stressed, they don't behave well. And we're seeing this incredible uptick in disruptive behaviors, and no doubt it's because of how horrible people feel and stressed, these high cortisol levels that people are dealing with every day.

Renee:
I think there's a couple of things. Your organization needs to make self-care wellness just as important as PPE. Seriously. I know they're focused on making sure that these healthcare teams have protection. However, they also need to make wellness an equal priority. And it's not just the wellness of individuals, but it's the wellness of the teams. So, for example, during huddles, most departments, they do some type of huddle. There needs to be something built into that huddle that talks about how are we coping today? What do you need to get through today? And that's the other thing, Dan, that I think is incredibly powerful beyond the drinking water, eating healthy foods, all the things that we know are important, but it's also taking a look at helping people to cope with the now. What do you need today to get you through today?

Renee:
Because as human beings, part of our anxiety comes from the unknown. What's to come? What would happen if I come into work tomorrow and next week, the week after, and I get COVID, and then I bring it home to my family. And then I act out in my mind, all of those bad things happening as if they were true. And so my body responds in that way. Instead, helping people to focus on the now, today, this is what we need to do today. What do you need? How can I support you, and the other consideration that a lot of organizations aren't paying attention to, these leaders are getting just as burned out as their teams? I remember when COVID hit, I talked to a leader. She was an executive. She had worked seven weeks in a row, every single day, 12, 16 hour days. And she was responsible for taking care of her people, but who's taking care of her. So it's really the self-care of the teams and incorporating wellness into huddles, into the messages that are going out there. It's to really remind people that this is equally as important.

Dan:
Yeah, that's a good point. And last week Trusted, released a landing page for healthcare leaders to be able to have easy tools, to not only learn about burnout and mental wellness for their teams, but also some quick, easy, conversation starters for one-on-ones for teams and that kind of thing. And it's like, what do you need today? Or I see that you're struggling; how can I help? Or can I get anything for you? Just those simple, just normal human connection conversation starters can go a long way to assessing burnout. And then the other piece that I see a lot is when this stuff goes on addressed, it comes to a head into some big dramatic pimple pop sort of thing moment. And there's little behaviors every day that you can do to stomp it out before it builds up. And I think it really is that building relationships and those conversations starters. Are there any other quick tips on kind of checking the pulse daily?

Renee:
Yes. Something that happens a lot is leaders tell me, as soon as they walk in the door, they get hit with all these complaints, and people, especially right now are spending a lot of time complaining. It's part of the negativity bias. We're always looking for things that are negative, and that's a whole other conversation. However, when you've got people who are complaining, it's taking a pause and say to that person, tell me one good thing that happened or tell me one good thing or three good things. So it's forcing them to think about something positive. So there's that. The other tip, and it's surprising to me that leaders don't know this. They need to start every single meeting, every huddle, every time they walk in the department, they need to start with something positive. And it was funny. I was talking to a leader. She's like, "Oh my gosh, I usually end with something positive."

Renee:
I'm like, "No, no, no, start with something positive." Because when you do that, it influences people to see the positive for a few more hours after that meeting that you had. And one more thing, Dan, your break rooms in your departments, please make them no complaining zones. They're called break room for a reason.

Dan:
Yeah. You need a place to distress.

Renee:
Yes. I know people want to vent, but don't do it in the break room. That needs to be a sacred space where people can just put all of the issues with their patients and the organization. I always say, put it in a box, put it on the shelf. They need to set it aside for a period of time to give their brain a COVID break from all of this. And they're just simple tools, but if you do them, they make a big difference over time.

Dan:
There's a lot of evidence in the way organizational cultures are shaped with those artifacts, the safe break room, the way you start meetings, the way you have conversations with people. All of those send those unconscious signals sometimes that eventually shape the values of your organization. And so the leader has to be really intentional about all these things. And you can't just come into a meeting willy nilly you have to have a plan and at least have a couple of these, key points being positive. Having the conversation being ready to stomp out some of the uncivil behaviors or you're building a culture that will create its own values and will follow the people that you may not want it to follow.

Renee:
Exactly.

Dan:
I know you've done a lot of work on this. You consult on this, you've written. I hear you have a new book coming out or that's out, tell us about that.

Renee:
It's actually my second book on the topic of disruptive behaviors. My first book was called Do No Harm Applies To Nurses Too: Strategies to Protect and Bulletproof Yourself at Work. And that was really focused on that bedside nurse, that staff nurse who was dealing with some disruptive behaviors of their coworkers, and that was early on in this work. And then I realized that you know what, I really need to focus on the leaders because if I can equip the leaders with the skills and tools that they need to set behavioral expectations and hold their people accountable for professional conduct then, that's going to make a bigger impact on a lot more of the nurses. And obviously, everybody on the healthcare team. So my second book came out last year. It's called, Enough, okay. Like enough already, Eradicate Bullying and Incivility in Healthcare: Strategies for Front Line Leaders. And this is really designed to give frontline leaders the practical skills and tools that they need to truly set behavioral expectations, hold their people accountable so they can cultivate a professional, respectful workforce culture. It's, I'd say, some of the best work that I've done on this topic all wrapped up in one book.

Dan:
I love it. Yeah. Well, it should be a must-read. I think we don't give enough light to the toxic cultures in healthcare, and I think we need to hold it. My dream would be that we can make it another nurse-sensitive indicator and that we start tracking it like we do falls in pressure ulcers, and infections and toxic behavior becomes just the norm of assessment so that we can give language to it, call it out and then measure its impact and maybe hold people accountable for not allowing it to happen.

Renee:
So, I'm just going to focus on what you just said, and that's going to be my mantra every day now. I'm going to say, okay, we need to make this part of everything else that we're tracking. I agree with you so much, Dan.

Dan:
Maybe we could get joint commission or something to make it a new standard. I don't know. I mean, magnet, the same thing, there's ways we can just codify this, I think. But yeah, so let's fight that fight together.

Renee:
I'm honored.

Dan:
Love it. Renee, where can we find more information about your work and get in touch with you in case someone out there wants to engage you in this important work?

Renee:
They can find me on my website. It's healthyworkforceinstitute.com and my books, and I have an online academy. I've got a lot of free resources on my website that you can download. We have videos. There's a plethora of content on our website that really is designed to support anyone who works in healthcare, who truly wants to address disruptive behaviors so that they can cultivate a professional environment. We spend a lot of time at work. We want that work environment to be one where we feel valued, that we feel we can be our best selves. And as long as you're ignoring bad behavior, that'll never happen.

Dan:
That's great, and that's totally true. You got to address it, you can't ignore it, and we'll stomp this out together. Renee, one of the things we like to do at the end of the podcast is hand off that one piece of information that people can take home. What would you like to hand off to our listeners?

Renee:
Thank you for asking me that because this is something that I never used as a final tip until COVID hit. Because as we said, we'd been seeing an uptick in disruptive behaviors, even from our good staff, even from the nurses who were always role models for professionalism. And what we're finding is that leaders are ignoring bad behavior because they understand it. They understand that their staff are stressed and they're dealing with a lot. So they just turn a blind eye. And so my advice to anyone who's listening, is that we can not ignore bad behavior anymore just because we understand it. Because doing so has a negative ripple impact on everyone in your organization, including the patients who you're serving. So don't ignore bad behavior just because you understand it.

Dan:
That's a great piece to end on because it's about calling it out, holding people accountable, and realizing that when you do that you're impacting dozens and hundreds of lives by stomping this piece out. So Renee, thanks so much for being on the show. Check out Renee on her website, on the books. We'll put those in the show notes, and join us in the fight to stop this incivility and bullying because it is not acceptable and it is killing patients and our nurses. We just need to stop it now, Renee. Thanks so much.

Renee:
You're welcome. Thank you for having me, Dan.

Dan:
Thank you so much for tuning into The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple Podcasts or wherever. Listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan. See you next time.

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