Nursing Leadership: Creating and Sustaining Healthy Relationships

1. Nursing Leadership:Creating and Sustaining Healthy Relationships Oklahoma Nurses Association Kathleen Bartholomew, RN, RC, MN kathleenbart@msn.com

2. “All great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time.” J.Kenneth Gailbraith

4. Horizontal HostilityA consistent (hidden) pattern of behavior designed to control, diminish, or devalue another peer (or group) that creates a risk to health and/or safety(Quine 1999, Farrell 2005)

6. Shares 3 elements common to racial and sexual harassments laws:1. Defined in terms of effect on recipient2. Must be a negative effect on victim3. The bullying behavior must be consistent(Quine, 1999)

7. Overt: • name-calling, sarcasm, bickering, fault-finding, back-stabbing, criticism, intimidation, gossip, shouting, blaming, put-downs, raising eyebrows, etc. • Covert: • unfair assignments, eye-rolling, ignoring, making faces (behind someone’s back), refusal to help, sighing, whining, sarcasm, refusal to work with someone, sabotage, isolation, exclusion, fabrication, etc.

9. Why do nurses minimize HH? • Doesn’t match our virtue image • They also do it • Too close – focus is on workload • Poor conflict/confrontation skills • Low confidence/self-esteem • “Herd Mentality” – expect HH Farrell, 2000

10. Prevalence: Internationally1 in 3 plan on leaving due to HH 44% reported “bullying” Bullied staff had lower job satisfaction higher stress, depression, & anxiety and higher intent to leave 33% were intending to leave because of verbal abuse

11. United States Verbal abuse from physicians 90-97% Verbal abuse cited as reason nurses leave 60% of newly registered nurses leave their first position within 6 mo. because of some form of lateral violence

12. “Of all types of aggression nurses experience, peer to peer hostility is the most harmful.”( Farrell 1999)

14. Impact on the Individual - Psychological, physical, emotional and social- Nurses who report highest degree of conflict also report the highest degree of burnout - Decreased job satisfaction and morale,- Increased intent to leave

15. Psychological - PTSD – 50% continue to suffer from stress five years after the incident - Burnout – depersonalization, lack of control - Maladaptive responses – substance abuse, over-eating

16. Physical - Decreased immune response/ resistance to infection - Increase in stress related disease - Cardiac arrhythmias (increased risk of heart attack due to continuously circulating catecholamines)

17. Emotional - Anger, irritability - Decreased self-esteem, self-doubt - Lack of motivation and feelings of failure from being unable to meet own expectations - Depression

18. “All too often we leave the workplace bone tired and soul weary, trying to shake off the sticky residue of moral distress, that awful realization that we could not give patients the care they deserved.” Thomas (2004)

19. Social - 1/3 to ½ of relationships and family members worsen after someone simply witnesses bullying - Low interpersonal support and/or absence of emotional support

20. Life Classic Photographs by J. Loengard

21. Life Classic Photographs by J. Loengard

22. The Current Situation Our lifestyles, our choices… 23.7% married with kids children sicker than parents 5 million> relocating a year decreased time for self/community 60+ hr. work week/longer commute the pace of our lives

24. Intrinsic Factors • Emotional State – anger, burnout • Personality Style – Type “A” • Beliefs and expectations • Inadequate communication and • conflict management skills

25. Extrinsic Factors • Violent workplace – verbal abuse from • patients, families, and physicians • Poor nurse-physician relationships • Task and time imperatives • Demands for efficiency/productivity • Culture

26. Work Complexity • Multiple goals, unpredictability and constant change • 8 Factors • Disjointed work supply sources • Missing equipment/supplies • Repetitive travel • Multiple interruptions • Waiting – for system or processes • Difficulty in accessing resources • Inconsistent communication • Breakdown in communication(Ebright)

27. Emotions running strong… Because nurses do not have an outlet for frustration do not have an opportunity to process (reflection) are wounded by horizontal hostility lack a support system/solidarity have adapted to an increased pace of work and workload

28. Impact on Nursing Profession - Recruitment/ Retention in a shortage - Lack of staff due to increased sick days related to stress and burnout - Creates a toxic work environment - Failure of nursing to achieve solidarity - Cost lacks behind actual problem - Patient safety – can’t think clearly when upset

30. Failures of group decision making • Failure to anticipate a problem before it arrives. • When the problem does arrive, the group fails to perceive it. • After perception, the group fails to solve the problem. • Group tries to solve problem but does not succeed. (Diamond, J. 2005. Collapse)

31. Leadership Action Plan • Depends entirely on three things: • Awareness: Our ability to see the problem • Our communication network • Our response

32. Awareness Indications of Horizontal Hostility Poor employee satisfaction scores High Turnover rates Dueling shifts or units Presence of cliques Incident report increase Absenteeism Behavior Clues

33. 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 ________________

34. Communication Use questionnaires to assess cohesiveness Education: Charge Nurse development Assessment tools Individual Action Plans Inservices on assertiveness and conflict mgmt. Establish a Unit Philosophy Role Modeling Mentoring: Encouraging a hierarchy of voice Creating a new belief system Performance Evaluations

35. Response: Strategies and Tools • Decrease negativity, gossip and a culture of blame • by maintaining a zero tolerance for any communication that is unhealthy • Increase a climate of safety and healthy communication by role modeling and utilizing opportunities to teach interpersonal and confrontation • skills.

36. Any intervention that… • Flattens the hierarchical structure • Empowers staff, increases “voice” • Builds self esteem • Raises awareness of the problem • Provides opportunities for networking • Supports reflective practice • Illuminates the problem by showing the consequences …will decrease horizontal hostility

37. Nurturing Our Young “ The profession of nursing has an obligation to reduce lateral violence... Griffin 2004

38. 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

39. Action Plan for New Nurses • Preceptor Feedback • Increase One-on-One Time • - cover for lunch • - share a meal the first month • - decrease the preceptor’s workload • Encourage compliments • Make time for reflective practice • Review professional behaviors with staff • Speak to rotating nursing students

40. Staff Action Plan • Be aware of the signs and symptoms of HH • Understand the many forces nurses affecting nurses today • Speak your truth – to co-workers, and manager • Adopt a zero tolerance philosophy • Demonstrate the effect – hold crucial conversations

41. Evaluate your belief system • Take the time to reflect on your practice • 8. Education • - Assertiveness training, • - Confrontation skills • - Crucial Conversation skills • Compliment each other – often! • Provide opportunities for socialization

42. To thrive horizontal hostility needs: secrecy shame silent witness

43. Organizational Level “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).

44. On an organizational levelTo increase a healthy culture… • Establish Senior Leadership Commitment • Create infrastructures to support staff • - and each other! • Provide a constructive feedback for accountability • Foster leadership; confrontation training • Monitor the “organizational climate” • Increase social capital

45. To decrease HH… • Adopt a zero tolerance policy • Round for a full day every six months • Provide leadership training for managers/charge nurses • Provide education for staff on effects of hostility • Create a system for reporting and monitoring • Participate in passing legislation

47. Failures of group decision making • Failure to anticipate a problem before it arrives • When the problem does arrive, the group fails to perceive it • After perception, failure to solve it • Trying to solve the problem, and not succeeding • A conflict of interest among group members (Diamond, J. 2005. Collapse)

48. When the problem does arrive, the group fails to perceive it • The origin of the problem is unperceivable • Distant managers • The trend is very slow • “Creeping normalcy” • “Landscape amnesia”

49. “Landscape amnesia” – forgetting how different the surrounding landscape looked ___ years ago.” • “Creeping normalcy – trends concealed within noisy fluctuations.” (Diamond, J. 2005. Collapse)

50. “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…