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Bullying in the Workplace, by Loraleigh Keashly

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Bullying in the Workplace, by Loraleigh Keashly

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Slides from the University of Michigan Investing in Ability 2015 series of events. The presenter is from Wayne State, and we are hosting the slides here for the convenience of our audience.

Slides from the University of Michigan Investing in Ability 2015 series of events. The presenter is from Wayne State, and we are hosting the slides here for the convenience of our audience.

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Bullying in the Workplace, by Loraleigh Keashly

  1. 1. Bullying in the workplace: Causes, consequences and actions Loraleigh Keashly Dept of Communication, Wayne State U October 9 2015 l.keashly@wayne.edu UMich Abilities Week 1
  2. 2. Healthcare Environment •  Everyone needs healthcare - high demand •  Fastest growing industry – regulations •  Spiraling costs •  Multiple providers – competition; mergers •  Operating in a political and legalistic env’t •  New technologies
  3. 3. Healthcare Environment Mitchell et al 2012; Longo & Hain 2014) •  Challenging health issues •  Sophisticated and increasingly complex •  Requires a multi-professional team-based approach (Mitchell et al 2012) •  Goal: Providing quality care and protect patient safety •  Requires skills in collaboration & coordination; •  Grounded in mutual trust and professional respect •  Critical importance of communication and clear expectations
  4. 4. Culture of Safety & Health https://www.osha.gov/SLTC/etools/safetyhealth/mod2_culture.html Basic elements (OSHA) •  All individuals within the organization believe they have a right to a safe and healthy workplace •  Each person accepts personal responsibility for ensuring his or her own safety and health. •  Everyone believes he or she has a duty to protect the safety and health of others. 4 In essence, this is about relationships and necessity of connection and coordination
  5. 5. Quality work environment •  What does a constructive and productive work environment: • Feel like? • Look like? Behaviors?
  6. 6. Scenario You observe a nurse in your unit, Sam, respond to the actions of a tech, Chris, in a hostile manner. Chris questioned Sam about an order and Sam stated “what an unbelievably stupid question…you should know to just do what’s ordered.” With that, Sam turned away from Chris, threw hands up, and strode away. Chris was clearly embarrassed in front of all the others in the unit. Not long afterwards you learn that Chris has gone home early due to “not feeling well.” 6
  7. 7. Definition of Disruptive Behavior •  Behavior that interferes with work or creates a hostile environment, e.g.: –  verbal abuse, sexual harassment, yelling, profanity, vulgarity, threatening words/actions; –  unwelcome physical contact; threats of harm; behavior reasonably interpreted as intimidating; –  passive aggressive behaviors: e.g., sabotage and bad-mouthing colleagues or organization •  Behavior that creates stressful environments and interferes with others’ effective functioning, impacts ability of the team to achieve the intended outcome •  Chronic or patterns of disruptive behavior are costly –  Bullying, mobbing, lateral violence Vanderbilt University and Medical Center Policy #HR-027 ; Center for Patient and Professional Advocacy acpe.org at Vanderbilt 7
  8. 8. Continuum of Conflict Civil..…...Uncivil…...Misconduct…...Illegal….....Criminal © 2012 Tom Sebok University of Colorado at Boulder •  Respectful Disagreement •  Friendly Competition •  Creative •  Destructive •  Dangerous Climate •  Violent Bullying Mobbing Discrimination Harassment Disruptive Behaviors
  9. 9. Incivility Low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect. Uncivil behaviors are characteristically rude and discourteous, displaying a lack of regard for others. (Andersson & Pearson 1999)
  10. 10. Bully Frequent and Prolonged Mobbing Victim Frequent and Prolonged Bullying •  Repeated, persistent, patterned, and enduring acts of aggression. •  Unwanted by the victim. •  Done deliberately or unconsciously •  Cause humiliation, offence, distress. •  Creates unpleasant work environment, interfere with job performance and health harming consequences for targets and bystanders. •  Power imbalance impacts ability to defend(Einarsen 1999) Mobbing •  Malicious attempt to force a person out of the workplace through unjustified accusations, harassment, and emotional abuse. •  Involves rallying others into systematic and frequent “mob- like” behavior against target. •  “ganging up” (Davenport et al 1999)
  11. 11. Scenario A physician demanded a nurse be drug tested because the nurse questioned an order. The order would have placed the patient at risk. The physician then demanded the nurse be fired because the nurse ‘evidently wasn’t competent to care for a slug.’ The physician also called the nurse names and cursed at the nurse in front of staff and family members. 11
  12. 12. Distinguishing features •  Negative behaviors •  Persistent/Repeated •  Frequency •  Single episode? •  Enduring - occurs over a period of time – how long? •  Patterned – variety and sequencing/ progression •  Critical consideration •  Micro-aggressions and micro-inequities •  Focused on the identity & character of another •  Unwelcome & unsolicited
  13. 13. Distinguishing features •  Violations of a standard of appropriate conduct towards others •  Self-regulating profession •  Exposure causes harm •  Power imbalance (formal v. informal) •  Ability to defend oneself – Key distinction re conflict •  Multiple sources of power – not just organizational power •  Use/abuse of power
  14. 14. Not bullying •  People not getting along •  Expression of conflicting opinions •  Direct communication •  High performance standards •  Constructive feedback, guidance or advice about work-related behavior and performance; corrective feedback
  15. 15. Categories of behavior Rodriguez-Carballeira et al 2010 •  Isolation – restricting interaction with others and/or seeking physically separating from others, seeking to marginalize or exclude •  Control and manipulation of information – selecting and manipulating info, lying, interfering with info transmission •  Emotional abuse – offensive actions and expressions aimed at attacking, injuring and sneering at worker feelings and emotions •  Intimidation and threats •  Disrespect, humiliation and rejection of the person
  16. 16. Categories of behavior Rodriguez-Carballeira et al 2010 •  Control- abuse of working conditions – intervening or acting negligently in work env’t and work conditions in order to upset worker as they attempt to perform tasks or put their health at risk •  Obstructionism •  Dangerous work •  Professional discredit and denigration – discrediting and denigrating worker’s professional reputation and standing, belittling his or her knowledge, experience, efforts, performance etc..
  17. 17. Categories of behavior Rodriguez-Carballeira et al 2010 •  Devaluation of the role in the workplace – undervaluing the importance of the role of the worker, unjustifiably relieving the worker of their responsibilities or assigning useless, impossible or clearly inferior task to person’s category in the organization.
  18. 18. •  Escalatory sequence 1.  Aggressive behavior – subtle, indirect to direct, overt 2.  Bullying – frequency and having difficulty defending self !  Target becomes increasingly disabled in responding; more ineffective responses 3. Stigmatization – when unable to defend becomes stressed, which may lead to performance issues. •  Focus now on job performance of the target; acceptance of “offender’s” interpretation. •  Others join in – spirals, mobbing 4. Severe trauma – if not address without further victimization. Process of bullying (Einarsen 1999)
  19. 19. In Healthcare •  Active research area since the 1980’s •  Early attention to nurses’ and medical students’ experiences of abusive treatment (e.g., Cox 1991; Rosenberg & Silver 1984; Lanza 2006) •  High rates of verbally abusive behavior (50-97%,); Bullying 27% (e.g.,Johnson & Rea 2009; Solfield & Salmond 2003 ) •  Witnessing – 77% Physicians, 65% Nurses (Rosenstein & O’Daniel 2008) •  “kick down” kind of treatment – those higher up mistreat those lower down. •  Horizontal and interdisciplinary (Keashly, 1998)
  20. 20. Immediate effects of disruptive behavior (Rosenstein & O’Daniel 2005) •  Stress •  Frustration •  Loss of concentration •  Reduced team collaboration •  Reduced information transfer •  Reduced communication •  Impaired professional relationship
  21. 21. Broader implications of exposure (Rosenstein, 2011) •  Negative staff satisfaction and morale •  Staff turnover •  Compromises in patient safety – medical error, adverse events •  Joint Commission noncompliance •  Negative hospital reputation •  Decreased patient satisfaction •  Increased liability and malpractice exposure •  Increase cost of care
  22. 22. Some reasons why (Baillien et al 2009; Salin 2003) •  Intra/interpersonal influences •  Poor or miscommunication •  Poorly managed conflict •  Poorly managed stress •  Group/Org’l influences •  Low perceived costs/risks for behavior •  Lack of normative guidance re behaviors •  Competition for scarce resources •  People perceived as “different” – conformity •  Threats to perceived status •  Env’t – rigid hierarchy, uncertainty, lots of change, productivity demands, role state stressors
  23. 23. Why so hesitant to act? (Hickson et al 2007; Rosenstein 2011) •  Power differential – impact on responding •  Lack of awareness of impact (risk) •  Lack of effective policies •  Leaders do not act consistently – Tie to “idiosyncrasy credits” – Fear of no organizational backup •  History of tolerance & code of silence •  Lack of training on how to deal with disruptive behaviors 23
  24. 24. Just as disruptive behavior is multi- determined, addressing it must be multi-layered: - individually - team/unit - institutionally Multi layered approach
  25. 25. What if it is happening to you? Getting clear and taking care (Dutton, 2003) •  Label what is happening to you (Naming) –  Conflict, incivility, bullying? •  Enlist support from other coworkers –  If possible, reduce dependence on other (Bound & Buffer) •  Enlist support from family and friends •  Engage in outside activities that build self esteem (Buttress & Strengthen)
  26. 26. Deciding what to do (Target & transform) •  Clarify own needs •  Get information about the other’s needs •  Think through alternatives •  Sources of power and influence you have and the other has: – Positional - reward, coercion, legitimate – Personal - expert, referent, informational – BATNA - Best alternative to a negotiated agreement
  27. 27. Happening to you Confronting the actor: •  high risk of becoming more isolated or losing job •  positive move if done early in the process when bullying/intimidation has not become established part of working relationship. •  when no threat to physical safety •  assertion and conflict management •  Crucial conversations model – Grenny 2009 Do not retaliate!
  28. 28. Happening to you •  Keep factual log of events •  Look for internal bullying/harassment policies in personnel handbook or mission statement •  Look for violation of discrimination laws •  Keep copies of letters, memos and emails
  29. 29. Happening to you •  Report disruptive behavior to person identified in workplace policy, supervisor or HR •  Consider outside consultation with a union representative or an employment lawyer •  Leaving the job may be the only option in light of significant health risks.
  30. 30. Strategies for witnesses 30
  31. 31. What if you see it? Two decisions you need to make: 1.  Level of involvement - willingness to take action; how much involve self publicly •  Range from noninvolvement •  High - put self into episode •  Low - involve but outside public eye 2.  Immediacy - in current situation or later •  High - interrupt specific incident •  Low - efforts to prevent future incidents (Bowes-Sperry & O’Leary-Kelly 2005)
  32. 32. Choices in responding Low Immed-High Involvement • Report actor to Administration • Accompany target when reports it • Talk to target about experience • Confront actor after incident • Work to develop/implement policies • Build the business case High Immed-High Involvement •Tell actor to stop conduct • Name or acknowledge offense • Publicly encourage target to report conduct • Get others to publicly denounce conduct Low Immed-Low Involvement • Privately advise target to avoid actor • Covertly keep actor away from target • Advise target to report incident • Refuse to share gossip/rumors Hi Immed-Low Involvement • Redirect actor from situation • Remove target from situation • Interrupt the incident • Affirm the target • Use body language to show disapproval, e.g., silent stare Immediacy Involvement
  33. 33. Strategies for actors 33
  34. 34. Accused? Take it seriously •  Listen carefully •  Don’t be defensive •  Take time to reflect •  Use of silent witness (another set of eyes & ears) •  Consider accusations rationally •  Ask what behavior prefer •  Apologize for offense •  Request a third party to help with conversation If false, take to higher up (Rayner, Hoel, & Cooper 2002)
  35. 35. Questions we should all ask… •  Am I aware of how I come across to staff, colleagues and boss/supervisor? •  Do I ask for feedback on the way I behave? •  Do I pay attention to my own emotions while at work? •  Is my body language in tune with what I am saying? •  Do I join in when jokes are made at someone else’s expense? (Rayner, Hoel, & Cooper 2002)
  36. 36. Unit/team level action •  Graduated Intervention model •  Development of a communication protocol •  Cues for rising “temperature” - “Tempo” •  CREW – VHA initiative •  Fostering and affirming exemplary behavior 36
  37. 37. Responding to disruptive behavior (Hickson et al 2007; Pritchert et al 2013) •  Model of graduated intervention •  Premised on idea of self-regulation and professionalism •  Evidence-based – providing information on impact of behaviors (risk) – Patient At Risk Score (PARS Risk), patient complaints, surveillance •  Engaging “peer messengers” – informal cup of coffee conversation 37
  38. 38. Apparent pattern Single “unprofessional" incidents (merit?) When action needed: Graduated intervention model "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 2 “Guided" Intervention by Authority Level 3 "Disciplinary" Intervention Pattern persists No ∆ Vast majority of professionals - no issues - provide feedback on progress Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Mandated Reviews Mandated
  39. 39. Guide to graduated intervention (see Vanderbilt CPPA Toolkit Sept 2013) Single unprofessional incident " Informal “cup of coffee conversation” (collegial) •  raise the issues/incident •  actor’s experience/explanation is sought •  highlighting the cost of the incident to those involved •  request and discussion of different ways of responding and future action # Espresso conversation: involve a respected higher up 39
  40. 40. Guide to graduated intervention Apparent pattern " Level 1 – “Awareness” intervention – more formal discussion with higher up •  note the pattern •  the costs •  the behavior must change – specific outcomes required; Pattern persists " Level 2 – “Guided” intervention by authority •  Review prior interventions/discussions •  Note persistence and unacceptability of behavior •  consequences for not changing – what would be the discipline? No change " Level 3 – “Disciplinary” intervention
  41. 41. Responding? •  Early! •  Assessment is critical •  Focus on situation, issues or behaviors, not the person (See Westhues, 2012) •  Get both sides plus witnesses •  Gather information; test out hypotheses •  Be cognizant of your own biases, perspective and experiences •  Identifying resources •  Sequencing of actions
  42. 42. Developing shared norms: Communication protocol Hoover (2003) •  Provides a set of agreed upon procedures that a department, team or unit creates to promote productive outcomes to conflicts or complaints that arise between and among members of the group •  Promotes informal problem-solving between people; not close doors to usual system resources and policies •  May include guidelines for decision-making, based on the culture and norms of the department or unit
  43. 43. Communication Protocol: Prompts Sebok 2014 •  If you have a concern or complaint that you would like to address with another member of your group, what will you agree to do? •  If you are the receiver of a complaint, what will you agree to do? •  If both parties make a good faith effort to resolve the problem but are unable to do so, what are the options? •  If one party initiates a conversation with a colleague about an issue with a third person in the department, what should the person approached do? What should they not do?
  44. 44. Climate/culture change: VHA • Authorized to act • Accountable Civility, Respect and Engagement in the Workforce
  45. 45. What can facilities do? Focus on developing a healthy, respectful work climate It starts with having conversations; lots of conversations
  46. 46. Knowing how we are here •  Describing climate and culture; data driven; joint effort •  Mission and core values including quality of care and patient safety •  Data driven; data collection •  Surveys; focus groups; case studies •  Relevant unit annual reports •  Policies and practices reviews •  Sharing and discussing information with system members •  What it means to them; making sense of the data •  Multiple opportunities for input and discussion
  47. 47. Knowing how we are here •  Identifying key areas of focus & action teams •  Develop actions, implement, assess •  Regular and accessible updates for campus •  Visible and meaningful action
  48. 48. Characteristics of effective policies Leape et al (2012) •  Fairness of process for responding to breaches •  Include all in process of development •  Consistency – responsive to all complaints •  Graded response – proportional to nature of incident •  Restorative process – goal to change behavior and continue as member of team •  Surveillance mechanisms •  Proactive •  Safe reporting 48
  49. 49. Code of Conduct •  Code of conduct – Develop with administration, mgmt, staff •  Tie to mission and values; Jt. Commission core competencies •  Acceptable and unacceptable behaviors – provide examples •  Tie to risks to quality of care and patient safety •  Address & applies to all - employees & “non”employees •  Professional codes are valuable resources – e.g., AMA •  All team members accountable for modeling and enforcing the code •  Reference policies or procedures re when breach of code •  Clearly delineated reporting channels- Include non-retaliatory clauses •  Review process of information and facts •  If infraction, intervention – coaching, mentoring; •  If ineffective, disciplinary action - When and how Good example of the process: Capitulo 2009
  50. 50. Policy relies on reporting: Challenges •  Higher up or others may trivialize complaints •  Feel ashamed not able to handle situation •  Not want to be labeled a “troublemaker” or not collegial •  Fear of retaliation (work and social forms) •  Unaware of policies or view as ineffective •  Investigation biased if actor is more senior or tenured or better connected •  Covert, indirect, and often passive nature of behaviors hard to describe and to assess.
  51. 51. Educational initiatives 1.  Appropriate professional behaviors 2.  Introducing policies regarding disruptive behaviors •  People’s responsibilities 3.  Building communication and conflict mgmt skills; working in multi-professional teams 4.  Responding to disruptive behaviors; Fostering and affirming exemplary behaviors
  52. 52. Leader role and responsibilities… Adapted from : http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/ RespectfulCampus/index.htm#whatisrespect •  see prevention as your own responsibility •  ensure others know you are open to listening and dealing with situations •  identify behaviors that can be considered disruptive, intimidating, bullying, unprofessional •  communicate that problems/difficulties are manageable •  promote the concept that mistreatment, intimidation, bullying or harassment of any type will not be tolerated
  53. 53. Leader role and responsibilities… Adapted from: http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/ RespectfulCampus/index.htm#whatisrespect •  Do not wait for a complaint. Deal with inappropriate behavior whenever you see it •  encourage co-workers to identify and address inappropriate, unprofessional behavior •  recognize the danger signals. Take the initiative to talk with someone if it looks like they are under stress •  make a habit of positive feedback; affirming exemplary behavior •  deal with retaliation
  54. 54. Leader role and responsibilities… http://www.mtroyal.ca/CampusServices/CampusResources/DiversityHumanRights/ RespectfulCampus/index.htm#whatisrespect •  be supportive •  role model respectful and constructive behaviour •  discuss facility's policies and procedures related to disruptive, unprofessional behavior
  55. 55. References Andersson, L.M., & Pearson, C.M. (1999). Tit for tat? The spiraling effect of incivility in the workplace. Academy of Management Review, 24, 452-471. Baillen, E., Neyens, I., De Witte, H., & Cuyper, N. (2009). A qualitative study on the development of workplace bullying: Towards a three way model. Journal of Community and Applied Social Psychology, 19, 1-16 Bowes-Sperry, L., & O’Leary-Kelly, A. M. (2005). To act or not to act: The dilemma faced by sexual harassment observers. Academy of Management Review, 30, 288– 306. Capitulo, K. L. (2009). Addressing disruptive behavior by implementing a code of professionalism to transform hospital culture. Nurse Leader, 7(2), 38-43. Cox, H. (1991). Verbal abuse nationwide, Part I: Oppressed group behavior. Nursing Management, 22(2), 32-35. Davenport, N., Schwartz, R.D., and Elliott, G.P. (1999). Mobbing: Emotional abuse in the American workplace. Civil Society Pub. 55
  56. 56. References Dutton, J. (2003). Energizing your workplace. University of Michigan. Einarsen, S. & Nielsen, M.B. (2014). Workplace bullying as an antecedent of mental health problems. A five-year prospective and representative study. International Archives of Occupational and Environmental Health, DOI 10.1007/s00420-014-0944-7 Grenny, J. (2009). Crucial conversations; The most potent force for eliminating disruptive behavior. The Health Care Manager, 28(30, 240-245. Hickson, G.B., Pichert, J.W., Webb, L.E. & Gabbe, S.G. (2007). A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine, 82(11), 1040-1048. Hicks, D & Tutu, D.. (2011). Dignity: Its essential role in resolving conflict. Yale University Press. Hodgson, M., Reed, R., Craig, T., Belton, L., Lehman, L., & Warren, N. (2004). Violence in healthcare facilities: Lessons from VHA. Journal of Occupational Environmental Medicine, 46, 1158-1165 56
  57. 57. References Larry Hoover, University of California-Davis, “Developing Departmental Communication Protocols” in the Conflict Management in Higher Education Report, October 2003, Volume 4, Number 1, ( http://www.campus-adr.org/cmher/ReportArticles/Edition4_1/hoover4_1a.html) Johnson, S.L. & Rea, R.E. (2009). Workplace bullying: concerns for nurse leaders. Journal of Nursing Administration, 35, 84-90 Joint Commission, Behaviors that undermine a culture of safety. Sentinel Event Alert, July 09, 2008. Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect. Academic Medicine, 87(7), 853-858. Keashly, L. (1998). Emotional abuse at work: Conceptual and empirical issues. Journal of Emotional Abuse, 1(1), 85-95. Keashly, L & Neuman, J.H. (2009). Building constructive communication climate: The U.S. Department of Veterans Affairs Workplace Stress and Aggression Project. In P. Lutgen-Sandvik & B.D. Sypher (eds). Destructive organizational communication: Processes, consequences and constructive ways of organizing. Routledge/LEA 57
  58. 58. References Keashly, L. & Jagatic, K (2010). North American perspectives on workplace hostility and bullying. Chapter in S. Einarsen, H. Hoel, & D. Zapf. Workplace bullying: Developments in theory, research and practice. London, UK: Taylor Francis Lanza, M. (2006). Violence in nursing. In E.K. Kelloway, J. Barling & J. Furrell (eds). Handbook of Workplace Violence; Thousand Oaks: Sage Publications. Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect. Academic Medicine, 87(7), 853-858. Leiter, M. (2013). Analyzing and theorizing the dynamics of the incivility crisis. Spring Briefs in Psychology. Longo, J., (2010) "Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 5. Longo, J. & Hain D. (2014). Bullying: A hidden threat to patient safety. Nephrology Nursing Journal, 41(2), 193-199. 58
  59. 59. References Mitchell, P., Wynia, )M., Golden, R., McNellis,B., Okun, S., Webb, C.E., Rohrbach,R. & Von Kohorn.I (2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu/tbc. . Osatuke, K., Moore, S.C., Ward, C. Dyrenforth, S.R. & Belton, L. (2009). Civility, respect, engagement in the workforce (CREW): Nationwide organization development intervention at Veterans Health Administration. Journal of Applied Behavior Science, 45, 384-411 Pichert J.W., Moore I.N., Karrass J, et al. (2013). An intervention that promotes accountability: Peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf; 39(10):435–446. Rau-Foster, M (2004). Workplace civility and staff retention. Nephrology Nursing Journal, 31(6), 702. Rayner, C., Hoel, H., & Cooper, G.L. (2002). Bullying at work: What we know, who is to blame and what can we do? London: Taylor & Francis 59
  60. 60. References Rosenberg, D. A., & Silver, H. K. (1984). Medical student abuse: An unnecessary and preventable cause of stress. JAMA, 251(6), 739-742. Rosenstein, A. (2011). The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. American Journal of Medical Quality, http:// ajm.sagepub.com/content/early/2011/04/21/1062860611400592 Rosenstein, A. & O’Daniel, M (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 105, 54-64. Rosenstein A. & O’Daniel, M. (2008) A survey of the impact of behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf ;34(8): 464-71. Salin, D. (2003). Ways of explaining workplace bullying: A review of enabling, motivating and precipitating structures and processes in the work environment. Human Relations, 56(10), 1213-1232. 60
  61. 61. References Sebok, T. (2014). Promoting a respectful working environment. Workshop presented at the Annual International Ombudsman Association Conference, Denver, CO, April. Sofield, L. & Salmond, S.W. (2003). Workplace violence: A focus on verbal abuse and intent to leave organization. Orthopaedic Nursing, 22, 274-283. Excellent web resources: www.workplacebullying.org (Gary and Ruth Namie – rich with resources) www.centerforamericannurses.org/displaycommon.cfm? an=1&subarticlenbr=195 •  10 tips for addressing disruptive behavior: 61

Notas do Editor

  • The context for our conversation about workplace bullying in healthcare settings. The industry is rapidly changing with pressures of high demand, external regulation, and cost management.
  • Health and managing it is increasingly sophisticated and complex. Thus, it requires health professions to work together to provide quality care and protect patient safety. While the people in the team are subject matter experts, they also require additional skills and experience in working collaboratively. They need to appreciate each other’s knowledge and contributions and develop trust in the team’s capabilities.
  • https://www.osha.gov/SLTC/etools/safetyhealth/mod2_culture.html
  • An activity to map out what the constructive and productive work environments look and feel like. This can be a very useful activity for a unit or team to do as well. Having discussion about what makes an env’t productive and constructive can reveal places of shared expectations and places where they diverge.
    An example of such an approach is the CREW initiative (Civility, Respect, and Engagement in the Workforce) by the Veteran’s Health Administration. This approach recognizes that definitions of respectful engagement need to be surfaced and explicitly discussed in any unit or workplace.
  • Thoughts on this situation? How does what happened here map on to what you have identified as a productive and constructive work environment? What are the implications of this interaction if left as is for Chris, Sam, and others in the unit? Alternative ways to handle this situation? Who is responsible for addressing this?
  • The Joint Commission Sentinel Event Alert, July 09, 2008.
    What the key accrediting body has to say about what is considered disruptive behavior.
  • This diagram depicts the handling of challenges and conversations with each other from constructive and lively engagements to uncivil, misconduct (counterproductive, demeaning, destructive) to conduct that breaches laws and to criminal activity.
  • 9/26/13
  • What is problematic here? What is the impact/implications?
  • What distinguishes bullying tactics fromnconflict and similar forms of healthy aggression, such as productive competition and collegial argumentativeness, is that the acts of the aggressor attack the character or identity of an individual, are unwelcome by the recipient, and are repeated over time.
    Heinz Leymann , the first scholar-practitioner to identify these interactions as problematic and traumatic, has argued that it is less the specific nature of the behavior and more its frequency, patterned nature and enduring quality that are responsible for the nature and extent of negative impact.
  • It is important when talking about what bullying is to also distinguish it from other challenging and often difficult interactions. This list comes from Mary Chavez Rudolph and Tom Sebok who were part of a 4-part webinar in 2011 sponsored by the International Ombuds Association.
    Direct communication here refers to the blunt no frills style of delivering feedback and information. This can feel challenging.
    I have heard ALL of them said AND . . .
    Some people may honestly think of these as “bullying” BUT
    Often: I suspect these things are said:
     
    By someone engaging in bullying to minimize the real problem
    Help conflict-avoidant supervisors avoid confronting bullying
    By employees seeking to avoid discussion of performance problems
    So it is important to do a full assessment of the situation using the defining elements as guides for discerning whether bullying or not.
  • “It is the accumulated number of acts over time, and the summarized pattern of behaviors, and not the particular and individual acts involved, that constitutes the menace. As isolated acts of aggression, such incidents may be mildly offensive and even tolerable. However, when accumulated over time, these acts will be highly destabilizing and a distressing situation to those exposed. Following from this notion, bullying does not seem to be an either-or phenomenon, but rather a slowly escalating process with increasingly more harsh treatment of the target.”
    (Einarsen & Nielsen 2014, pg. 2)
    Implications for assessment
    - Theiss – identify where are in the process as that highlights the most immediate needs.
  • So what is the situation in healthcare regarding workplace bullying (disruptive behavior)?
  • Compromises culture of safety and health
  • So knowing workplace bullying exists and it harms, it is important to determine the reasons why it is occurring. Such assessment needs to consider individual, group, intergroup and institutional level influences. Understanding why has implications for the focus and nature of action to address.
  • Reward power refers to ability to control resources or other things that another values; Coercive power is the ability to punish another; Expert power comes from having specialized knowledge and experience that others do not have but they need; Referent power comes from relationships you have with others in the system, more specifically how well liked and respected you are by others. Informational power captures the influence you have when you have information critical to others achieving their goals. BATNA is a term from negotiation. You are in your strongest position to negotiation, i.e., influence others to get what you need when you have a strong and viable alternative (Plan B), should the other not want to negotiate or you are unable to get what you needed from themm.
  • The success of confronting (speaking directly to) the actor depends upon timing and your own sources of power. If this is one early on (i.e., the not-yet-bullied phase), then you have the resources and strength to take them on. The Crucial conversations model is a thoughtful approach for addressing inappropriate behaviors with someone early on. However, if bullying has become established, your power and ability to respond have been undermined, and you would be vulnerable to them utilizing the conversation to continue to undermine and demean you.
    It is vital that you do not retaliate. To the extent that others are not aware of what is going on, your retaliation is often the first time they are aware and you can get labelled as the problem. Also, by retaliating, you can fuel an escalatory spiral that will consume your energy and you in the process. Sometimes, we need to get others to help us.
  • Record date, time and what happened; witnesses and outcome of event. Remember number of behaviors/events, frequency and and patterning can reveal bullying. This is important affirmation for you for your experience and it will be useful information should you decide to take the situation to others.
  • If the people you take it to, do not take action then proceed to next level of management if concerns minimized.
  • Bystander intervention is about recognizing the powerful influence of peers in the workplace. I believe this to be particularly true for faculty. It is faculty colleagues who are present, who have the relationships with each other, who are important in the overall culture and climate and thus, need to be mindful and intentional in taking action to influence more constructive interactions.
    The Literature on coworker influence supports the power of the peer:
    Work stress literature – coworkers (ppers) are incredible sources of support – they can energize, support, buffer and protect.
    Coworker influences regarding hostility
    Witnessing rates – 13-50%
    Targets talk to coworkers about experience (92.1% in 2008 university study) – Peers know what is going on!
    Mobbing – peers joining in
    Creative responding - Code White/Pink (Nurses responding to abusive behaviors by physicians), Gatekeeper e.g., the secretary who lets you know whether the boss is in a “good” mood or “bad” mood today. – examples of how coworkers have banded together to provide buffering to targets or to communicate unacceptability of behavior…often to a higher power actor.
    Immediacy – intervene to de-escalate early on; peers are typically present or aware of what is going on…more on the scene so more able to intervene quickly if needed.
    Credibility – bystanders/witnesses are more likely be perceived as credible than are targets.
    Observers(bystanders) to problematic behavior are faced with a couple of decisions in deciding on action. They are decided how involved they will get (in essence, how publicly they will be in their involvement) and whether they will take action now or after the incident/situation.
  • Here are some examples of different kinds of actions that can be utilized by observers/witnesses/bystanders. There are a range of possible actions that vary in degree of risk to the bystander. The choices will also be influenced by the goals you wish to achieve, i.e., is it important to get the interaction to stop immediately before further harm is done? Then options under high immediate opens up possibilities such as telling the person to stop or if you feel that is too risky, then distracting/redirecting the actor from the situation or removing the target…this stops the immediate interaction and creates time and space to think of other actions to prevent recurrence.
  • Much attention has been paid in the healthcare literature to addressing what they term “disruptive practitioner behavior”. This was facilitated by rigorous and empirical data that such behaviors on the part of healthcare professionals were costly to the quality of patient and the culture of safety. It was these data that resulted in the Joint Commission, which accredits almost all the healthcare systems in the US, requiring that it was important for systems to have policies and procedures in place to address disruptive behavior. Gerry Hickson of Vanderbilt Medical Center has developed and tested a model of graduated intervention that has been very effective in managing physician behavior. Thus, I think it is useful to share this with administrators, faculty and staff as a way of thinking about graduated/coordinated strategy for managing problematic behavior.
  • This is a model for “progressive discipline” or as it is used here re responding to physician disruptive behavior “graduated intervention”. This is framed within the broader notion of feedback for development. This is from the work of Gerry Hickson and his colleagues at the Vanderbilt Medical Center. Two things to note here….the use of staged action, based on where a situation is at the time. So in the case of an initial incident that raises questions re “professionalism” (a term used here that encompasses disruptive, hostile, bullying types of behavior…viewed as unprofessional), if it is particularly egregious (e.g., slapping a nurse), then other actions come into play (assault charges). Or if it is a mandated response situation e.g., sexual harassment, then those policies and procedures are engaged. If it is outside those realms and “ambiguous” re is this something to be worried about, Hickson proposes a colleague engage the actor in an “informal” cup of coffee conversation. The issue is raised, the actor’s experience/explanation sought, highlighting of the cost of the incident to those involved, and request and discussion of different ways of responding and future actions. If behavior continues, i.e., a pattern develops, then a more formal discussion with someone higher up occurs, noting the pattern, its costs, and that behavior must change. If still persists, then more specific guidance is provided with consequences for not changing. And if it does not change, then “discipline” occurs ,e g.. suspension of hospital privileges etc. Hickson has developed a training for colleagues in the “informal cup of coffee conversation” and the data indicate it is useful in managing disruptive and unprofessional behavior.
  • A concise overview of key principles to your responding:
    Ken Westhues (mobbingportal.ca) talks about being open when you entered an assessment phase. Gather a range of information and surface and test out various hypotheses. He suggests that in assessing a situation for workplace bullying, there are three possible hypotheses
    Person is the problem – as presented by others; difficult person…bully!
    Null – there is no problem
    Mobbing hypothesis – others are ganging up and framing the person as a problem to be removed, i.e., the “actor” is actually a “target”
    Part of this assessment is the recognition of one’s own biases. I have seen fairly stereotypical notions of physicians by nurses and other healthcare professionals and of other healthcare professionals by physicians that compromise the ability of the perceiver to assess what is happening, seeking only confirming evidence (i.e., confirmation bias). Also one’s experience does influence how one perceives and thus responds to a situation or in this case an assessment.
    Knowing what resources are available (policies, practices, training, HR, labor, rewards, contingencies) and support for actions is important in choosing how to respond.
    A contingency approach to third party conflict intervention (see Keashly & Nowell, 2010) recognizes that in “advanced” situations like entrenched or established bullying, a variety of actions becomes necessary and they should be sequenced. For example, a first step may be to “separate the parties” to immediately stop the harm or aggression. That will not suffice but it does provide time to consider other options based on a thorough assessment.
  • This is a very specific tool for either addressing conflictual climates that have developed or in an effort to establish constructive climates to reduce the likelihood of destructive confrontation and discussion. This comes from the work of Larry Hoover (2003) at University of California, Davis. Maureen Brodie, ombuds at University of California San Francisco has developed this further with a trainer’s guide for this discussion. This is an explicit discussion among members of a unit of how they want to handle challenging issues.
  • These are the types of questions that are explored and the results of which are utilized to structure the protocol. This specific set of questions comes from Tom Sebok, Director of the Ombudsman Office at U of Colorado – Boulder.
  • The CREW initiative is characterized by several features:
    - Define respectful relationships here – recognition that definitions of behaviors and relationships is heavily dependent on the people around the table and the facility within which they operation. We talk about “commonsense” but in reality that is about shared expectations and norms…we should not assume these, they should be explicitly negotiated and articulated.
    - Facilitate difficult conversations
    - Contextualized - locally crafted
    - Regular meetings/huddles of unit members
    - Comprehensive Toolkit developed and provided.
    - Intensive support - CREW companion NCOD
    - Pre-post intervention data
    Viral spread
    Leiter 2013; Osatuke et al 2009
  • Genuinely engaging organizational members in conversations regarding the nature of the working and learning environment, the roles and needs of different groups in this environment, and ways to build and nurture constructive environments in which challenging discussions can be engaged in with passion and with respect, focused on developing solutions and actions that permit individuals and the organizations to fulfill their purpose in concert is vital.
  • I am a big proponent about knowing who we are as a healthcare facility, unit or office. And that means getting as accurate a picture of the climate and culture. Health care is about being “data-driven”, “evidence-based”, building arguments for our perspectives and conclusions and putting them out for review, critique and enhancement.. We need to apply this same framework and rigor to understanding how we are here. This is an effort that needs to be truly joint as understanding the facility and its climate and culture requires knowing the perspectives, experiences and expectations of its members. And when such information is developed, it needs to be shared and discussed with members. One of the frustrations of organizational members is that they are asked for their input and then never hear where it went and how it influenced what happens in the organization. Having the organizational members help “make sense of the data”, develops that sense of working together and shared understandings and appreciation for the different perspectives that exist in the organization. Those understandings of the data should then drive the choice and development of actions to address what have been identified as issues from the data gathered. Implementation and evaluation of actions needs to feed back into this process. The very act of working together across group lines to identify issues and address them is a real life illustration of a constructive working climate.
    Our work with Veterans Administration on a 5 year project on workplace stress and aggression demonstrated the value of such processes. Keashly & Neuman (2009)
  • An important organizational tool are policies and procedures. They capture the values and goals of the facility and articulate processes and procedures by which we operate together to reflect those values and to achieve those goals. Policies are explicity articulation of expectations.
  • ACGME/Joint Commission six core competencies:
    Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism (peer and coworker relationships) systems-based practice
    Longo, J., (2010) "Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 5.
    American Medical Association: www.ama-assn.org/ama/pub/about-ama/our-people/membergroups-sections/organized-medical-staff-section/helpful-resources/disruptivebehavior.
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    HC Pro: www.strategiesfornursemanagers.com/ce_detail/225618.cfm
    Leape et al (2012). Culture of respect, Part 2: Creating a culture of respect. Academic Medicine, 87(7), 853-858.
  • Why people may not report incidents or situations is a critical discussion when devising policies. This is important to understand for if these concerns are not addressed, then formal reporting mechanisms are rendered ineffective, providing incomplete information regarding the situations in a unit or facility and thus hampering everyone’s abilities to address issues effectively. Understanding these influences has implications for the development and implementation of relevant policies and procedures.
  • 10 tips for addressing disruptive behavior: www.centerforamericannurses.org/displaycommon.cfm?an=1&subarticlenbr=195.
    I have highlighted fostering and affirming exemplary behaviors because it is important we not only articulate what is NOT acceptable here, i.e., what is counterproductive and harmful, but we must also know what it is we want (see the earlier slide on what a productive and constructive work environment looks and feels like). And if we really want those behaviors, then we need to support and affirm those behaviors and the people associated with them when they occur. Thus, people need to be recognized and reinforced when they are engaging in behaviors that make the workplace productive and a great place to be.
  • While I believe we all have responsibility and are critical to the development and maintenance of productive and constructive work environments, leaders have a special set of roles and responsibilities and they and other organizational members need to understand what those are. I like this articulation, which comes from Mount Royal University in Calgary, AB, Canada.
  • As can be seen, deans and chairs are expected to manage the work env’t and thus, the interactions that occur.

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