UROLOGIC NURSING ASSIGNMENT

UROLOGIC NURSING ASSIGNMENT

Urologic Nursing Assignment

UROLOGIC NURSING / January-February 2015 / Volume 35 Number 1 39

The Joint Commission(2008) stated, “Intimi -dating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to prevent- able adverse outcomes, in crease the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments” (p. 1). With the new Medicare reimbursement mechanisms for hospitals, these issues of cost, safety, and patient satisfaction become even more crucial to address. Yet various kinds of disruptive behaviors – incivility, bullying, horizontal/lateral violence – still are tolerated in many health care settings (Rosenstein & O’Daniel, 2005; Wilson, Diedrich, Phelps, & Choi, 2011).

The majority of clinicians enter their chosen discipline with a strong interest in caring for patients. Nurses’ idealism and professional- ism can be undermined by the allowed presence of individuals who create an unhealthy or even hostile work environment. In this article, the ethical issues and ethical justifications for zero tolerance for these disruptive behaviors are described. After types of disruptive behaviors are defined and the prevalence discussed, the focus will shift to the ethical issues and justifications for change for the individual nurse and for the health care organization. Four suggested practical change strategies are provided.

Urologic Nursing Assignment

Examples of disruptive behaviors are throwing objects, banging down the telephone receiver, intentionally damaging equipment, and exposing patients or staff to contaminated fluids or equipment. In Figure 1 the types of disruptive behaviors are defined and other key behaviors are outlined. The overlap of behaviors in the literature makes it difficult to separate the individual’s actions into different types, as overlap will be noticed (Read & Laschinger, 2013). However, bullying is beyond the ambivalent disrespect of incivility because it is intentional, intense mistreatment that tar- gets particular individuals or groups (e.g., nurses’ aides, novice nurses). Some authors consider these two disruptive behaviors as forms of horizontal/lateral violence (Purpora, Blegen, & Stotts, 2012).

Prevalence of Problem

Although the prevalence of various types of disruptive behaviors is unknown, some research suggests the widespread nature of this ethical issue. “A survey on intimidation conducted by the Institute for Safe

Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator” (Institute for Safe Medication Practices, 2003, p. 4). Recent reports show 39% of graduates in their first year of practice witnessed bullying (Laschinger, 2011), and 31% experienced bullying (Laschinger & Grau, 2012). In a statewide survey of South Carolina nurses on the issue of horizontal violence, more than 85% of respondents reported being victims, with experienced nurses often listed as perpetrators (Dulaney & Zager, 2010). Wilson and colleagues (2011) also found 85% of nurses had experienced horizontal/lateral violence.

Disruptive Behaviors are A Violation of the Code of Ethics for Nurses

The Code of Ethics for Nurses (American Nurses Association [ANA], 2001) is the profession’s nonnegotiable ethical standard. Its first three provisions define the most essential values and commitments of the nurse, with four interpretative statements that are relevant to ethical issues surrounding disruptive behaviors. Each will be presented and ethical justification for change presented.

Ethical Issues in the Disruptive Behaviors of Incivility, Bullying, And Horizontal/Lateral Violence Vicki D. Lachman

Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a Consulting and Coaching Company, Philadelphia, PA. She serves on the American Nurses Association Ethics and Human Rights Advisory Board.

General Clinical Practice

Reprinted from MEDSURG Nursing, 2014, Volume 23, Number 1, pp. 56-58, 60. Reprinted with permission of the publisher, Jannetti Publications, Inc., East Holly Avenue, Box 56, Pitman, NJ 08071-0056; 856-256-2300; FAX 856-589- 7463; Email: [email protected]; Website: www.ajj.com

40 UROLOGIC NURSING / January-February 2015 / Volume 35 Number 1

1.5 Relationships with Colleagues and Others

The principle of respect for per- sons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to fair treatment of individuals, to integrity preserving compromise, and to resolving conflict (ANA, 2001, p. 9). This statement further emphasizes the standard of conduct prohibits any form of harassment or intimidating behavior and the expectation that nurses will value the unique contribution of all individuals. Clearly, statement 1.5 strictly prohibits nurses from engaging in incivility, bullying, or horizontal/lateral violence.

2.3 Collaboration Because of the complexity of

the health care delivery system, a multidisciplinary approach is need- ed. “By its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared decision making about patient care, and open dialogue among all parties…” (ANA, 2001, pp. 10-11). Disruptive behaviors interfere significantly with nurses’ intra-professional cooperation and multidisciplinary partnership.

3.5 Acting on Questionable Practice

Nurses are expected to recognize and take action concerning any occurrences “of incompetent, un ethical, illegal, or impaired practice by any member of the health care team…” (ANA, 2001, p. 14).

Further more, nurses are expected to express their concern to the per- sons observed with the question- able practice and, if needed to resolve the situation, direct their concern to an administrator. As the previous two interpretative statements indicate, incivility, bullying, and horizontal/lateral violence are considered unethical practice. This interpretative statement also indicates the organization’s ethical responsibility to have a well-publicized process to address practices that violate the expected code of conduct in the organization. Urologic Nursing Assignment.

3.6 Addressing Impaired Practice

This statement views impaired practice as not just substance abuse problems, but any colleagues “adversely affected by mental or physical conditions.

Figure 1. Definition and Key Behaviors

Type Definition Key Behaviors Sources

Incivility Lack of respect for others • Psychological in nature • Low-intensity, rude, or

inconsiderate conduct • Unclear intent to harm

target

• Rude comments • Offensive or condescending

language • Name calling • Public criticism • Ethnic or sexual jokes • Screaming • Attacking a person’s

integrity • Disregard for

interdisciplinary input about patient care

Andersson, Pearson, & Wagner, 2001; Felblinger, 2009; Read & Laschinger, 2013

Bullying • Repetitive behavior that happens a minimum of twice a week

• Long-term behavior that continues for a minimum of 6 months

• Targeted person finds self- defense difficult and cannot stop the abuse

• Persistent hostility • Regular verbal attacks • Repeated physical threats • Refusal to assist with duties • Write retaliatory comments

about the nurse to nurse manager

• Taunting the nurse in front of others

• Speaking negatively about the nurse to administrators

Felblinger, 2009; Lutgen- Sandvik, Tracy, & Alberts, 2007; McNamara, 2012; Read & Laschinger, 2013; Tuckey, Dollard, Hosking, & Winefield, 2009

Horizontal/Lateral Violence

“Unkind, discourteous, antagonistic interactions between nurses who work at comparable organizational levels and commonly characterized as divisive backbiting and infighting” (Alspach, 2008, p. 13).

• Complaints shared with others without first discussing with the individual

• Sarcastic comments • Withholding support • Ignoring or discounting

individual’s input • Insulting, condescending,

patronizing behaviors

Alspach, 2008

UROLOGIC NURSING / January-February 2015 / Volume 35 Number 1 41

cal illness or by personal circum- stances” (ANA, 2001, p. 15). This statement also identifies the ethical responsibility of the organization to have workplace polices that support the nurse in the confrontation and the individual who clearly needs help in managing life in a more effec- tive way. Incivility, bullying, and horizontal/lateral violence affect the work climate, job performance, and satisfaction of all who are impacted by such behaviors. Urologic Nursing Assignment.

Practical Intervention Strategies

No one solution exists for the complex problem of negative human interaction within the organizational culture. However, the literature suggests ways to prevent and address disruptive behaviors. As an organizational consultant, I often am involved in helping individuals and leaders deal with disruptive behavior and have found these four strategies as crucial.

Standards and Code Of Conduct

The Joint Commission (2008) Sentinel Event Alert “Behaviors that Undermine a Culture of Safety” addresses an organization’s account- ability to develop standards, a code of conduct, and suggestions to eliminate behaviors that undercut a culture of patient and staff safety. Standards to make a zero tolerance policy work were developed by the American Association of Critical Care Nurses (2004; 2005). The six standards are authentic leadership, skilled communication, true collaboration, effective decision making, appropriate staffing that matches patient needs and competencies, and meaningful recognition. Authentic leaders do not tolerate incivility and bullying, as they role- model respectful treatment and see the need for trust between leaders and followers within the organization (Read & Laschinger, 2013). Abuse will continue unless programs for multidisciplinary skill development are established and actions are taken by administrators to institute and enforce zero-tolerance policy. Offenders need to be disciplined and victims need support. Urologic Nursing Assignment.

Skill Development Most participants in the study

by Wilson and colleagues (2011) had at least a bachelor’s degree in nursing, yet nearly 90% noted difficulty confronting someone who was demonstrating horizontal/lateral violence. This lack of skill reflects the importance of conflict resolution training for all in the workplace. Many organizations have developed their own training based on the book Crucial Conversations: Tools for Talking When the Stakes are High (Patterson, Grenny, McMillan, & Switzler, 2012). Others have sent educators to the trainer certification provided by VitalSmarts® (2014), a well-known training model using this book. In my experience many clinical nurses and nurse leaders lack the needed assertiveness and negotiation skills necessary to deal with disruptive behaviors in the workplace. Urologic Nursing Assignment.

Empowerment Structural empowerment provides nurses with access to four structures: information, opportunities, resources, and support (Laschinger, 2008). Empowerment is correlated inversely with workplace incivility and supervisor incivility in the general nursing population (Laschinger, Leiter, Day, & Gilin, 2009), as well as to bullying among new graduates (Laschinger, Grau, Finnegan, & Wilk, 2010). Acts of incivility and bullying are attempts to take power from others; therefore, structural empowerment is related to lower levels of incivility, bullying, and horizontal/lateral violence.

Addressing Practitioner Impairment

How often is substance abuse, ineffective management of stress, or mental illness (specifically personality disorders) at the root of the disruptive behavior? In my 35 years of organizational consulting experience, the answer is “very often” (Lachman, 2012). Abusers habitually feel above the workplace rules and policies (McNamara, 2012). They see themselves as deserving special privilege and entitled to behave in their chosen way because of what they perceive as incompetent or inefficient behavior of others. They are often excellent clinicians, but they lack insight into how they fail to work well with others. They often respond in a defensive and abusive manner to anyone who challenges their practice, especially when the challenge comes from someone they perceive as beneath them in the organization.

The top-level administrator of this clinician (e.g., CNO or CMO) needs to be involved in resolution of the problem, as abusers will not take seriously any intervention by a person of a lower status. Senior people in the organization need to be prepared for threats of getting them fired, taking the issue to the Board of Nursing or a local paper, or initiating a law suit. These are the tough cases, but the willingness of senior administrators to deal or not deal with these disruptive individuals defines the organizational culture. An ethical culture requires leaders to have the moral courage to address disruptive behavior, regard- less of who is violating the desired code of conduct. Urologic Nursing Assignment.

Conclusion

Incivility, bullying, and horizontal/lateral violence are examples of workplace mistreatment that injure individual nurses and the ethical climate of the organization. When these behaviors are allowed, nurse job satisfaction and even retention are affected. The Code of Ethics for Nurses (ANA, 2001) clearly identifies intimidating behaviors as unethical and describes the individual nurse’s responsibility to not engage in such behaviors. In addition, this Code recognizes the responsibility of nurse leaders to implement and enforce policies, processes, education to correct the disruptive behaviors.

References Alspach, G. (2008). Lateral hostility

between critical care nurses. Critical Care Nurse, 28(2), 13-19.

American Association of Critical Care Nurses. (2004). Zero tolerance for abuse position statement. Retrieved from http://www.aacn.org/wd/ practice/ docs/publicpolicy/zero-tolerance-for- abuse.pdf

American Association of Critical Care Nurses. (2005). Standards for establishing and sustaining healthy work environments: A journey to excellence. American Journal of Critical Care, 14(3), 187-197.

American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Andersson, L.M., Pearson, C.M., & Wagner, C.W. (2001). When workers flout convention: A study of workplace inci- vility. Human Relations, 54, 1387- 1419.

Dulaney, P., & Zager, L. (2010). Lateral violence: It’s time to stop this blight on our profession. South Carolina Nurse, 17(1), 1.

Felblinger, D.M. (2009). Bullying, incivility, and disruptive behaviors in the healthcare setting: Identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13-23.

Institute for Safe Medication Practices. (2003). Results from ISMP survey on workplace intimidation. Retrieved from https://ismp.org/Survey/survey results/Survey0311.asp

Lachman, V.D. (2012, November 15). Beyond difficult people: Dealing with personality disorders in the work- place. Paper presented at the Shippensburg Chamber of Commerce, Shippensburg, PA.

Laschinger, H.K.S. (2008). Effects of empowerment on professional prac- tice environments, work satisfaction, and patient care quality: Further test- ing the nursing worklife model. Journal of Nursing Care Quality, 23(4), 322-330.

Laschinger, H.K.S. (2011). Job and career satisfaction and turnover intentions in newly graduated nurses. Journal of Nursing Management, 20(4), 472- 484.

Laschinger, H.K.S., & Grau, A.L. (2012). The influence of personal dispositional factors and organizational re sources on workplace violence, burn out, and health outcomes in new graduate nurses: Cross-sectional study. Inter – national Journal of Nurs ing Studies, 49(3), 282-291.

Laschinger, H.K.S., Grau, A.L., Finnegan, J., & Wilk, P. (2010). New graduate nurses’ experiences of bullying and burnout in hospital settings. Journal of Advanced Nursing, 66(12), 2732- 2742.

Laschinger, H.K.S., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empower- ment, incivility, and burnout: Impact on staff nurse recruitment and reten- tion outcomes. Journal of Nursing Management, 18(8), 302-311.

Lutgen-Sandvik, P.S., Tracy, J., & Alberts, K. (2007). Burned by bullying in the American workplace: Prevalence, perception, degree, and impact. Journal of Management Studies, 44, 837-862.

McNamara, S.A. (2012). Incivility in nurs- ing: Unsafe nurse, unsafe patients. AORN Journal, 95(4). doi:10.1016/ j.aorn. 2012.01.020

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2012). Crucial conversa- tions: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.

Purpora, C., Blegen, M.A., & Stotts, N.A. (2012). Horizontal violence among hospital staff nurses related to oppressed self or oppressed group. Journal of Professional Nursing, 28, 306-314.

Read, E., & Laschinger, H.K.S. (2013). Correlates of new graduate nurses’ experiences of workplace mistreat- ment. Journal of Nursing Admin istra – tion, 43(4), 221-228.

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The Joint Commission. (2008). Behaviors that undermine a culture of safety. Sentinel event alert, issue 40. Retrieved from http://www.joint commission.org/assets/1/18/SEA_40. pdf

Tuckey, M.D., Dollard, M.E., Hosking, P.J., & Winefield, A.H. (2009). Workplace bullying: The role of the psychologi- cal workplace environment factors. International Journal of Stress Management, 16(3), 215-232.

VitalSmarts. (2014). Crucial conversation training. Retrieved from http:// www.vitalsmarts.com/products- solutions/crucial-conversations/

Wilson, B.L., Diedrich, A., Phelps, C.L., & Choi, M. (2011). Bullies at work: The impact of horizontal hostility in the hospital setting and intent to leave. The Journal of Nursing Admini – stration, 41(11), 453-458.

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