PATIENT SAFETY FIRST Transforming the Health Care Environment Collaborative COLLEEN BURGESS, EdD, RN, PMH, CNS-BC; MOLLY PATTON CURRY, DNP, RN
A
considerable amount of evidence exists in nursing and health care literature documenting the disturbing pattern of harmful nonproductive communication in the health care setting. The Joint Commission1 issued a Sentinel Event Report identifying communication and leadership as ranking in the top three root causes of adverse patient events (Figure 1). Nurse researchers have explored and analyzed this persistent pattern of destructive behavior among nurses and professionals in health care for more than 30 years. Roberts2 identified the phenomenon in nursing as oppressed group behavior and referenced the seminal work of the social scientist Paulo Freire.3 Nursing literature uses a variety of terms to describe these oppressed group survival behaviors, such as lateral violence, horizontal violence, incivility, and disruptive behavior. A number of factors contribute to the persistent and perpetual cycle of verbal, emotional, intellectual, spiritual, and, less frequently documented, physical abuse in the workplace. According to Patton,4 there are several contributing factors to lateral violence in the workplace that include not only oppressed group behaviors but the hierarchal system that devalues nursing knowledge and expertise and the perception among nurses that they are impotent to effect change. Violent communication can be overt or covert. Overt aggression is demonstrated by belittling,
criticizing, finding fault, and obstructing patient care, whereas covert aggression is not quite as obvious and consists of behaviors such as excluding the intended victim from essential group e-mails and office communication, withholding information, and ignoring or excluding that person from conversations. A list of documented overt and covert aggressions that are seen in the workplace is outlined in Table 1. Some of the patterns of violent communication documented in the nursing literature include bullying, incivility, verbal abuse, insulting or disparaging remarks, sabotage, and professional terrorism.2,5-20 Some specific examples include spreading malicious rumors or gossip, refusing to speak to another or answer his or her questions, failing to speak up in another’s defense when he or she is unfairly criticized, and scapegoating. Within the recent past, the Institute of Medicine Future of Nursing21 report recommended that nurses lead improvement efforts to transform health care. Because they are at the center of health care delivery, nurses are in a strategic position to lead a positive change and to put an end to dysfunctional communication patterns that exist in the workplace. It is disconcerting that workplace violence and incivility persist in light of the overwhelming evidence documenting this threat to patient safety. An atmosphere of mutual respect and civility is
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.01.012
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Figure 1. Most frequently identified root causes 2010-2012 ª The Joint Commission, 2013. Reprinted with permission.
necessary to provide safe and effective care. The Joint Commission22 issued a guide for leadership standards for health care organizations encouraging civil, open communication and the development of conflict management processes. National nursing organizations such as The National League for Nursing, the American Association of Colleges of Nursing, Quality and Safety Education for Nurses, the American Nurses Association, and AORN support these recommendations; AORN also has a position statement on creating safe environments.23 As champions of patient safety, AORN is committed to making changes to improve safety in the workplace. Numerous articles have been published in the AORN Journal addressing these disturbing behaviors in the workplace,24-26 and AORN published a position statement that focuses on promoting workplace safety through communication23
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and a just culture tool kit,27 which offers resources for nurses. Other professional organizations have contributed to the effort to eliminate workplace violence and disruptive behavior. The American Association of Colleges of Nursing, in collaboration with private industry, created VitalSmarts,28 a survey of 1,700 health care professionals that revealed the majority (84%) of participating health care professionals admitted observing dangerous shortcuts in patient care by colleagues, and only 10% spoke up and confronted the individual. An additional study, The Silent Treatment,29 conducted in collaboration with VitalSmarts, the American Association of Colleges of Nursing, and AORN, surveyed 6,500 nurses and nurse managers, and revealed that safety tools used to prevent inadvertent errors do not address the following three
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TABLE 1. Overt and Covert Violent Communication Overt
Covert
Personal attacks n Using intimidation and verbal threats n Raising voices or pointing fingers n Staring n Watching or following someone n Tampering with or destroying personal belongings n Compromising or obstructing patient care n Singling out, scrutinizing, humiliating, or belittling someone n Standing over, pushing, or shoving someone n Using verbal putdowns or denigrating nicknames, name calling, gossiping about, blaming, comparing, or criticizing someone n Making suggestions of mental instability n Highlighting someone’s mistakes publicly
Personal attacks n Ignoring n Excluding others from conversations or activities n Rolling eyes
Professional terrorism n Publicly denigrating another’s ability or achievements n Questioning someone’s skills and ability n Assigning demeaning work n Making unsubstantiated negative performance claims n Spreading rumors, slander, and character slurs n Questioning another’s competency or credentials n Limiting another’s career opportunities n Denying someone opportunities that lead to promotion n Overlooking someone for promotion n Excluding someone from committees, activities, or educational opportunities n Relocating someone to make his or her job difficult n Removing of administrative support and necessary equipment n Giving an excessive or unreasonable workload n Sabotaging or hampering work n Varying targets and deadlines n Excessively scrutinizing work n Denying due process, breaks, or leave time n Limiting opportunity to work n Dismissing someone from a position n Reclassifying someone’s position to a lower status
Professional terrorism n Making someone feel stupid n Not including someone in essential group e-mails n Excluding someone from routine information n Organizing work to isolate someone
areas that nurses reportedly fail to confront: dangerous shortcuts, incompetence, and disrespect. Important lessons gleaned from the aforementioned studies highlight the need for leadership skill development to empower nurses to speak up and put an end to the incivility that threatens the wellbeing of patients and nurses alike. The purpose of this article is to describe a collaborative educational initiative to pool resources and consolidate efforts
in North Carolina to lead a change in behavior and communication in the health care environment. The purpose of the educational workshop was to increase the awareness of nurses at all levels of care of the threat to patient safety from violent communication, provide nurses with resources, and help nurses develop collegiality and interprofessional collaboration to address communication and leadership issues in the workplace. The project AORN Journal j 531
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team held three sequential nursing workshops in North Carolina to empower nurses to make positive changes in health care. A COLLABORATIVE PROBLEM-SOLVING APPROACH Integral to the future of nursing education is the enhancement of leadership skills, advocacy, and collaboration. Interdisciplinary teamwork and collaboration are essential skills that are necessary for providing quality care, evaluation, and process improvement. Healthy, effective, and nonviolent communication is an essential leadership skill that helps influence changes in group behavior. Collaboration is a powerful tool to facilitate intraprofessional communication and engage stakeholders within all areas of nursing education, leadership, and practice to lead change and empower nurses to influence and alter disruptive behavior in the workplace. As leaders in helping others alter behavior or learn new skills, nurse educators are committed to improving communication, disseminating evidence-based information, and promoting the safety and well-being of patients and nurses. Nurse leaders in North Carolina assembled at a statewide summit in 2010 to respond to the Institute of Medicine’s call for action. These leaders formed the North Carolina Future of Nursing Action Coalition (NCAC)30 and identified four priority areas for action, one of which was to empower nurses to lead in transforming health care by improving communication and eliminating or reducing disruptive behavior and workplace violence. The NCAC formed the North Carolina Action Coalition Leadership Taskforce (NCACLT) as a subcommittee of the NCAC to focus on the goal of improving health outcomes for North Carolina nurses by developing a nursing workforce prepared to innovate and lead at all levels of care.30 The NCACLT consisted of nurse leaders practicing in acute and long-term care, nurse executives and educators, faculty of the Area Health Education Consortium, and clinical practice partners. These 532 j AORN Journal
PATIENT SAFETY FIRST NCACLT members met and identified the need to disseminate information and current evidence that would engage nurses at all levels of practice to develop communication and leadership skills. The project chair and the project coordinator presented an evidence table of research literature to the NCACLT along with a proposal that was coauthored by the project chair to provide an educational intervention to nurses across the state. A NCACLT member and advanced practice, boardcertified, psychiatric mental health clinical nurse specialist (CNS) serving as the project chair recruited a doctor of nursing practice (DNP) leadership candidate, an educator, and an experienced critical care nurse to join the NCACLT as project coordinators. The DNP candidate expressed an interest in pursuing her doctoral project in concert with the NCACLT to lead efforts toward improving communication in the workplace. The Intervention Together, the NCACLT project chair and coordinators presented a proposal to the NCAC to create a series of evidence-based workshops to disseminate the most current evidence about how leadership and communication affect patient safety and to motivate nurses in North Carolina to lead a transformation of the health care system by improving communication and eliminating or reducing disruptive behavior and workplace violence. The proposal was for the NCACLT to spearhead a collaborative series of workshops to educate, empower, and network with nurses in North Carolina to transform the health care setting. The intent was to build collective awareness of the need to develop communication, conflict management, and leadership skills, and to spark energy in nurses for engagement, group commitment, and innovation to lead this change. The basic premise of the workshops was the belief that informed nursesdunited by the shared nursing professional values to protect the safety of patients and colleaguesdwould transform the health care system. Although nurses are not alone in perpetuating
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credibility to the project. Grant funding paid for the cycle of violent communication in the workregistration, gifts, a tool kit, ice-breaker raffles and place, the focus of the NCACLT was the developprizes, and food in an effort to express appreciation ment of professional communication and conduct for the participants and foster a collegial atmosphere. within the practice of nursing. Nurses are the Each NCACLT member volunteered and contriblargest professional group in health care and, if uted to the project. A transformational leader, Mary enabled, are capable of embracing their collective Ann Wilcox, senior vice president and system power to model appropriate behavior and effect nurse executive at Carolinas Healthcare System, system-wide changes. Charlotte, North Carolina, demonstrated support An essential element of change is to empower by announcing the workshops via an e-mail flyer nurses through engagement, collaboration, and to nurses across the state within the Carolinas commitment. The NCACLT members networked Healthcare system. She also attended and addressed and collaborated with nurses, nurse executives, workshop participractice partners, pants, urging nurses stakeholders, and nursing organizations An essential element of change is to empower to engage in leading across the state of nurses through engagement, collaboration, and change to improve commitment. patient safety and North Carolina to communication. This provide, plan, denurse leader referred velop, and implement the workshop coordinators to Sharon McNamara, this state-wide collaborative project. Members of MS, BSN, RN, CNOR, a nurse expert on patient the NCACLT brainstormed and decided to pool safety at AORN. McNamara has dedicated time existing resources and stakeholders within North and substantial energy and action to improve paCarolina to optimize the success and sustainability tient safety and agreed to speak about her work of the workshop project. The authors of this addressing patient safety and communication at column submitted a special projects proposal to each of the three workshops. the North Carolina Nurses Association (NCNA) The authors held the three workshops between through its Professional Practice Action CoaliOctober 2012 and March 2013. Participants earned tion (PPAC) and secured funding to support the six continuing education contact hours per workworkshops. The special projects grant enabled shop. We used several adult learning strategies collaboration among the various nursing orgaduring the workshops, including nizations to finance the workshops. The workshops involved coordinating efforts among the n an online personality inventory that participants NCACLT, PPAC, and the Nurses Transforming completed before attending the first workshop; Nursing (NTN) initiative of NCNA to develop n interactive activities, such as audience polls; leadership skills for RNs in North Carolina. n small and large group activities and sharing, The NCACLT members collaborated with acawhich were intended to construct group meandemic and practice partners to assist in providing ing drawn from videos. the three educational workshops. The authors of this column approached practice partners, CNSs, Participants used self-disclosure to encourage selfand chief nurse executives to collaborate and conreflection and sharing in dyads and large groups. tribute to the development of the workshops. Staff They were asked to write a professional epitaph to educators, CNSs, and clinical nurses encouraged share at the second workshop, outlining what they attendance at the workshops. Organizational supwould want to be remembered for by their peers. port was paramount to engage nurses and add The content for these workshops was different in AORN Journal j 533
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NTN initiative, and Colleen Burgess, EdD, RN, PMH, CNS-BC, project chair, facilitated the education sessions for all three workshops. The project coordinator and DNP candidate, Molly Patton Curry, MSN, RN, served as a leadership resource and workshop coordinator. McNamara presented The workshops were well attended because of current evidence about lateral violence and progthe collaborative efforts of NCACLT members and ress toward eliminating it and improving patient practice partners. More than 450 nurses participated safety in North Carolina. The North Carolina Orin one or more of the three workshops. Nurse ganization of Nurse Leaders executive and presiparticipants represented many areas of practice dent, Doris Esslinger, MS, RN, CNAA, executive from perioperative, maternal child, public health, director of the North Carolina Organization of acute and chronic medical and surgical, and psyNurse Leaders, presented state efforts by the NCAC chiatric mental health, and the majority of nurses committees and closed the third workshop with a were bachelor-of-science prepared. Continuing edcall for participants to commit to join and lead the ucation credit for attendees at all three workshops transformation of the workplace. was paid for at no cost to attendees through conTransformational leadership provided a theorettributions from a large acute care facility; Sigma ical framework for the workshops. Bass31 described Theta Tau, Upsilon Mu Chapter; the North Cartransformational leaders as individuals who act olina Organization of Nurse Leaders; NCNA; and above individual needs for the sake of the group. other private industry stakeholders. Transformational leaders are able to act on principles rather than individual personalities and use Workshop Format and Content group values to inspire, intellectually stimulate, Networking is important to support the future and support individuals, and align them with the of nursing and health care leadership. Transmission of the group.32 Followers are empowered formational leaders build strong alliances with and encouraged to champions who hold be creative. Transsimilar values. Workformational leadership shop leaders invited Networking is important to support the future principles increase practice leaders and of nursing and health care leadership, and representatives of transformational leaders build strong alliances productivity, satisfaction, and perfornursing organizations with champions who hold similar values. mance.33 The ability in the state of North to communicate a Carolina to particishared vision is an essential skill of a transpate and present at the workshop. They also formational leader, and transformational leaders invited nurse executives to address the particioperate from their values, ethics, and morals.34 pants and kick off the workshops. Two nurse The use of the American Nurses Association Code executives opened the workshop by discussing of Ethics for Nurses35 and A Nursing Manifesto: An the importance of the Institute of Medicine Emancipatory Call for Knowledge Development, Future of Nursing report and its potential effect Conscience, and Praxis36 provided a fulcrum for on nursing leadership. the workshops to develop leadership skills based on Two advanced practice psychiatric nurse leaders professional values. The facilitator provided copies from the NCNA/NTN initiative and the NCNA of both documents for the enrichment of group PPAC participated in the workshops. Dona Cainediscussion. Frances, MSN, PNP, PMH, CNS, presented the each session: Surviving, Thriving, and Transforming the health care environment. At these sessions, nurse educators analyzed, synthesized, and presented current research and evidence about leadership and communication.
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behaviors described in the literature and inWorkshop One. The first workshop, “Survivcluded it in the handouts. ing,” focused on the more than 30 years of evidence During the first workshop, Burgess explained documenting the oppression of nurses and the these toxic behaviors in a nonaccusatory manner as pervasive overt and covert violent communication an adaptive response and a means of survival in behaviors prevalent in the workplace. Violent a disempowered system. She explained that it is communication in the health care environment is imperative that, as nurses, we must not only recreflective of the long history of the oppression of ognize the behaviors and factors that perpetuate the woman. Oppressed group behavior involves patcycle but reflect on our own participation in the terns of defensive, often hostile, coping mechaprocess. When we consciously acknowledge our nisms that group members develop to survive and participation in this phenomenon, as nurses, we to protect themselves against the stressful and can collectively empower each other to change. threatening interpersonal interactions at work. National health care Participants were organizations are prompted through actively enabling preworkshop personPolicies for disruptive behaviors without nurses to develop ality testing and consequences and a lack of accountability in the health care environment reinforce and enforce policies workshop videos negative behavior. to protect nurses in to focus within and the workplace. During identify their surthe workshop discusvival behaviors that sion, Burgess cautioned that policies for disruptive contribute to the violent communication in the behaviors without consequences and a lack of achealth care environment. To prepare for the countability in the health care environment rein“Surviving” workshop, the coordinators sent regforce negative behavior. istered participants an e-mail with their registration Workshop facilitators created an open, no-blame confirmation before the workshop and a link to an atmosphere to facilitate participants’ self-disclosure open source personality test to prompt reflection and reflection. Workshop facilitators’ demonstrated and self-awareness. The goals of the first session self-disclosure and self-reflection by using the were to workshop format to share personal examples of n increase the collective awareness of the persistheir own ineffective communication and the tent overt and covert violent communication in consequent negative effect on patient safety. They the workplace, then divided participants into groups of 10 to pron offer support and resources for nurses from the cess the information. Each group was asked to bedside to the boardroom, report back to the large group their feelings and n present evidence of the effects of survival bereactions about each scenario. Participant feedback haviors on patient safety and their negative efabout this workshop was overwhelmingly positive. fect on the health and well-being of nurses, and The facilitators provided resources to particin provide workshop attendees with resources and pants first by allocating time at the workshop to support. network and process with other participants. Then, All participants received a self-directed learning in addition, the tool kit, the facilitators provided “Survival Toolkit,” which included several handparticipants with a means to access the web sites of outs and Internet resources addressing problemnational organizations (eg, American Nurses Asatic behaviors in the workplace. The authors of sociation, American Association of Critical-Care the tool kit developed a checklist of the toxic Nurses, AORN, Agency for Healthcare Research AORN Journal j 535
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and Quality and TeamSTEPPS,37 NCNA, The Joint Commission) so they could search for relevant information about workplace communication. The packet contained the link to Silence Kills,28 the NCNA Nurses Transforming Nursing Tool Kit,38 communication tools, motivational thoughts, detailed references, links to national web sites and organizations dedicated to leadership skill development, and the nurse survey developed by Patton.4 Presenters shared content related to effective and assertive communication and patient safety, and they stimulated audience engagement through videos and facilitator storytelling. Presenters directed participants to share their feelings and thoughts about the videos presented in small groups and to demonstrate civility. In the conclusion of the “Surviving” workshop, the participants were asked to complete their professional epitaph describing what they would like to be remembered for by their peers in preparation for workshop two, “Thriving.”
PATIENT SAFETY FIRST increased and enabled participants to share during the large group discussion. After the small group discussions, participants reported back to the large group. Participants shared, offered support, and validated each other, thus setting the stage for group discovery. The facilitators reframed participants’ stories of lateral violence as opportunities to motivate the full group toward a positive change. The large group discussed how their individual personalities affected group behavior and the profession. The work in small groups and sharing of insights in the large group was a part of the group discovery process in preparation for the third workshop, “Transforming.”
Workshop Three. A necessary formula for group transformation is a combination of group synergy aligned with a shared vision; rigorous self-honesty; the courage to speak up and out; and a willingness to share personal experience, individual strength, and group hope. The “Transforming” workshop was centered on developing Workshop Two. The goals of the second workand modeling leadership through the sharing of shop, “Thriving,” shifted from creating awareness successful transformational experiences. Feedback to empowering nurses to view themselves as from the previous leaders. The transworkshop evaluations formational process indicated that paroccurs from the inA necessary formula for group transformation ticipants needed side out. The facilis a combination of group synergy aligned with a shared vision; rigorous self-honesty; more information itators planted seeds the courage to speak up and out; and a on violence in the of transformation willingness to share personal experience, workplace. The through personal stoindividual strength, and group hope. presenters shared rytelling to model the examples of their use of their own exown experience with periences with violent violent communication in a variety of settings. communication in the workplace. The message was An NCACLT team member and staff educator to transform participants’ experiences into strength asked a graduate student to lead and present current and hope for the large group. The facilitators literature on lateral violence to the participants at prompted discussion by dividing participants into the third workshop. Speakers shared a successful small groups and encouraging them to share intransformational experience at their organization sights gained from their personality profile and to implementing a change project by managing share both their strengths and weaknesses. The conflict, sharing feelings and ideas, and thwarting workshop allotted time for participants to share divisive behavior through group cohesion. The their stories in small groups. A flurry of group speakers modeled transformational leadership discussion ensued, and the trust level of the groups
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PATIENT SAFETY FIRST in their presentation by sharing their fallibility, thoughts, and feelings as well as the values they learned from these experiences. OUTCOMES OF THE WORKSHOPS These collaborative workshops were supported by nurses and nursing organizations across the state of North Carolina and provided the opportunity for nurse educators to disseminate an abundance of current evidence addressing the topic of workplace violence and the negative impact on nurses and the safety of their patients. The workshop coordinator, Molly Patton, successfully completed her DNP in leadership and published her dissertation through the University of South Carolina, Columbia. Team members from NCNA presented the NTN initiative38 throughout North Carolina, and members of the PPAC of NCNA have formed a Beyond Bullying Taskforce39 with volunteers from the workshops. The authors of this article presented at the NCNA Convention in October 2013, in Greensboro, North Carolina, 40 and were invited to speak at other locations across the state on the topic of lateral violence and beyond bullying. At the final workshop, 58 nurses within North Carolina committed to changing their own communication techniques and volunteered to participate in future collaborative initiatives by using existing state resources. The project team also collected signatures from committed attendees and assembled a list of nurses willing to move forward in developing intraprofessional communication. The Beyond Bullying Taskforce obtained additional funding through a special projects grant from NCNA PPAC. This grant funded the design of a logo and NCNA convention banner to draw attention to the display about the initiative to stop bullying and to speak up. The design was attached to a badge reel (ie, a retractable lanyard attached to the badge) distributed at the October 2013 convention. Members of the Beyond Bullying
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Taskforce hosted a table at the convention to disseminate information to attendees. Staff educators reported using the tool kit that was provided at the first workshop for staff member education, nursing management meetings, and their own personal growth. Participants’ comments from the workshop evaluations were encouraging and supportive of change. Participants’ comments included the following: n n
n n
n
n
n
“[The] discussions help me value others for different approaches.” “We had situations occurring that were being overlooked, but I spoke up as a result of this conference, and they were dealt with. I am glad that I was able to intervene on behalf of this individual and stop what was happening to her and others, I’m sure.” “I attended all three sessions and can say I am a different, better nurse because of them.” “This was an excellent series of workshops! Very empowering on both a personal and professional level.” “Wonderful, honest, courageous speakers with amazing stories. Thank you for bringing ‘nursing’s dirty little secret’ to light. My hope is to continue more work toward changing this trend.” “This Transformation in Nursing class I attended on March 22, 2013, was one of the most outstanding classes I have ever attended. We all have difficult people we work with. This lecture helped me to identify the bullying in myself as well as tools to deal with people bullying me.” “Outstanding series, thanks.”
CONCLUSION Transformational nurse leaders are improving communication for the safety of our patients. The journey begins with nurses having the courage to reflect on their strengths and fallibilities, honestly appraise their communication skills, and align their values with their communication and behaviors. Critical to transformational leadership is the ability
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to align values, thoughts, feelings, and behaviors to effect change. The power to transform group behaviors within nursing exists in the collective values of the nursing profession. Nurses who are committed to the process must begin the journey within themselves by improving the way they behave with others and their professional organizations. The way nurses think and feel is reflected in words and actions, and nurses must commit to a code of ethics. AORN offers the “Perioperative explications for the American Nurses Association Code of Ethics for Nurses” in its Perioperative Standards and Recommended Practices.41 Nurses should read the code and AORN’s perioperative explications of it to gain empowerment and guidance for their professional actions. Acknowledgments: The authors thank AORN, the NCAC Leadership Taskforce, NCNA, PPAC, Beyond Bullying Taskforce, and all the aforementioned leaders and nursing organizations for the success of this collaborative intervention. Editor’s note: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD. References 1. Sentinel Event Data: Root Causes by Event Type. 20042Q 2012. The Joint Commission. http://www.jointcommi ssion.org/assets/1/18/Root_Causes_Event_Type_2004_ 2Q2012.pdf. Accessed November 21, 2013. 2. Roberts SJ. Oppressed group behavior: implications for nursing. ANS Adv Nurs Science. 1983;5(4):21-30. 3. Freire P. Pedagogy of the Oppressed. New York, NY: Continuum; 2009. 4. Patton M. A Pilot Intervention to Engage Nurses to Lead Transformation. [doctoral project]. Columbia, SC: University of South Carolina; 2013. 5. Barrett A, Piatek C, Korber S, Padula C. Lessons learned from a lateral violence and team building intervention. Nurs Admin Q. 2009;33(4):342-351. 6. Daiski I. Changing nurses’ dis-empowering relationship patterns. J Adv Nurs. 2004;48(1):43-50. 7. Duffy E. Horizontal violence: a conundrum for nursing. J Royal Coll Nurs Austr. 1995;2(2):5-17. 8. Farrell G. Aggression in clinical settings: nurses’ views d a follow-up study. J Adv Nurs. 1999;29(3):532-541. 9. Farrell G. Aggression in clinical settings: nurses’ views. J Adv Nurs. 1997;25(3):501-508.
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PATIENT SAFETY FIRST 10. Gardner D. Conflict and retention of new graduate nurses. West J Nurs Res. 1992;14(1):76-85. 11. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Cont Educ Nurs. 2004;35(6):1-7. 12. Guidroz A, Burnfield-Geimer J, Clark O, Schwetschenau H, Jex S. The nursing incivility scale: development and validation of an occupation-specific measure. J Nurs Manag. 2010;18(3):176-200. 13. Hutchinson M. Restorative approaches to workplace bullying: educating nurses towards shared responsibility. Contemp Nurse. 2009;32(1-2):147-155. 14. Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace bullying in nursing: towards a more critical organisational perspective. Nurs Inquiry. 2006;13(2): 118-126. 15. McKenna B, Smith N, Poole S, Cloverdale J. Horizontal violence: experiences of registered nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96. 16. Roberts SJ, DeMarco R, Griffin M. The effect of oppressed group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change. J Nurs Manag. 2009;17(3):288-293. 17. Rogers-Clark C, Pearce S, Cameron M. Management of disruptive behavior within nursing work environments: a comprehensive systematic review of the evidence. JBI Library Syst Rev. 2009;7(15):615-678. 18. Sheridan-Leos N. Understanding lateral violence in nursing. Clin J Oncol Nurs. 2008;12(3):399-403. 19. Stanley K, Martin M, Michel Y, Welton J, Nemeth L. Examining lateral violence in the nursing workforce. Issues Mental Health Nurs. 2007;28(11):1247-1265. 20. Vessey JA, DeMarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal & organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009; 25(5):299-306. 21. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. 22. The Joint Commission. Leadership in healthcare organizations: a guide to Joint Commission leadership standards. 2009. http://www.jointcommission.org/Leader ship_in_Healthcare_Organizations. Accessed January 10, 2014. 23. AORN Position Statement: Creating a Practice Environment of Safety. Denver, CO: AORN, Inc; 2011. http:// www.aorn.org/PracticeResources/AORNPositionState ments. Accessed January 16, 2014. 24. Bigony L, Lipke T, Lundberg A, McGraw C, Pagac G, Rogers A. Lateral violence in the perioperative setting. AORN J. 2009;89(4):688-696. 25. Dunn H. Horizontal violence among nurses in the operating room. AORN J. 2003;78(6):977-988. 26. Coursey JH, Rodriguez RE, Dieckmann LS, Austin PN. Successful implementation of policies addressing lateral violence. AORN J. 2013;97(1):101-109. 27. Just Culture Tool Kit. AORN, Inc. http://www.aorn.org/ Clinical_Practice/ToolKits/Just_Culture_ToolKit/Just_ Culture_Tool_Kit.aspx. Accessed January 13, 2014.
PATIENT SAFETY FIRST 28. Silence Kills: The Seven Crucial Conversations for Healthcare. Vital Smarts; American Association of Critical-Care Nurses. http://www.silenttreatmentstudy .com. Accessed November 7, 2013. 29. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. VitalSmarts, AORN, American Association of Critical Care Nurses. http:// www.silenttreatmentstudy.com. Accessed November 7, 2013. 30. North Carolina Future of Nursing Action Coalition. Foundation of Nursing Excellence. http://www.ffne.org/ nc-future-of-nursing-action-coalition. Accessed November 7, 2013. 31. Bass B. Leadership: good, better, best. Organizational Dynamics. 1985;13(3):26-40. 32. Munir F, Nielson K. Does self-efficacy mediate the relationship between transformational leadership behaviours and healthcare workers’ sleep quality? A longitudinal study. J Adv Nurs. 2009;65(9):1833-1843. 33. Colbert A, Kristof-Brown A, Bradley B, Barrick M. CEO transformational leadership: the role of goal importance congruence in top management teams. Acad Manag J. 2008;51(1):81-96. http://users.business.uconn.edu/jgood man/MGMT%206201%20Assigned%20Readings% 202008/2%20Leadership/Colbert%20et%20al%202008 .pdf. Accessed January 13, 2014. 34. Fu P, Tsui A, Liu J, Li L. Pursuit of whose happiness? Executive leaders’ transformational behaviors and personal values. Admin Sci Q. 2010;55:222-254. http://asq .sagepub.com/content/55/2/222.refs. Accessed January 13, 2014. 35. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Silver Spring, MD: ANA Nursing World; 2001. http://www.nursingworld.org/ codeofethics. Accessed January 16, 2014. 36. Kagan PN, Smith MC, Cowling WR, Chinn PL. A nursing manifesto: an emancipatory call for knowledge development, conscience, and praxis. Nurs Philos. 2009;11(1):67-84. 37. TeamSTEPPS;: Strategies and Tools to Enhance Performance and Patient Safety. Agency for Healthcare
www.aornjournal.org
38.
39.
40.
41.
Research and Quality. http://www.ahrq.gov/profes sionals/education/curriculum-tools/teamstepps/index .html. Accessed January 16, 2014. Nurses Transforming Nursing Toolkit. Nurses Transforming Nursing (NTN). http://ntn.ncnurses.org/ntn-tool kit. Accessed January 13, 2014. Beyond Bullying Taskforce. North Carolina Nurses Association. http://www.ncnurses.org/workforce_advocacy/ ncna-beyond-bullying-taskforce.dot. Accessed January 13, 2014. North Carolina Nurses Association Convention Schedule. North Carolina Nurses Association. http://www.ncnurses .org/education/convention/2013/2013_Convention_Sched ule.pdf. Accessed January 11, 2014. Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 19-42.
Colleen Burgess, EdD, RN, PMH, CNS-BC, is the chair of the BSN Completion Program and associate professor at Cabarrus College of Health Sciences, Concord, NC. Dr Burgess has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Molly Patton Curry, DNP, RN, is the director of Health Academic Programs at William Peace University, Raleigh, NC. Dr Curry has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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considerable amount of evidence exists in nursing and health care literature documenting the disturbing pattern of harmful nonproductive communication in the health care setting. The Joint Commission1 issued a Sentinel Event Report identifying communication and leadership as ranking in the top three root causes of adverse patient events (Figure 1). Nurse researchers have explored and analyzed this persistent pattern of destructive behavior among nurses and professionals in health care for more than 30 years. Roberts2 identified the phenomenon in nursing as oppressed group behavior and referenced the seminal work of the social scientist Paulo Freire.3 Nursing literature uses a variety of terms to describe these oppressed group survival behaviors, such as lateral violence, horizontal violence, incivility, and disruptive behavior. A number of factors contribute to the persistent and perpetual cycle of verbal, emotional, intellectual, spiritual, and, less frequently documented, physical abuse in the workplace. According to Patton,4 there are several contributing factors to lateral violence in the workplace that include not only oppressed group behaviors but the hierarchal system that devalues nursing knowledge and expertise and the perception among nurses that they are impotent to effect change. Violent communication can be overt or covert. Overt aggression is demonstrated by belittling,
criticizing, finding fault, and obstructing patient care, whereas covert aggression is not quite as obvious and consists of behaviors such as excluding the intended victim from essential group e-mails and office communication, withholding information, and ignoring or excluding that person from conversations. A list of documented overt and covert aggressions that are seen in the workplace is outlined in Table 1. Some of the patterns of violent communication documented in the nursing literature include bullying, incivility, verbal abuse, insulting or disparaging remarks, sabotage, and professional terrorism.2,5-20 Some specific examples include spreading malicious rumors or gossip, refusing to speak to another or answer his or her questions, failing to speak up in another’s defense when he or she is unfairly criticized, and scapegoating. Within the recent past, the Institute of Medicine Future of Nursing21 report recommended that nurses lead improvement efforts to transform health care. Because they are at the center of health care delivery, nurses are in a strategic position to lead a positive change and to put an end to dysfunctional communication patterns that exist in the workplace. It is disconcerting that workplace violence and incivility persist in light of the overwhelming evidence documenting this threat to patient safety. An atmosphere of mutual respect and civility is
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.01.012
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Figure 1. Most frequently identified root causes 2010-2012 ª The Joint Commission, 2013. Reprinted with permission.
necessary to provide safe and effective care. The Joint Commission22 issued a guide for leadership standards for health care organizations encouraging civil, open communication and the development of conflict management processes. National nursing organizations such as The National League for Nursing, the American Association of Colleges of Nursing, Quality and Safety Education for Nurses, the American Nurses Association, and AORN support these recommendations; AORN also has a position statement on creating safe environments.23 As champions of patient safety, AORN is committed to making changes to improve safety in the workplace. Numerous articles have been published in the AORN Journal addressing these disturbing behaviors in the workplace,24-26 and AORN published a position statement that focuses on promoting workplace safety through communication23
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and a just culture tool kit,27 which offers resources for nurses. Other professional organizations have contributed to the effort to eliminate workplace violence and disruptive behavior. The American Association of Colleges of Nursing, in collaboration with private industry, created VitalSmarts,28 a survey of 1,700 health care professionals that revealed the majority (84%) of participating health care professionals admitted observing dangerous shortcuts in patient care by colleagues, and only 10% spoke up and confronted the individual. An additional study, The Silent Treatment,29 conducted in collaboration with VitalSmarts, the American Association of Colleges of Nursing, and AORN, surveyed 6,500 nurses and nurse managers, and revealed that safety tools used to prevent inadvertent errors do not address the following three
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TABLE 1. Overt and Covert Violent Communication Overt
Covert
Personal attacks n Using intimidation and verbal threats n Raising voices or pointing fingers n Staring n Watching or following someone n Tampering with or destroying personal belongings n Compromising or obstructing patient care n Singling out, scrutinizing, humiliating, or belittling someone n Standing over, pushing, or shoving someone n Using verbal putdowns or denigrating nicknames, name calling, gossiping about, blaming, comparing, or criticizing someone n Making suggestions of mental instability n Highlighting someone’s mistakes publicly
Personal attacks n Ignoring n Excluding others from conversations or activities n Rolling eyes
Professional terrorism n Publicly denigrating another’s ability or achievements n Questioning someone’s skills and ability n Assigning demeaning work n Making unsubstantiated negative performance claims n Spreading rumors, slander, and character slurs n Questioning another’s competency or credentials n Limiting another’s career opportunities n Denying someone opportunities that lead to promotion n Overlooking someone for promotion n Excluding someone from committees, activities, or educational opportunities n Relocating someone to make his or her job difficult n Removing of administrative support and necessary equipment n Giving an excessive or unreasonable workload n Sabotaging or hampering work n Varying targets and deadlines n Excessively scrutinizing work n Denying due process, breaks, or leave time n Limiting opportunity to work n Dismissing someone from a position n Reclassifying someone’s position to a lower status
Professional terrorism n Making someone feel stupid n Not including someone in essential group e-mails n Excluding someone from routine information n Organizing work to isolate someone
areas that nurses reportedly fail to confront: dangerous shortcuts, incompetence, and disrespect. Important lessons gleaned from the aforementioned studies highlight the need for leadership skill development to empower nurses to speak up and put an end to the incivility that threatens the wellbeing of patients and nurses alike. The purpose of this article is to describe a collaborative educational initiative to pool resources and consolidate efforts
in North Carolina to lead a change in behavior and communication in the health care environment. The purpose of the educational workshop was to increase the awareness of nurses at all levels of care of the threat to patient safety from violent communication, provide nurses with resources, and help nurses develop collegiality and interprofessional collaboration to address communication and leadership issues in the workplace. The project AORN Journal j 531
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team held three sequential nursing workshops in North Carolina to empower nurses to make positive changes in health care. A COLLABORATIVE PROBLEM-SOLVING APPROACH Integral to the future of nursing education is the enhancement of leadership skills, advocacy, and collaboration. Interdisciplinary teamwork and collaboration are essential skills that are necessary for providing quality care, evaluation, and process improvement. Healthy, effective, and nonviolent communication is an essential leadership skill that helps influence changes in group behavior. Collaboration is a powerful tool to facilitate intraprofessional communication and engage stakeholders within all areas of nursing education, leadership, and practice to lead change and empower nurses to influence and alter disruptive behavior in the workplace. As leaders in helping others alter behavior or learn new skills, nurse educators are committed to improving communication, disseminating evidence-based information, and promoting the safety and well-being of patients and nurses. Nurse leaders in North Carolina assembled at a statewide summit in 2010 to respond to the Institute of Medicine’s call for action. These leaders formed the North Carolina Future of Nursing Action Coalition (NCAC)30 and identified four priority areas for action, one of which was to empower nurses to lead in transforming health care by improving communication and eliminating or reducing disruptive behavior and workplace violence. The NCAC formed the North Carolina Action Coalition Leadership Taskforce (NCACLT) as a subcommittee of the NCAC to focus on the goal of improving health outcomes for North Carolina nurses by developing a nursing workforce prepared to innovate and lead at all levels of care.30 The NCACLT consisted of nurse leaders practicing in acute and long-term care, nurse executives and educators, faculty of the Area Health Education Consortium, and clinical practice partners. These 532 j AORN Journal
PATIENT SAFETY FIRST NCACLT members met and identified the need to disseminate information and current evidence that would engage nurses at all levels of practice to develop communication and leadership skills. The project chair and the project coordinator presented an evidence table of research literature to the NCACLT along with a proposal that was coauthored by the project chair to provide an educational intervention to nurses across the state. A NCACLT member and advanced practice, boardcertified, psychiatric mental health clinical nurse specialist (CNS) serving as the project chair recruited a doctor of nursing practice (DNP) leadership candidate, an educator, and an experienced critical care nurse to join the NCACLT as project coordinators. The DNP candidate expressed an interest in pursuing her doctoral project in concert with the NCACLT to lead efforts toward improving communication in the workplace. The Intervention Together, the NCACLT project chair and coordinators presented a proposal to the NCAC to create a series of evidence-based workshops to disseminate the most current evidence about how leadership and communication affect patient safety and to motivate nurses in North Carolina to lead a transformation of the health care system by improving communication and eliminating or reducing disruptive behavior and workplace violence. The proposal was for the NCACLT to spearhead a collaborative series of workshops to educate, empower, and network with nurses in North Carolina to transform the health care setting. The intent was to build collective awareness of the need to develop communication, conflict management, and leadership skills, and to spark energy in nurses for engagement, group commitment, and innovation to lead this change. The basic premise of the workshops was the belief that informed nursesdunited by the shared nursing professional values to protect the safety of patients and colleaguesdwould transform the health care system. Although nurses are not alone in perpetuating
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credibility to the project. Grant funding paid for the cycle of violent communication in the workregistration, gifts, a tool kit, ice-breaker raffles and place, the focus of the NCACLT was the developprizes, and food in an effort to express appreciation ment of professional communication and conduct for the participants and foster a collegial atmosphere. within the practice of nursing. Nurses are the Each NCACLT member volunteered and contriblargest professional group in health care and, if uted to the project. A transformational leader, Mary enabled, are capable of embracing their collective Ann Wilcox, senior vice president and system power to model appropriate behavior and effect nurse executive at Carolinas Healthcare System, system-wide changes. Charlotte, North Carolina, demonstrated support An essential element of change is to empower by announcing the workshops via an e-mail flyer nurses through engagement, collaboration, and to nurses across the state within the Carolinas commitment. The NCACLT members networked Healthcare system. She also attended and addressed and collaborated with nurses, nurse executives, workshop participractice partners, pants, urging nurses stakeholders, and nursing organizations An essential element of change is to empower to engage in leading across the state of nurses through engagement, collaboration, and change to improve commitment. patient safety and North Carolina to communication. This provide, plan, denurse leader referred velop, and implement the workshop coordinators to Sharon McNamara, this state-wide collaborative project. Members of MS, BSN, RN, CNOR, a nurse expert on patient the NCACLT brainstormed and decided to pool safety at AORN. McNamara has dedicated time existing resources and stakeholders within North and substantial energy and action to improve paCarolina to optimize the success and sustainability tient safety and agreed to speak about her work of the workshop project. The authors of this addressing patient safety and communication at column submitted a special projects proposal to each of the three workshops. the North Carolina Nurses Association (NCNA) The authors held the three workshops between through its Professional Practice Action CoaliOctober 2012 and March 2013. Participants earned tion (PPAC) and secured funding to support the six continuing education contact hours per workworkshops. The special projects grant enabled shop. We used several adult learning strategies collaboration among the various nursing orgaduring the workshops, including nizations to finance the workshops. The workshops involved coordinating efforts among the n an online personality inventory that participants NCACLT, PPAC, and the Nurses Transforming completed before attending the first workshop; Nursing (NTN) initiative of NCNA to develop n interactive activities, such as audience polls; leadership skills for RNs in North Carolina. n small and large group activities and sharing, The NCACLT members collaborated with acawhich were intended to construct group meandemic and practice partners to assist in providing ing drawn from videos. the three educational workshops. The authors of this column approached practice partners, CNSs, Participants used self-disclosure to encourage selfand chief nurse executives to collaborate and conreflection and sharing in dyads and large groups. tribute to the development of the workshops. Staff They were asked to write a professional epitaph to educators, CNSs, and clinical nurses encouraged share at the second workshop, outlining what they attendance at the workshops. Organizational supwould want to be remembered for by their peers. port was paramount to engage nurses and add The content for these workshops was different in AORN Journal j 533
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NTN initiative, and Colleen Burgess, EdD, RN, PMH, CNS-BC, project chair, facilitated the education sessions for all three workshops. The project coordinator and DNP candidate, Molly Patton Curry, MSN, RN, served as a leadership resource and workshop coordinator. McNamara presented The workshops were well attended because of current evidence about lateral violence and progthe collaborative efforts of NCACLT members and ress toward eliminating it and improving patient practice partners. More than 450 nurses participated safety in North Carolina. The North Carolina Orin one or more of the three workshops. Nurse ganization of Nurse Leaders executive and presiparticipants represented many areas of practice dent, Doris Esslinger, MS, RN, CNAA, executive from perioperative, maternal child, public health, director of the North Carolina Organization of acute and chronic medical and surgical, and psyNurse Leaders, presented state efforts by the NCAC chiatric mental health, and the majority of nurses committees and closed the third workshop with a were bachelor-of-science prepared. Continuing edcall for participants to commit to join and lead the ucation credit for attendees at all three workshops transformation of the workplace. was paid for at no cost to attendees through conTransformational leadership provided a theorettributions from a large acute care facility; Sigma ical framework for the workshops. Bass31 described Theta Tau, Upsilon Mu Chapter; the North Cartransformational leaders as individuals who act olina Organization of Nurse Leaders; NCNA; and above individual needs for the sake of the group. other private industry stakeholders. Transformational leaders are able to act on principles rather than individual personalities and use Workshop Format and Content group values to inspire, intellectually stimulate, Networking is important to support the future and support individuals, and align them with the of nursing and health care leadership. Transmission of the group.32 Followers are empowered formational leaders build strong alliances with and encouraged to champions who hold be creative. Transsimilar values. Workformational leadership shop leaders invited Networking is important to support the future principles increase practice leaders and of nursing and health care leadership, and representatives of transformational leaders build strong alliances productivity, satisfaction, and perfornursing organizations with champions who hold similar values. mance.33 The ability in the state of North to communicate a Carolina to particishared vision is an essential skill of a transpate and present at the workshop. They also formational leader, and transformational leaders invited nurse executives to address the particioperate from their values, ethics, and morals.34 pants and kick off the workshops. Two nurse The use of the American Nurses Association Code executives opened the workshop by discussing of Ethics for Nurses35 and A Nursing Manifesto: An the importance of the Institute of Medicine Emancipatory Call for Knowledge Development, Future of Nursing report and its potential effect Conscience, and Praxis36 provided a fulcrum for on nursing leadership. the workshops to develop leadership skills based on Two advanced practice psychiatric nurse leaders professional values. The facilitator provided copies from the NCNA/NTN initiative and the NCNA of both documents for the enrichment of group PPAC participated in the workshops. Dona Cainediscussion. Frances, MSN, PNP, PMH, CNS, presented the each session: Surviving, Thriving, and Transforming the health care environment. At these sessions, nurse educators analyzed, synthesized, and presented current research and evidence about leadership and communication.
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behaviors described in the literature and inWorkshop One. The first workshop, “Survivcluded it in the handouts. ing,” focused on the more than 30 years of evidence During the first workshop, Burgess explained documenting the oppression of nurses and the these toxic behaviors in a nonaccusatory manner as pervasive overt and covert violent communication an adaptive response and a means of survival in behaviors prevalent in the workplace. Violent a disempowered system. She explained that it is communication in the health care environment is imperative that, as nurses, we must not only recreflective of the long history of the oppression of ognize the behaviors and factors that perpetuate the woman. Oppressed group behavior involves patcycle but reflect on our own participation in the terns of defensive, often hostile, coping mechaprocess. When we consciously acknowledge our nisms that group members develop to survive and participation in this phenomenon, as nurses, we to protect themselves against the stressful and can collectively empower each other to change. threatening interpersonal interactions at work. National health care Participants were organizations are prompted through actively enabling preworkshop personPolicies for disruptive behaviors without nurses to develop ality testing and consequences and a lack of accountability in the health care environment reinforce and enforce policies workshop videos negative behavior. to protect nurses in to focus within and the workplace. During identify their surthe workshop discusvival behaviors that sion, Burgess cautioned that policies for disruptive contribute to the violent communication in the behaviors without consequences and a lack of achealth care environment. To prepare for the countability in the health care environment rein“Surviving” workshop, the coordinators sent regforce negative behavior. istered participants an e-mail with their registration Workshop facilitators created an open, no-blame confirmation before the workshop and a link to an atmosphere to facilitate participants’ self-disclosure open source personality test to prompt reflection and reflection. Workshop facilitators’ demonstrated and self-awareness. The goals of the first session self-disclosure and self-reflection by using the were to workshop format to share personal examples of n increase the collective awareness of the persistheir own ineffective communication and the tent overt and covert violent communication in consequent negative effect on patient safety. They the workplace, then divided participants into groups of 10 to pron offer support and resources for nurses from the cess the information. Each group was asked to bedside to the boardroom, report back to the large group their feelings and n present evidence of the effects of survival bereactions about each scenario. Participant feedback haviors on patient safety and their negative efabout this workshop was overwhelmingly positive. fect on the health and well-being of nurses, and The facilitators provided resources to particin provide workshop attendees with resources and pants first by allocating time at the workshop to support. network and process with other participants. Then, All participants received a self-directed learning in addition, the tool kit, the facilitators provided “Survival Toolkit,” which included several handparticipants with a means to access the web sites of outs and Internet resources addressing problemnational organizations (eg, American Nurses Asatic behaviors in the workplace. The authors of sociation, American Association of Critical-Care the tool kit developed a checklist of the toxic Nurses, AORN, Agency for Healthcare Research AORN Journal j 535
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and Quality and TeamSTEPPS,37 NCNA, The Joint Commission) so they could search for relevant information about workplace communication. The packet contained the link to Silence Kills,28 the NCNA Nurses Transforming Nursing Tool Kit,38 communication tools, motivational thoughts, detailed references, links to national web sites and organizations dedicated to leadership skill development, and the nurse survey developed by Patton.4 Presenters shared content related to effective and assertive communication and patient safety, and they stimulated audience engagement through videos and facilitator storytelling. Presenters directed participants to share their feelings and thoughts about the videos presented in small groups and to demonstrate civility. In the conclusion of the “Surviving” workshop, the participants were asked to complete their professional epitaph describing what they would like to be remembered for by their peers in preparation for workshop two, “Thriving.”
PATIENT SAFETY FIRST increased and enabled participants to share during the large group discussion. After the small group discussions, participants reported back to the large group. Participants shared, offered support, and validated each other, thus setting the stage for group discovery. The facilitators reframed participants’ stories of lateral violence as opportunities to motivate the full group toward a positive change. The large group discussed how their individual personalities affected group behavior and the profession. The work in small groups and sharing of insights in the large group was a part of the group discovery process in preparation for the third workshop, “Transforming.”
Workshop Three. A necessary formula for group transformation is a combination of group synergy aligned with a shared vision; rigorous self-honesty; the courage to speak up and out; and a willingness to share personal experience, individual strength, and group hope. The “Transforming” workshop was centered on developing Workshop Two. The goals of the second workand modeling leadership through the sharing of shop, “Thriving,” shifted from creating awareness successful transformational experiences. Feedback to empowering nurses to view themselves as from the previous leaders. The transworkshop evaluations formational process indicated that paroccurs from the inA necessary formula for group transformation ticipants needed side out. The facilis a combination of group synergy aligned with a shared vision; rigorous self-honesty; more information itators planted seeds the courage to speak up and out; and a on violence in the of transformation willingness to share personal experience, workplace. The through personal stoindividual strength, and group hope. presenters shared rytelling to model the examples of their use of their own exown experience with periences with violent violent communication in a variety of settings. communication in the workplace. The message was An NCACLT team member and staff educator to transform participants’ experiences into strength asked a graduate student to lead and present current and hope for the large group. The facilitators literature on lateral violence to the participants at prompted discussion by dividing participants into the third workshop. Speakers shared a successful small groups and encouraging them to share intransformational experience at their organization sights gained from their personality profile and to implementing a change project by managing share both their strengths and weaknesses. The conflict, sharing feelings and ideas, and thwarting workshop allotted time for participants to share divisive behavior through group cohesion. The their stories in small groups. A flurry of group speakers modeled transformational leadership discussion ensued, and the trust level of the groups
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PATIENT SAFETY FIRST in their presentation by sharing their fallibility, thoughts, and feelings as well as the values they learned from these experiences. OUTCOMES OF THE WORKSHOPS These collaborative workshops were supported by nurses and nursing organizations across the state of North Carolina and provided the opportunity for nurse educators to disseminate an abundance of current evidence addressing the topic of workplace violence and the negative impact on nurses and the safety of their patients. The workshop coordinator, Molly Patton, successfully completed her DNP in leadership and published her dissertation through the University of South Carolina, Columbia. Team members from NCNA presented the NTN initiative38 throughout North Carolina, and members of the PPAC of NCNA have formed a Beyond Bullying Taskforce39 with volunteers from the workshops. The authors of this article presented at the NCNA Convention in October 2013, in Greensboro, North Carolina, 40 and were invited to speak at other locations across the state on the topic of lateral violence and beyond bullying. At the final workshop, 58 nurses within North Carolina committed to changing their own communication techniques and volunteered to participate in future collaborative initiatives by using existing state resources. The project team also collected signatures from committed attendees and assembled a list of nurses willing to move forward in developing intraprofessional communication. The Beyond Bullying Taskforce obtained additional funding through a special projects grant from NCNA PPAC. This grant funded the design of a logo and NCNA convention banner to draw attention to the display about the initiative to stop bullying and to speak up. The design was attached to a badge reel (ie, a retractable lanyard attached to the badge) distributed at the October 2013 convention. Members of the Beyond Bullying
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Taskforce hosted a table at the convention to disseminate information to attendees. Staff educators reported using the tool kit that was provided at the first workshop for staff member education, nursing management meetings, and their own personal growth. Participants’ comments from the workshop evaluations were encouraging and supportive of change. Participants’ comments included the following: n n
n n
n
n
n
“[The] discussions help me value others for different approaches.” “We had situations occurring that were being overlooked, but I spoke up as a result of this conference, and they were dealt with. I am glad that I was able to intervene on behalf of this individual and stop what was happening to her and others, I’m sure.” “I attended all three sessions and can say I am a different, better nurse because of them.” “This was an excellent series of workshops! Very empowering on both a personal and professional level.” “Wonderful, honest, courageous speakers with amazing stories. Thank you for bringing ‘nursing’s dirty little secret’ to light. My hope is to continue more work toward changing this trend.” “This Transformation in Nursing class I attended on March 22, 2013, was one of the most outstanding classes I have ever attended. We all have difficult people we work with. This lecture helped me to identify the bullying in myself as well as tools to deal with people bullying me.” “Outstanding series, thanks.”
CONCLUSION Transformational nurse leaders are improving communication for the safety of our patients. The journey begins with nurses having the courage to reflect on their strengths and fallibilities, honestly appraise their communication skills, and align their values with their communication and behaviors. Critical to transformational leadership is the ability
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to align values, thoughts, feelings, and behaviors to effect change. The power to transform group behaviors within nursing exists in the collective values of the nursing profession. Nurses who are committed to the process must begin the journey within themselves by improving the way they behave with others and their professional organizations. The way nurses think and feel is reflected in words and actions, and nurses must commit to a code of ethics. AORN offers the “Perioperative explications for the American Nurses Association Code of Ethics for Nurses” in its Perioperative Standards and Recommended Practices.41 Nurses should read the code and AORN’s perioperative explications of it to gain empowerment and guidance for their professional actions. Acknowledgments: The authors thank AORN, the NCAC Leadership Taskforce, NCNA, PPAC, Beyond Bullying Taskforce, and all the aforementioned leaders and nursing organizations for the success of this collaborative intervention. Editor’s note: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD. References 1. Sentinel Event Data: Root Causes by Event Type. 20042Q 2012. The Joint Commission. http://www.jointcommi ssion.org/assets/1/18/Root_Causes_Event_Type_2004_ 2Q2012.pdf. Accessed November 21, 2013. 2. Roberts SJ. Oppressed group behavior: implications for nursing. ANS Adv Nurs Science. 1983;5(4):21-30. 3. Freire P. Pedagogy of the Oppressed. New York, NY: Continuum; 2009. 4. Patton M. A Pilot Intervention to Engage Nurses to Lead Transformation. [doctoral project]. Columbia, SC: University of South Carolina; 2013. 5. Barrett A, Piatek C, Korber S, Padula C. Lessons learned from a lateral violence and team building intervention. Nurs Admin Q. 2009;33(4):342-351. 6. Daiski I. Changing nurses’ dis-empowering relationship patterns. J Adv Nurs. 2004;48(1):43-50. 7. Duffy E. Horizontal violence: a conundrum for nursing. J Royal Coll Nurs Austr. 1995;2(2):5-17. 8. Farrell G. Aggression in clinical settings: nurses’ views d a follow-up study. J Adv Nurs. 1999;29(3):532-541. 9. Farrell G. Aggression in clinical settings: nurses’ views. J Adv Nurs. 1997;25(3):501-508.
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PATIENT SAFETY FIRST 10. Gardner D. Conflict and retention of new graduate nurses. West J Nurs Res. 1992;14(1):76-85. 11. Griffin M. Teaching cognitive rehearsal as a shield for lateral violence: an intervention for newly licensed nurses. J Cont Educ Nurs. 2004;35(6):1-7. 12. Guidroz A, Burnfield-Geimer J, Clark O, Schwetschenau H, Jex S. The nursing incivility scale: development and validation of an occupation-specific measure. J Nurs Manag. 2010;18(3):176-200. 13. Hutchinson M. Restorative approaches to workplace bullying: educating nurses towards shared responsibility. Contemp Nurse. 2009;32(1-2):147-155. 14. Hutchinson M, Vickers M, Jackson D, Wilkes L. Workplace bullying in nursing: towards a more critical organisational perspective. Nurs Inquiry. 2006;13(2): 118-126. 15. McKenna B, Smith N, Poole S, Cloverdale J. Horizontal violence: experiences of registered nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96. 16. Roberts SJ, DeMarco R, Griffin M. The effect of oppressed group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change. J Nurs Manag. 2009;17(3):288-293. 17. Rogers-Clark C, Pearce S, Cameron M. Management of disruptive behavior within nursing work environments: a comprehensive systematic review of the evidence. JBI Library Syst Rev. 2009;7(15):615-678. 18. Sheridan-Leos N. Understanding lateral violence in nursing. Clin J Oncol Nurs. 2008;12(3):399-403. 19. Stanley K, Martin M, Michel Y, Welton J, Nemeth L. Examining lateral violence in the nursing workforce. Issues Mental Health Nurs. 2007;28(11):1247-1265. 20. Vessey JA, DeMarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal & organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs. 2009; 25(5):299-306. 21. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. 22. The Joint Commission. Leadership in healthcare organizations: a guide to Joint Commission leadership standards. 2009. http://www.jointcommission.org/Leader ship_in_Healthcare_Organizations. Accessed January 10, 2014. 23. AORN Position Statement: Creating a Practice Environment of Safety. Denver, CO: AORN, Inc; 2011. http:// www.aorn.org/PracticeResources/AORNPositionState ments. Accessed January 16, 2014. 24. Bigony L, Lipke T, Lundberg A, McGraw C, Pagac G, Rogers A. Lateral violence in the perioperative setting. AORN J. 2009;89(4):688-696. 25. Dunn H. Horizontal violence among nurses in the operating room. AORN J. 2003;78(6):977-988. 26. Coursey JH, Rodriguez RE, Dieckmann LS, Austin PN. Successful implementation of policies addressing lateral violence. AORN J. 2013;97(1):101-109. 27. Just Culture Tool Kit. AORN, Inc. http://www.aorn.org/ Clinical_Practice/ToolKits/Just_Culture_ToolKit/Just_ Culture_Tool_Kit.aspx. Accessed January 13, 2014.
PATIENT SAFETY FIRST 28. Silence Kills: The Seven Crucial Conversations for Healthcare. Vital Smarts; American Association of Critical-Care Nurses. http://www.silenttreatmentstudy .com. Accessed November 7, 2013. 29. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. VitalSmarts, AORN, American Association of Critical Care Nurses. http:// www.silenttreatmentstudy.com. Accessed November 7, 2013. 30. North Carolina Future of Nursing Action Coalition. Foundation of Nursing Excellence. http://www.ffne.org/ nc-future-of-nursing-action-coalition. Accessed November 7, 2013. 31. Bass B. Leadership: good, better, best. Organizational Dynamics. 1985;13(3):26-40. 32. Munir F, Nielson K. Does self-efficacy mediate the relationship between transformational leadership behaviours and healthcare workers’ sleep quality? A longitudinal study. J Adv Nurs. 2009;65(9):1833-1843. 33. Colbert A, Kristof-Brown A, Bradley B, Barrick M. CEO transformational leadership: the role of goal importance congruence in top management teams. Acad Manag J. 2008;51(1):81-96. http://users.business.uconn.edu/jgood man/MGMT%206201%20Assigned%20Readings% 202008/2%20Leadership/Colbert%20et%20al%202008 .pdf. Accessed January 13, 2014. 34. Fu P, Tsui A, Liu J, Li L. Pursuit of whose happiness? Executive leaders’ transformational behaviors and personal values. Admin Sci Q. 2010;55:222-254. http://asq .sagepub.com/content/55/2/222.refs. Accessed January 13, 2014. 35. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Silver Spring, MD: ANA Nursing World; 2001. http://www.nursingworld.org/ codeofethics. Accessed January 16, 2014. 36. Kagan PN, Smith MC, Cowling WR, Chinn PL. A nursing manifesto: an emancipatory call for knowledge development, conscience, and praxis. Nurs Philos. 2009;11(1):67-84. 37. TeamSTEPPS;: Strategies and Tools to Enhance Performance and Patient Safety. Agency for Healthcare
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38.
39.
40.
41.
Research and Quality. http://www.ahrq.gov/profes sionals/education/curriculum-tools/teamstepps/index .html. Accessed January 16, 2014. Nurses Transforming Nursing Toolkit. Nurses Transforming Nursing (NTN). http://ntn.ncnurses.org/ntn-tool kit. Accessed January 13, 2014. Beyond Bullying Taskforce. North Carolina Nurses Association. http://www.ncnurses.org/workforce_advocacy/ ncna-beyond-bullying-taskforce.dot. Accessed January 13, 2014. North Carolina Nurses Association Convention Schedule. North Carolina Nurses Association. http://www.ncnurses .org/education/convention/2013/2013_Convention_Sched ule.pdf. Accessed January 11, 2014. Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 19-42.
Colleen Burgess, EdD, RN, PMH, CNS-BC, is the chair of the BSN Completion Program and associate professor at Cabarrus College of Health Sciences, Concord, NC. Dr Burgess has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Molly Patton Curry, DNP, RN, is the director of Health Academic Programs at William Peace University, Raleigh, NC. Dr Curry has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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