Running head: FROM THE PLAYGROUND TO THE HOSPITAL

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From the Playground to the Hospital H. Bryce McFarland St. Luke‟s College

FROM THE PLAYGROUND TO THE HOSPITAL From the Playground to the Hospital

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It may have been almost 24 years ago now, but I remember it like it was yesterday. I was 6 years old and was in Mrs. Phillips first grade class at Stilwell Elementary School. There was a boy in my class named Damon who was the perfect definition of the word “bully”. He had terrorized many of my classmates in kindergarten, and while I had rarely been a target of his bullying antics, I was sick and tired of watching him rule the playground. I knew that there was nothing I could do to him physically. I stood no chance against him in a fight. I was the smallest kid in my class while he was the largest. Still to this day, I am convinced he had a five o‟clock shadow in the first grade. But, I knew I had to do something. So, I showed up on the first day of first grade armed with what I thought to be the ultimate “bully weapon”, and I was prepared to use it. Morning recess arrived, and we actually made it through without any altercations. I thought maybe Damon had changed over the summer, possibly an “Extreme Makeover; Damon Edition”. However, when the afternoon recess arrived, Damon quickly reverted to his old bullying ways. So, I quickly rehearsed in my mind what I was to do and began marching toward him. You see, that summer, between kindergarten and first grade, I had gone to Vacation Bible School at a local church and had learned that God was bigger than anyone or anything. We memorized a verse from Romans 8:31, “If God be for us, who can be against us.” We even learned a catchy little song to go with it. And it was with this song, and my new found knowledge of God, that I was going to confront Damon. He didn‟t stand a chance, or so I thought.

FROM THE PLAYGROUND TO THE HOSPITAL I marched right up to Damon and side-stepped between him and his current victim. I

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poked him in his belly and could have sworn that I felt a six-pack under that black thundercats tshirt. But, I was not going to be deterred. I looked straight up at him and demanded that he, “Stop, or else.” The “or else,” part wasn‟t planned. I just sort of got caught up in the moment. As soon as it came out, I wished I could have it back. But, there was no going back. Damon looked down at me and in his deep Barry-White-kinda-voice said, “What are you gonna do about it?” Then, without saying a word, I braced myself, stuck out my chest, put my fists on my hips, and began singing with everything that was in me. Of course, that consisted of nothing more than my squeaky little prepubescent first grader voice, but I was going to let him have it. “If God be for us, who can be against us? If God is on our side, why should we run and hide? If our maker is our defender there is no need for surrender. If God be for us, tell me, who can be against us?” After the first verse I was feeling pretty good about myself. Damon hadn‟t leveled me yet, he was just staring at me. I was thinking to myself, “Maybe this is actually gonna work.” As I wrapped up the first verse, I paused in order to take a deep breath in preparation for the second verse. However, I never got the second verse out that day, because just as I was about to let it fly, Damon let me fly. He pushed me down into a mud puddle, which only made him more angry because I splashed mud on his new tennis shoes. Luckily the teacher intervened before the situation digressed into a personal Armageddon for myself. However, while the teacher was there to throw me a proverbial life vest on that occasion, she couldn‟t be there for me 24/7, and Damon knew this. Let‟s just say that first grade was not my favorite year of elementary school. I wish I could tell you that I never had another encounter with a bully ever again after that day. I wish I could tell you that bullies only survived on the playgrounds of elementary schools. But, that just isn‟t the case. My twenty-some-odd-years of life experience since first grade have

FROM THE PLAYGROUND TO THE HOSPITAL given me reason to believe that there will always be bullies. I could tell you stories of bullies

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from summer camps, sports teams, junior high, high school, and even from later on in life I could tell you stories of bullies from the work force. I guess, when I was younger, I always assumed that bullies would someday grow up and see the immature nature of their ways and leave the bullying antics behind. But, now that I have grown up, I see that just isn‟t the case. Apparently, it was quite naïve of me to believe that I could stand up to Damon in first grade and make a difference. It was naïve of me to think that bullies would someday have a “come-to-Jesusparty”, if you will, and leave their bullying ways behind. Now, in more recent years, I found myself being naïve about the whole bullying topic once again. Approximately two years ago I decided to return to college in search of another degree. This time I wanted to attain a degree in nursing. I can honestly say that I never consciously considered whether or not I would find bullies in the field of nursing. While I may have seen many bullies throughout my life, I have never been a big target, and so it has had little to no impact on my decision making. However, I will say that I didn‟t anticipate that I would see bullying in a field such as nursing. It just seems to me that a bully would be completely incompatible with a career in nursing. It strikes me as a bit of an oxymoron to think of a nurse and a bully being one in the same. After all, isn‟t nursing all about caring for the wellbeing of others, while bullying is all about having a complete disregard for the wellbeing of others. Nursing is all about other people, while bullying is all about yourself. Surely these two opposing forces could never coexist. How naïve of me. I wasn‟t sure what the intended meaning was the first time I heard the statement, “Nurses eat their own young.” However, I have since come to realize that this is the popular way of stating that bullying is alive and well in the field of nursing. I recently came across an article by Ward-Smith (2011) that makes the claim that 27.3% of nurses have experienced workplace

FROM THE PLAYGROUND TO THE HOSPITAL bullying. The same article claims that about 60% of new graduates leave their first nursing job within 6 months due to their experiences with nurse bullying. Many have even left the field of nursing altogether in response to the bullying. Other articles claim that as many as 9 out of 10 nurses report experiencing some sort of bullying at work (Guidroz, Burnfield-Geimer, Clark, Schwetschenau, & Jex, 2010). In light of the worldwide nursing shortage and an aging workforce, we should see this as a big deal. There are numerous studies pointing to the correlation between nurse bullying and a decrease in personal job satisfaction leading to professional disengagement and increased turnover. If we are going to meet the ever-increasing demand for nurses, it is crucial that we retain experienced team members as we raise up a new workforce of healthy well-trained and prepared individuals. Addressing the issue of bullying is not only important in order for us to be able to put together a nursing workforce large enough to handle increasing patient care needs, but it is

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important for many other reasons as well. Not only does bullying lead to a decreased number of nurses available to provide care for patients by causing them to leave the field, but it also leads to a decrease in the level of care provided by those who choose to remain in the field of nursing. According to Vessey, DeMarco, and DiFazio, (2011) bullying wreaks havoc on key components of teamwork, which is critical for proper and successful patient care. It stands in the way of communication, which is essential for the exchange of important health information and collaborative decision making. There has also been a positive correlation established between nurse bullying and patient falls, delayed medication administration, and medication errors, which all lead to an increase in negative outcomes for patients. In fact, in 2008, the Joint Commission issued a sentinel event alert concerning the impact of nurse bullying on patient safety. The alert identified the relationship between intimidating and disruptive behaviors and medical errors,

FROM THE PLAYGROUND TO THE HOSPITAL patient satisfaction, preventable adverse outcomes, the cost of care, and turnover, and now requires organizations to address the issue of bullying (Joint Commission, 2008).

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In a field where our primary goal is positive outcomes for patients, the simple correlation between bullying and negative patient outcomes ought to be enough for us, as nurses, to change our tune. However, just so that you don‟t think that you are somehow excluded from the farreaching effects of nurse bullying let me take this a step further and demonstrate how nurse bullying affects everyone, even those outside of the healthcare field, as it leads to increased healthcare costs. Not only do the poorer patient outcomes, discussed previously, lead to increased healthcare costs due to complications, but insurance companies are cracking down on what they will and will not pay for. Most insurance companies are unwilling to pay for a hospital acquired complication that was preventable, which means that hospitals pay for the care of these complications out of pocket. Plus, there are studies being done now showing the financial impact of decreased productivity by nursing staff related to bullying. One study conducted by Strasser, Hutton, and Gates (2008) estimated that the average annual financial cost from decreased productivity related to bullying for a nursing assistant is $1,235.14 and $1484.03 for an RN. This meant a total production loss related to bullying of $264,847.34 for the hospital setting in which the survey was conducted. It is estimated that some $400 million a year are lost in healthcare dollars related to nurse bullying across the United States. This is an astronomical cost associated with a group of behaviors that should have been left on a childhood playground years ago. All this information begs the question; What can be done? What can we do to change the culture of nursing that has created this milieu predisposed to bullying? Well, if we are going to

FROM THE PLAYGROUND TO THE HOSPITAL address the issue of nurse bullying, we must first agree on what it is we are trying to change. Many authors refer to bullying by different names, using such descriptors as incivility or

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horizontal violence, but no matter what you term it, bullying is an act of aggression, perceived or real, perpetrated by one nurse toward another. This includes, but is not limited to non-verbal innuendos, verbal insults, gossiping, sabotage, scapegoating, backstabbing, failure to respect privacy, broken confidences, and attempting to take the credit for someone else‟s accomplishments. All of these are detrimental to the caring environment that nursing demands. The services provided by nurses are far too important to allow this continued erosion of the field to persist. Something must be done. However, one of the biggest obstacles that we face in changing the culture of nursing is the reality of the blind eye. Managers and administrators have been turning a blind eye to the subject for years. Nursing literature is saturated with articles focusing on the reality and severity of bullying in the various fields of healthcare. However, while many are talking about it‟s existence, true evidence based research is scant, and suggested solutions to bullying are even more rare. The simple truth of the matter is that it is much easier to put a Band-Aid on it (pun intended )and pretend that everything is okay, than it is to actually deal with the issue directly. Many organizational leaders are in denial that the problem even exists. Maybe we need to begin by taking a page out of the playbook of our once alcoholic friends and start off by admitting that we have a problem. Once we acknowledge that we have a problem, we can get down to the dirty work of addressing it. The few organizations that are attempting to take on the issue of bullying are doing so in a variety of ways. Some have issued what they are referring to as “No Jerk” rules, a variance of zero-tolerance. Now, if such a rule is going to be instituted, it is very important to clearly define

FROM THE PLAYGROUND TO THE HOSPITAL

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the types of behavior that are to be considered worthy of the term “jerk”. In an article by Kerfoot (2009), the term “jerk” is defined as, “Those who are rude, temperamental, abusive, spread gossip, create factions, distort communications to their ends, and sabotage work processes, colleagues, and managers” (pg. 149). These are the type of individuals, that under a “No Jerk” policy, would not even be hired as a part of an organization. If they were hired and later discovered to be “jerks”, their behaviors would be addressed and appropriate actions would be taken to correct those behaviors. If they were unwilling to change their ways, they would instead be changing their jobs. Kerfoot (2009) offers a few examples of various companies who have instituted similar “No Jerk” rules. She points out that Southwest Airlines not only supports a jerk-free staff but is also very aggressive in not letting a passenger who is a jerk abuse their employees. The Men‟s Warehouse states that they will respond immediately, regardless of position, to any employee who is found to be degrading another. While these examples may be from outside of the field of healthcare, we would be foolish not to consider the best practices available. According to Fudge (2006), some healthcare organizations have even gone so far as instituting a new code. Hospitals are replete with different code colors, but some have now instituted a “Code Pink” which is to be called any time a healthcare professional is being bullied by another. When a “Code Pink” is called, any and all colleagues who can be released from patient care, rush to the room and stand, silently, starring at the bully. This is a culture and a mentality that must trickle from the top down through an organization. Once the philosophy and behavioral expectations have been clearly established, the next step is to hire against that philosophy and to internally implement any changes necessary to begin the transformation into a new bully-free culture.

FROM THE PLAYGROUND TO THE HOSPITAL Vessey et al. (2011) point out the importance of attacking bullying during every stage of the bullying process. It is crucial for an organization to consider not only primary prevention, but also secondary and tertiary prevention. Primary prevention deals with the idea of stopping bullying before it even starts. The best way to do this, as we already stated, is to avoid hiring those who will be bullies. However, that isn‟t always possible, and so there must be other attempts to stop bullying before it starts. One approach suggested by Longo and Sherman is to provide an opportunity for staff members to tell their stories about their first year in practice. It is widely accepted that a majority of bullying is directed at new nurses. Longo and Sherman (2007) believe that as stories are shared, they will stand as powerful reminders of the need to nurture our young rather than eat them. Secondary prevention focuses on early detection of bullying behaviors (Vessey et al.,2011). Research is certainly still in the early stages concerning how to detect and track the existence of bullying. However, one particular study presented in the Journal of Nursing has

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been drawing a lot of attention. The study was conducted in an effort to create a means by which to measure the prevalence of bullying amongst a group of nurses. The study produced what is known as the Nursing Incivility Scale (NIS). The NIS is a survey that can be administered via paper and pencil (Appendix), or through an electronic format. It consists of a series of 45 statements to which the respondents are asked to rate their level of agreement, ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). Once scored, the scale will provide management with a better understanding of the severity of nurse bullying within their different units (Guidroz, Burnfield-Geimer, Clark, Schwetschenau, & Jex, 2010). This does little to prevent bullying, but it aids in early detection of bullying and brings the topic to the forefront displaying to the staff the importance placed on civil behavior by administration.

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The third level of prevention is tertiary prevention. Tertiary prevention is required when bullying has been ignored or gone unnoticed and full-blown problems have erupted. Tertiary prevention consists of reprimand, counseling, disciplinary action, terminations, and in the worst case scenario, unit reorganizations. Ideally tertiary prevention would be avoided. However, when the need for tertiary prevention arises, it is important that it be carried out promptly and judiciously in order to make it clear that such behaviors will not be tolerated (Vessey et al., 2011). The gist of the issue is that an issue exists. Nurse bullying is proving to be far more costly than anyone would have ever anticipated, both in a financial sense and in terms of patient care. Nurse bullying is undermining our efforts as healthcare professionals. However, while it is out of control, it is not too late to begin implementing changes to create a more caring culture providing more favorable patient outcomes, and even lower healthcare costs. If we will begin working together and implementing the strategies that research has suggested we can, ultimately, leave bullying on the playground, where it belongs.

FROM THE PLAYGROUND TO THE HOSPITAL References Fudge, L. (2006). Why, when we are deemed to be carers, are we so mean to our colleagues? Canadian Operating Room Nursing Journal, 44(12), 13-16.

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Guidroz, A. M., Burnfield-Geimer,J. L., Clark, O., Schwetschenau, H. M., & Jex, S. M. (2010). The Nursing Incivility Scale: Development and validation of an occupation-specific measure. Journal of Nursing, 18(11), 176-200. Joint Commission. (2008, July 09). Behaviors that undermine a culture of safety. Retrieved from: www.jointcommission.org/SentinelEvents/Sentinel EventsAlert/sea_40.htm Kerfoot, K. M. (2009). Leadership civility and the „No Jerks‟ rule. Urologic Nursing, 28(2), 149-150. Longo, J., & Sherman, R. O. (2007). Leveling horizontal violence. Nursing Management, 52(3), 34-51. Strasser, P. B., Hutton, S., & Gates, D. (2008). Workplace incivility and productivity losses among direct care staff. American Association of Occupational Health Nurses, 56(4), 168-175. Vessey, J. A., DeMarco, R., & DiFazio, R. (2011). Annual review of nursing research: violence in the nursing workforce. New York, NY: Springer Publishing Company. Ward-Smith, P. (2011). Let‟s leave bullying on the playground. Urologic Nursing, 31(5), 257-263.

Appendix Nursing Incivility Scale Participant Instructions: Please tell us about the type of interactions you have with the people you meet at work. The following statements describe behaviors that sometimes occur in the workplace. Please indicate your level of agreement with each of the following statements using one number that best represents your present work situation. 1 = Strongly Disagree 2 = Disagree 3 = Neither Agree nor Disagree 4 = Agree 5 = Strongly Agree For the following items, please consider all individuals you interact with at work, including doctors and other nurses or hospital personnel. 1 2 3 4 5 6 7 8 9 Hospital employees raise their voices when they get frustrated. People blame others for their mistakes or offenses. Personal disagreements turn into personal verbal attacks on other employees. People make jokes about minority groups. People make jokes about religious groups. Employees make inappropriate remarks about one‟s race or gender. Some people take things without asking. Employees don‟t stick to an appropriate noise level (e.g., talking too loudly). Employees display offensive body language (e.g., crossed arms, body posture). For the following, describe your interactions with other nurses. Other nurses on my unit… 1 2 3 4 5 6 7 8 9 10 …argue with each other frequently. …have violent outbursts or heated arguments in the workplace. …scream at other employees. …gossip about one another. …gossip about their supervisor at work. …bad-mouth others in the workplace. …spread bad rumors around here. …make little contribution to a project but expect to receive credit for working on it. …claim credit for my work. …take credit for work they did not do.

Please think about interactions with your direct supervisor (i.e., the person you report to most frequently) and indicate how strongly you agree with the following statements. My direct supervisor… 1 2 3 4 5 6 7 …is verbally abusive. …yells at me about matters that are not important. …shouts or yells at me for making mistakes. …takes his/ her feelings out on me (e.g., stress, anger, “blowing off steam”). …does not respond to my concerns in a timely manner. …is condescending to me. …factors gossip and personal information into personnel decisions.

This section refers to physicians you work with. Please indicate your level of agreement with the following items. 1 2 3 4 5 6 7 Some physicians are verbally abusive. Physicians yell at nurses about matters that are not important. Physicians shout or yell at me for making mistakes. Physicians take their feelings out on me (e.g., stress, anger, “blowing off steam”). Physicians do not respond to my concerns in a timely manner. I am treated as though my time is not important. Physicians are condescending to me.

Please reflect upon your interactions with the patients you care for and their family and visitors and indicate the extent to which you agree with the following statements. Patients/visitors… 1 2 3 4 5 6 7 8 9 10 …do not trust the information I give them and ask to speak to someone of higher authority. …are condescending to me. …make comments that question the competence of nurses. …criticize my job performance. …make personal verbal attacks against me. …pose unreasonable demands. …have taken out their frustration on nurses. …make insulting comments to nurses. …treat nurses as if they were inferior or stupid. …show that they are irritated or impatient.

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