1. Creating A New Story Part II Creating Healthy Worplaces Kathleen Bartholomew, RN, MN

2. 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

3. How do we end horizontal hostility and create a healthy work enviornment?

4. Action Plan ! Depends entirely on three things: Awareness Communication Response

5. 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

6. 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.

7. Any intervention that … 1.Flattens the hierarchical structure 2.Empowers staff, increases “voice” 3.Builds self esteem 4.Raises awareness of the problem 5.Provides opportunities for networking 6.Supports reflective practice 7.Illuminates the problem by showing the consequences …will decrease horizontal hostility

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

9. “ Our lives begin to end the day we become silent about things that matter” M. L. King

10. 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)

11. 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.)

12. What do you say when you hear someone talking about you?

13. DESC Communication Model D - When… E - I feel…because S - Therefore, I want (I need) C - So that…

14. 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

15. 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

16. 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

17. 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

18. Sample Questionnaire I am respected by my peers 1 2 3 4 5 I feel supported by my peers1 2 3 4 5 I can safely express my opinions1 2 3 4 5 What I like the most about my team is_____________ What I need more from this team is ______________

19. The Grey Zone

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

21. 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

22. Responding 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”

23. 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?”

24. 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

25. 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

26. 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

27. RN Action Plan 1.Be aware of the signs and symptoms of HH 2.Understand the many forces nurses affecting nurses today 3.Speak your truth – hold crucial conversations 4.Adopt a zero tolerance unit philosophy 5.Take care of yourself

28. 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

29. 6.Evaluate your belief system 7.Take the time to reflect on your practice 8. Education - Assertiveness training - Confrontation skills – DESC model - Crucial Conversation skills - Non-violent communication 8. Compliment each other – often! 9. Provide opportunities for socialization 10. Never be a “silent witness” 11. Ask for feedback – peer review

30. Faculty Integrate into Nursing School curriculum - 1. Norms and culture of Nursing 2.Cognitive Rehearsal – role play 3. Assertive communication models 4. Professional image of Nursing 1.Survey both Faculty and Students on current culture

31. “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

32. Major concepts…. Flatten the hierarchy Focus on Language and Behavior Zero Tolerance Policy - 100% compliance “Chase ZERO” Lead Physicians to critical mass

33. 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

34. “ 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…

35. …If we want a different future we have to take responsibility for what we are doing in the present.” Wheatley 2002

36. Thank you! Kathleen Bartholomew kathleenbart@msn.com 206-356-2599 www.kathleenbartholomew.com To Purchase books at 40% off 800 650-6787 code# MB90008A