1. Incivility in Nursing Education: Using The Joint Commission Sentinel Event Alert #40 as a Springboard for Action
Presented by
Christopher L. Pate, Ph.D, MPA, CQIA
64th Annual Convention of the Texas Community College Teachers Association
29 January 2011
San Antonio, Texas

2. Agenda The Joint Commission Definitions Prevalence
Role
Sentinel Events
Sentinel Event Alert #40
Definitions
Prevalence
Incivility in nursing education
Mitigation through recommendations and steps described by the Joint Commission
Implications for higher education

3. Learning Outcomes
At the conclusion of this presentation, attendees will be able to:
Identify the critical features of Sentinel Event Alert Number 40
Describe sentinel events in the context of civility
Identify characteristics of the concept of civility in healthcare settings
Discuss findings of civility-related studies in US healthcare settings
List Joint Commission recommendations for improving the environment of care and reducing workplace aggression
Discuss causes and consequences of nursing incivility
Understand how organizational activities taken in response to the Joint Commission’s changes in civility-related accreditation standards are compatible with collaborative decision making in institutions of higher education

4. The Joint Commission The Joint Commission (TJC)
Seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value
Evaluates and accredits more than 17,000 health care organizations and programs in the United States
Independent, not-for-profit organization
Nation's oldest and largest standards-setting and accrediting body in healthcare (The Joint Commission, 2009).
Focused on all aspects of organizational performance
Particular interest and focus on
Quality
Safety
Processes

5. Sentinel Events Sentinel event defined
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The event is called ‘sentinel’ because it sends a signal or sounds a warning that requires immediate attention (The Joint Commission, 2007)
TJC began issuing Sentinel Event alerts in 1998 (McLaughlin, 2008)

6. Sentinel Event Alert: Issue 40
“Behaviors that undermine a culture of safety” (Joint Commission)
Issued July 2008
Effective 1 January 2009, as requirement for accreditation
Specifically linked to domain of organizational leadership
Elements of performance (EP)
Hospitals/organizations must have code of conduct that defines acceptable, disruptive and inappropriate behaviors
Leaders must create and implement a process for managing disruptive and inappropriate behaviors

7. Sentinel Events Four Key Goals of Sentinel Event Policies
Positive impact on improving patient care, treatment and services and preventing future occurrences
Focus attention on understanding the causes and on changing systems and processes to reduce likelihood of future occurrences
Increase knowledge about sentinel events, their causes and strategies for prevention
Maintain confidence of the public and accredited organizations in the accreditation process (The Joint Commission, 2007)

8. Undermining Culture of Safety: Behaviors and Outcomes
Relationship between intimidating and disruptive behaviors and outcomes
Medical errors
Poor patient satisfaction
Preventable adverse outcomes
Increase in cost of care
Retention; clinicians, administrators, managers engage in search for jobs external to the organization
Joint Commission, 2011 National Patient Safety Goals
#2: Improve staff communication
Source: Joint Commission,

9. Prevalence
Most research on topic conducted outside US (e.g., UK, Australia, Canada) US
American College of Physician Executives (2009)
Survey of 13K physicians and nurses
98% of respondents reported observation of behavioral problems between physicians and nurses within past year
30% indicated that bad behavior occurs several times year; 30% indicated weekly occurrence; approximately 25% occurring monthly
Most common: degrading comments, insults

10. Prevalence US
Agency for Healthcare Research and Quality (AHRQ, US Department of Health and Human Services, 2011)
2008 survey (citing work of Rosenstein & O'Daniel); 100 hospitals
77% of respondents reported observation of physicians engaging in disruptive behavior
65% reported witnessing disruptive behavior by nurses

11. Prevalence US
American Association of Critical Care Nurses (AACN), VitalSmarts (2004 Survey)
Focus group of 1700 physicians, nurses, administrators (VitalSmarts, 2005)
More than 75% “regularly work with doctors or nurses who are condescending, insulting or rude” (Grenny, 2009, p. 30)
About 1/3 of the participants reported that behavior includes name-calling, yelling, and swearing (p. 30)

12. Definitions Disruptive behavior Culture of safety
Behavior that interferes with effective communication among healthcare providers and negatively impacts performance and outcomes; behavior not supportive of a culture of safety (Agency for Healthcare Research and Quality, 2011; Center for American Nurses, 2008)
Culture of safety
“characterized by open and respectful communication among all members of the healthcare team in order to provide safe patient care. It is a culture that supports an organizational commitment to continually seeking to improve safety” (Institute of Medicine, as cited in Center for American Nurses, 2008)

13. Definitions Incivility
Lack of regard for others; violation of workplace norms that promote respectful, interpersonal interaction
3 key features
Psychological
Low intensity, inconsiderate
Ambiguous intent to harm target (Felblinger, 2009, p. 14)
Bullying
Goes beyond incivility; aggressive, deliberate, psychological or physical (Felblinger, 2009)
Behavior that is generally persistent, systematic and ongoing (Task Force on the Prevention of Workplace Bullying, as cited in Center for American Nurses, 2008)

14. Disruptive Behaviors and Incivility
Behaviors associated with incivility
Rude comments
Disrespectful verbal attacks
Offensive, condescending language
Lack of collaboration
Disregard for interdisciplinary input about patient care
Public criticism
Subtle or overt verbal aggression
Name calling
Withholding critical information (Felblinger, 2009)

15. Disruptive Behaviors and Incivility
Behaviors associated with incivility
Ethnic slurs or jokes
Sexual comments
Yelling
Screaming
Attacking a person’s integrity
Requesting input when decisions are already made
Superficial listening
Lacking empathy
Blaming others in front of family members; blaming team members when something goes wrong (Felblinger, 2009)

16. Lateral Violence Lateral or horizontal violence
Nursing defined as nurse-to-nurse aggression
“aggressive behavior between nurses on the same power level” (Simons, 2008)
Verbal or nonverbal
Common forms

17. Lateral Violence: Behaviors
Common forms
Non-verbal innuendo
Verbal affront
Undermining activities
Withholding information
Sabotage
Infighting
Scapegoating
Backstabbing
Failure to respect privacy; broken confidences (Griffin, as cited in Center for American Nurses, 2008)

18. Workplace Bullying Workplace bullying
“repeated inappropriate behavior, direct or indirect, whether verbal, physical or otherwise, conducted by one or more persons against another or others, at the place of work and/or in the course of employment, which could reasonably be regarded as undermining the individual’s right to dignity at work” (Task Force on the Prevention of Workplace Bullying, as cited in Center for American Nurses, 2008)

19. Specific Types of Bullying Behaviors in Healthcare Settings
Verbal abuse
Written abuse
Physical abuse
Intimidation
Displays of offensive material (Edwards, O’Connell, 2007, p. 28)

20. Verbal Abuse Verbal abuse
“disruptive form of behavior involving verbal communication that is associated with horizontal violence” (Center for American Nurses, 2008)
“any communication a nurse perceives to be a harsh, condemnatory attack upon herself or himself professionally or personally” (Cox, as cited in Center for American Nurses, 2008)
Examples
Offensive language or innuendo
Language that belittles a person’s abilities
Spreading malicious rumors
Sexist, racist, or patronizing remarks
Inappropriate or intimate questioning (NHS, as cited in Edwards, O’Connell, p. 28)

21. Bullying Behaviors in Healthcare Settings: Written and Physical Abuse
Letters, , faxes
Physical
Unwanted physical contact
Explicit physical threats or attacks
Unnecessary touching or assault
Stalking that is related to work, may occur at work or outside of work(NHS, as cited in Edwards, O’Connell, p. 28)

22. Bullying Behaviors in Healthcare Settings: Intimidation and Offensive Material
Slander
Belittling conduct (e.g., being yelled at)
Intrusion by pestering, following
Unnecessary closeness
Apportioning blame wrongly
Offensive material
Flags and emblems
Badges
Graffiti
Unnecessary highlighting of differences (NHS, as cited in Edwards, O’Connell, p. 28)

23. How Might this Look in Practice?

24. Root Causes Individual factors Organizational factors
Learned behavior, “perpetrators of bullying have been bullied themselves” (Paterson et al., as cited in Edwards & O’Connell, 2007)
Individual insecurities
Stress
Individuals lack training on appropriate behavior and expectations
Organizational factors
Power imbalances between organizational members (nursing as “oppressed group,” Hutchinson, Vickers, Jackson, & Wilkes, 2006, p. 119)
Lack of professional training
Lack of leadership
Organizational demands and stress, “do more with less” mentality, focus on productivity
Organizational change and uncertainty (Randle, Stevenson, & Grayling, 2007)

25. Effects on Individuals
Nurse-to-nurse hostility
Anxiety, fear, shock, anger, guilt, vulnerability, humiliation
Loss of self-confidence
Loss of self-esteem
Feeling threatened
Developing stress-related illness
Contemplating suicide (Leiper as cited in Bartholomew, 2006)

26. Practical Recommendations: An Individual Perspective with Organizational Implications
Disclosure
Knowledge of workplace protections
Documentation
Being assertive
Being empathetic
Use open questions
Buying time
Assertiveness training (Randle, Stevenson, & Grayling, 2007)

27. What and How to Address: Carefronting
Carefronting (Briles, 2009)
When you ________________
I felt _____________________
Because __________________
Was it your intent to _______
In the future ______________
Are you committed to ______
If there is not a change _____

28. Incivility in Nursing Education
Defined:
“rude or disruptive behaviors that often result in psychological or physiological distress for the people involved and may progress into threatening situations when left unaddressed” (Clark as cited in Clark & Springer, 2010, p. 320)
Faculty and student consequences
Disrupted student-faculty relationships
Problematic learning environments
Increased stress levels for faculty and students (Clark & Springer, 2010)

29. Creating a Culture of Civility in Nursing Education
Recognition that both students and faculty have responsibilities
Factors contributing to incivility
Faculty (high stress, negative attitude of superiority, assumption of “know it all” attitude, arrogance)
Students (consumer mentality, refusal to accept responsibility, making excuses, high stress)
“faculty and student stress and disparaging attitudes in conjunction with missed, avoided, or poorly managed opportunities for meaningful engagement are major contributions to incivility in nursing education” (Clark as cited in Clark & Springer, 2010, p. 320)

30. An Organizational Perspective
Strategies
Define the problem
Awareness and accountability
Organizational and leadership commitment
Policies and procedures
Staff education
Communication/team collaboration skills
Reporting policy and follow-through
Disruptive behavior policy
Address barriers
Implement intervention plan (Rosenstein, 2009, p. 332)

31. Specific Recommendations from the Joint Commission
Education
Enforce accountability
Consistency in enforcement
Model desirable behaviors
Development of comprehensive approach (policies/procedures)
Zero tolerance for intimidating or disruptive behaviors
Alignment of medical/professional staff policies with those of larger organization
Reducing fear of retaliation; protecting those who report—make non-retaliation clauses part of policy on addressing disruptive behaviors
Responding to patients and families that have witnessed intimidating or disruptive behaviors
How and when to begin disciplinary actions
Source: Joint Commission,

32. Specific Recommendations from the Joint Commission
Develop process for addressing that uses input from inter-professional team
Medical staff
Nursing staff
Administrators
Other employees
Provide skills-based training
Assessment
Develop system of reporting and surveillance
Use tiered approach to addressing
Conduct all interventions within context of improving organizational commitment to the health and well-being of the staff
Document all attempts to address intimidating and disruptive behaviors
Source: Joint Commission,

33. Zero Tolerance TJC Empower staff Good start
Needs follow-up with “strong communication that there is zero tolerance for these behaviors, and strong actions when they occur” (Physician Executive, 2009, p. 22)
“Implement a no-tolerance policy and enforce it 100% of the time” (p. 22)
Empower staff
“I am sorry, but you may not speak to me it that tone of voice” (p. 22)

34. Healthcare, Higher Education
Many similarities between higher education and healthcare
Emphasis on costs
Emphasis on output measurement, productivity
Increasing accountability
Organizational power centers
Codes of conduct (faculty, employees, students) necessary but insufficient to address disruptive behaviors
Collaboration is necessary
Inclusion of groups most likely targeted
Appropriate cultural mix
Accrediting body involvement and standards
Places of rigorous inquiry; health sciences education perfect place to start
Recognition of institutions that adopt a robust plan to address intimidating and disruptive behavior

35. Point of Contact
Contact info:
Christopher Pate, Ph.D, MPA, CQIA
Department of Radiology
Brooke Army Medical Center
Fort Sam Houston, TX

36. References
Agency for Healthcare Research and Quality. (2011). Disruptive and unprofessional behavior. Retrieved January 27, 2011 from
Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Marblehead, MA: HCPro, Inc.
Briles, J. (2009). Are there saboteurs in your midst? Retrieved January 27, 2011 from
Broome, B.A. (2008). Dealing with sharks and bullies in the workplace. ABNF Journal, 19(1), 28 – 30.
Center for American Nurses (2008). Lateral violence and bullying in the workplace. Retrieved August 15, 2009 from
Clark, C.M., & Springer, P.J. (2010). Academic nurse leaders’ role in fostering a culture of civility in nursing education. Journal of Nursing Education, 49(6), 319 – 325.
Edwards, S.L., & O’Connell, C.F. (2007). Exploring bullying: Implications for nurse educators. Nurse Education in Practice, 7(1), 26 – 35.
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.
Grenny, J. (2009). Crucial conversations: The most potent force for eliminating disruptive behavior. Physician-Executive, 35(6), 30 – 33.
Hutchinson, M., Vickers, M., Jackson, D., & Wilkes, L. (2006). Workplace bullying in nursing: Towards a more critical organizational perspective. Nursing Inquiry, 13(2), 118 – 126.

37. References
Johnson, C. (2009). Bad blood: Doctor-nurse behavior problems impact patient care. Physician-Executive, 35(6), 6 – 11.
McLaughlin, S. (2008). Historical perspective: The joint commission’s growing role in the environment of care. Health Facilities Management, 21(4), 43 – 45.
Randle, J., Stevenson, K., & Grayling, I. (2007). Reducing workplace bullying in healthcare organizations. Nursing Standard, 21(22), 49 – 56.
Rosenstein, A.H. (2009). Disruptive behaviour and its impact on communication efficiency and patient care. Journal of Communication in Healthcare, 2(4), 328 – 340.
Sheridan-Leos, N. (2008). Understanding lateral violence in nursing. Clinical Journal of Oncology Nursing, 12(3), 399 – 403.
Simon, S.L. (2008). Mission (im)possible? Nurse civility in the NICU. Neonatal Network, 27(2), 141 – 142.
The Joint Commission (2009). Facts about the Joint Commission. Retrieved November 16, 2009 from
The Joint Commission (2008). Sentinel event alert, Issue 40. Retrieved August 15, 2009 from
The Joint Commission (2007). Sentinel events policies and procedures. Retrieved August 15, 2009 from
VitalSmarts. (2005). Media advisory: Panel examines harmful communication gaps in healthcare system and provides prescription for change. Retrieved January 28, 2011 from