Original Article Featured in OR Today Magazine, November 2016 Edition
Do you believe that workplace bullying and incivility are the same?
No. Workplace incivility can best be defined as low-intensity unpleasant behavior that is rude, impolite, or inconsiderate. While the target can feel insulted or angry; an actual desire or intent to harm the other person is ambiguous. Anyone has the potential to behave inappropriately towards a coworker given the right circumstances coupled with a lack of self-management.
Workplace bullying however, is ongoing, offensive, abusive, intimidating or insulting behavior or actions directed at a person(s), causing the target to feel threatened, abused, humiliated or vulnerable. The person experiencing prolonged bullying can feel a range of psychological and physiological symptoms. The research supports that, those who bully, are very aware of their behavior and its effect on the others; even though they may deny that there is intent. Fortunately, there is only a very small percentage of the workforce that is capable of such sustained disregard for another individual.
So these behaviors are very different. Should the management be different as well?
Yes, they should and I want to be clear as to why. The two keys here are insight and sustainability. The person who behaves in an uncivil manner has the ability to self-reflect on that indiscretion, feel remorse or regret and make the active choice to work on their self-management skills and achieve personal growth. A bully does not have this ability.
It is vital that we understand and accept that a nurse bully is a narcissist with a license. A narcissist lacks the capacity for empathy. The ability to reflect empathically on the consequence that one’s poor behavior has on another is vital for driving the desire to change. Bullies (narcissists) are incapable of this.
An uncivil staff member can gain insight though coaching and training. Positive, sustained changes in behavior can be noted within six to twelve weeks of working a clear emotional intelligence improvement action plan. A narcissist typically reacts in one of two ways to someone attempting to hold them accountable. They may escalate their behavior and retaliate or they will tell you what you want to hear and vow to reform. However, they cannot sustain any improvement because they lack a connection with the need to improve.
So why is managing bullying behavior in nursing so challenging?
This is a complex issue but one reason is that nurses are professional caregivers. Nursing leaders have a good deal of difficulty coming to terms with the fact that a bully/narcissist cannot be fixed. It is not a part of our caregiver DNA to “give-up” on someone. We talk ourselves into believing that if we just try a little harder that this individual will have an epiphany and the problem will be resolved.
The bully/narcissist is hoping that you will react exactly in this manner. They are experts at taking your wonderful qualities of empathy, patience and the need to heal and use them against you to achieve their goal of never being held accountable to sustained improvement. Essentially, we need to get out of our own way in order to take charge of this situation. Nurse leaders must try to accept that once someone shows you their true colors, you need to resist repainting them.
The only performance improvement plan for a bully/narcissist is a collaborative effort put forth by administration, human resources and the nurse leader that is time sensitive and rich with mandatory training. The documentation should discuss the need for improvement to be demonstrated within three to six months then sustained for six months as well.
Most bully/narcissists will not be able to withstand this type of scrutiny and may decide to move on. The others may stay but will find it very challenging to sustain the improvement. Should termination be the only option left, you can have the peace of mind that a sincere effort was made on your part; and twelve months’ worth of documentation to support your action.
Originally published in the AORN Periop Insider Weekly Newsletter July 28, 2016. Authored by Carina Stanton
The term “bully” is often used incorrectly to classify both bullies and those expressing incivility. Understanding the distinction between the two can help to put structure around communication and action in attempts to weed out bad behavior in perioperative nursing care, according to nursing Career Coach Phyllis Quinlan, PhD, RN-BC.
“The 10% of nurses who are true bullies have a personality defect,” Quinlan says. “Knowing the distinction is key to protecting your staff and deciding whether to develop a plan of remediation or to get rid of a toxic staff member.”
Understanding Incivility vs. Bullying
Quinlan describes bullying as a threatening behavior based in intimidation that stems from the bully’s issue with personal power. “For a bully, their personal power is far more important than the other person’s needs—if the other person needs to feel supported, a bully says ‘tough.’”
A person who indulges in bullying is very egocentric and has far more limited opportunity for personal growth, introspection and a commitment to change.
In the practice setting, a bully will intimate to someone that “you are on your own, if you don’t do what I want I have the power to isolate you,” Quinlan explains. She says bullying is not distinct to one professional level because this bad behavior knows no direction. It can be top down (leadership to staff), down up (staff to leadership) or lateral (peer to peer).
Although incivility is also bad behavior, it stems more from not being fully respectful of the other person’s perspective. Incivility is commonly seen by Quinlan during patient hand-offs or when a patient is transferred to a different area of care, such as from the OR to PACU. “As the nurse is explaining the patient’s state and previous care, an uncivil reaction by the nurse listening is to act as though they are being inconvenienced or worse to provide negative judgment about the previous care, making the nurse handing off the patient feel as though they must justify themselves and their actions.
With 80% of communication being non-verbal, much uncivil behavior is expressed with a less-than-polite facial expression or a toe-tapping type of stance indicating the nurse talking should speed it up and finish what they are saying.
Seeing Bad Behavior as Neurotic Need
One common thread between incivility and bullying is denial of wrongdoing. “If you ask an uncivil or bullying nurse to assess their behavior, they will report they were unaware of wrong doing and may say the nurse who reported their behavior was ‘too sensitive’ or ‘took it the wrong way.’”
Yet research indicates that both uncivil and bullying nurses essentially know exactly what they are doing because it fills a neurotic need.
Quinlan recalls the words of Abraham Lincoln, in which he suggested you can see the character of a person when you give them power. “Someone with good character will take a role in power and be collegial, find common ground and be generous enough to give praise for a job well done. On the flip side, someone with problematic character will use a power role to offer criticism and make remarks that are self-serving.”
Catching It Early
For new employees, Quinlan recommends a set time frame for a probationary period in which the hire is observed for both clinical and behavioral performance. Quinlan says nurses who are good clinically but lacking in collegial behavior are often kept on staff to work on the behavior piece, what she hears nurses refer to as the “soft stuff.”
“Nonsense, behavior is the tough stuff and should be viewed as equally important to clinical skills,” Quinlan stresses. She advises a strong collaboration between nursing, hospital administration and human resources to establish strict behavioral boundaries that are reviewed wisely through the probationary period to measure knowledge, skills and behavioral benchmarks that are demonstrative of culture.
“Make sure everyone is on same sheet of music with clear descriptives of bullying and incivility weaved into your code of conduct and stand behind a zero-tolerance approach to toxic behavior,” she suggests. “If a true bully is identified, cut your losses quickly, otherwise you will lose good staff members.”
Register now to attend “Bringing Shadow Behavior into the Light of Day: Understanding and Addressing Incivility and Bullying Behavior,” AORN’s Nurse Executive Leadership Seminar with Phyllis Quinlan, and get the skills to build your own zero-tolerance policies and practices against bullying and incivility.
The topic of bullying has gotten a lot of attention in recent years as the negative effects of the bullying suffered by children have become more apparent. Children are being encouraged to report bullies and stand up for friends who are bullied. Unfortunately, children aren’t the only ones who are suffering at the hands of bullies. Bullying has long been an under-the-radar problem in the OR, but it is starting to attract more attention in the health care industry.
It’s going to take courageous souls willing to speak up and courageous hospital leadership that’s willing to implement regulations with teeth and enforce them in order for bullying in the OR to stop.”
– Phyllis Quinlan, PhD, RN-BC
How Prevalent is OR Bullying?
This is due in part to The Joint Commission identifying “intimidating and disruptive behavior” in a Sentinel Event Alert as fostering medical errors and contributing to poor patient satisfaction and preventable adverse outcomes (Issue 40, July 9, 2008). Also, studies are revealing just how prevalent bullying really is in the OR.
For example, in a study conducted by the Association of periOperative Registered Nurses (AORN) in 2013, 59 percent of perioperative nurses and surgical technicians reported witnessing coworker bullying on a weekly basis, while 34 percent reported witnessing at least two bullying acts per week.
Bullying was also consistently listed by respondents to the 2015 OR Today Readership Survey as a problem in the OR. For example, Carol Giese, MSN, RN, CSSM, CNOR, the manager of surgery and anesthesia at CHRISTUS St. Michael Health System in Texarkana, Texas, noted that lateral violence is among the top five most pertinent issues for OR nurses and surgical techs.
“I have observed this lateral violence in the OR throughout my entire 30-year career in perioperative nursing,” says Giese.
A study conducted by the Robert Wood Johnson Foundation revealed that nurses are more likely to be bullied if they’re young, working on the day shift or working in an understaffed unit. It identified a number of ill effects of bullying in the OR, including poor work group cohesion, more work-family conflict, and poor relations between nurses and surgeons.
Defining OR Bullying
So what exactly constitutes “bullying” in the OR? In the Sentinel Event Alert, The Joint Commission states that “intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.”
These behaviors “are often manifested by health care professionals in positions of power,” the Alert continues. “Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.”
Why does bullying occur in the OR? Obviously, the OR is a high-stress environment, and some surgeons just aren’t good at controlling this stress. Workplace bullies tend to want to be in control of all aspects of the work environment, and this certainly holds true for bullying surgeons in the OR.
Phyllis Quinlan, PhD, RN-BC, the president of MFW Consultants, says that the problem of bullying in the OR goes back many years.
“For a long time the attitude at hospitals was to keep the surgeons happy no matter what because hospitals couldn’t afford to lose them,” she says. “It was the Golden Rule: He who has the gold makes the rules.”
Quinlan says The Joint Commission’s Sentinel Event Alert about bullying was a turning point in the issue of bullying getting the attention it deserves.
“In fact, this led to the ‘stop the line’ practice in the OR in which anyone in the OR has the right to speak up and stop the procedure if they don’t think something is right,” she says. “Before this, heaven forbid if anyone questioned a surgeon.”
ChrysMarie Suby, the president and CEO of the Labor Management Institute, says that bullying in the medical profession, and in the OR specifically, is not uncommon.
“In my work, I see it coming from three sources in the OR and other perioperative units: patterns of condescension, secondary bullies who have learned how to survive in the organization, and institutional bullies,” says Suby. “The latter are managers, charge nurses, supervisors, service line directors, and C-suite and administrator-level leaders who bully those below them.”
“I have seen different variations on bullying in the OR every since I first became a perioperative nurse in 1991,” says Diana Lopez-Zang, RN, CNOR, the director of system perioperative education at Northwell Health. “A big reason for bullying is the hierarchical environment in the OR.”
Lopez-Zang says she has actually seen surgeons throw instruments in the OR, and one time an OR nurse was hit in the ankle with a dirty instrument.
“Mostly, though, bullying consists of verbal abuse by surgeons, including cursing,” she says.
“Bullying in the OR is still a problem today that I think it’s going to take some time to resolve due to the long history,” Lopez-Zang adds. “Unfortunately, I don’t think it’s getting much better yet — anecdotally, I’d say it’s about the same as it’s always been.”
Solving the Problem
According to Suby, awareness of the problem is a good first step toward minimizing and eventually eliminating bulling in the OR.
“However, nothing will change and the problem will only get worse if nothing is done to intervene,” she says.
The Labor Management Institute offers hospitals a Schedule Best Practice Audit© that can identify scheduling and staffing behaviors that demonstrate workplace bullying.
“We see frequent examples of OR staff who are being bullied via unfair scheduling practices,” says Suby. “It is usually new nurses and those with less seniority who are bullied in this way.”
Once your hospital has conducted a scheduling audit, address the findings of the audit and involve human resources and professional committees to be sure that discipline policies are being used and codes of conduct enforced.
“We often find that organizations have these in place but victims are being intimidated from using them,” says Suby.
“With the audit’s findings in hand, hospitals can provide education and training to help fix scheduling and staffing conflicts at their roots,” she adds.
Quinlan says that solutions to OR bullying can be narrowed down to two main things: peer pressure from others in the OR to stop bullying behavior, and HR regulations, policies and procedures that create a zero-tolerance environment for intimidating, disruptive and uncivil behavior.
“Education and remediation are also needed to put a stop to these behaviors that can put both OR personnel and patients at risk,” adds Quinlan.
In fact, she says that families of patients are starting to report conflicts between surgeons and perioperative nurses due to concerns that these conflicts are putting their loved ones at risk.
Taking a Stand
The good news on the OR bullying front is that younger perioperative nurses who are entering the field today are less likely to tolerate bullying than many nurses may have been in the past, according to Quinlan.
“Many Generation X and Millennial perioperative nurses have taken a stance on what’s right and wrong,” she says. “They often tend to be a little more idealistic and they want to stand up and make a difference for the profession.”
“It’s going to take courageous souls willing to speak up and courageous hospital leadership that’s willing to implement regulations with teeth and enforce them in order for bullying in the OR to stop,” says Quinlan. “Nothing’s going to really change until these things happen.”
Originally featured in OR Today, May Issue http://ortoday.com/
I find it frustrating to acknowledge that despite all the work of recent years to implement initiatives aimed at creating healthy and safe workplace environments, that lateral and horizontal hostility still remains within the nursing profession. I think we all hoped that when the idea of Zero Tolerance bloomed into an actual Human Resource policy the darkest days were behind us. Disappointingly, this is not what I hear from my private coaching clients and other professional caregivers across the country. The elephant remains in the room and the reluctance to talk openly about it continues as well.
I do not feel the need to define bullying behavior or outline the toll such shadow behavior takes on individuals. You are all too familiar with it most likely because you have been on the receiving end of it. What I want to shed some light on is the nature and makeup of someone who engages in bullying tactics. Having insight into the mindset of the enemy goes a long way to taking the power away from them and empowering yourself.
First I want to point out that we often use the term Bully to describe a coworker or leader that exhibits uncivil conduct but is not a true bully. Unfortunately, we live in a time where uncivil behavior is celebrated. Just consider some of the popular reality TV programs currently enjoying high ratings let alone the antics demonstrated along the campaign trail of 2016. Engaging in uncivil behavior is the consequence of a low emotional intelligence and an unrefined ability to manage one’s emotions under stress in the workplace. Keep in mind that we are all capable of giving into the needier side of our neurotic selves under pressure.
People who are, at times, uncivil usually have the ability to step outside themselves and reflect on a disagreeable interpersonal exchange and take ownership of their behavior when they cool off or are held responsible and accountable by others. They are also capable of expressing genuine remorse and of taking steps to improve in the future. Bullies do not have that capacity.
Consider the following characteristics of an individual with the neurotic personality disorder known as narcissism. They include but are not limited to:
- Having a strong need for control
- A desire to dominate people and situations
- Perceiving themselves as a special, elite individuals that are deserving of VIP treatment
- Lacking in empathy toward others
- Having a tendency to be exploitative of others
Now think of someone you work with that is knowingly intimidating and/or cruel; someone who has no desire to consider how their words or behaviors affect others. That’s right! Bullies are narcissists. Investing time and efforts into trying to appeal to their higher nature and grow from coaching sessions or disciplinary actions will prove very frustrating. An individual must first be capable of acknowledging that there is an issue before they can buy into their responsibility to remedy the issue. Narcissists lack the ability to grow from insight and introspection.
Addressing both uncivil and bullying behavior requires a true collaboration between administration, the human resources department and in organizations with collective bargaining agreements, labor. All stakeholders must agree on a unified definition of bullying behavior and a unified approach to bullying conduct. The finish line for tolerating this type of misconduct must be fixed and unaffected by the manipulating skills of the bully.
Managing someone who is given to uncivil behavior is very different than addressing someone with a true bullying mentality. The person given to regular demonstrations of low emotional intelligence must understand that we are now in a time in the industry of healthcare and the profession of nursing when skills and knowledge are not enough to secure your professional future.
The literature demonstrates that the level of one’s emotional intelligence directly correlates with that person’s ability to demonstrate a consistent caring behavior to patients and families as well as own their responsibility to maintain a healthy work environment (McQueen 2004). If these individuals are not willing to grow from in-the-moment feedback, coaching and in-depth discussions during the performance evaluation process then; the conversation must move onto asking if they are in the right working environment.
Unfortunately, the personality of a narcissist does not make them amenable to demonstrating sustained improvement with conventional managerial interventions. In these instances, clear performance improvement plans must be crafted and immediate and sustained improvement demonstrated. The push-back will be relentless but there are very few options.
So my question becomes, if we are not willing to put an end to abusive conduct in the workplace now, when will we be willing? Let us resist getting caught up in finger pointing and complaining about how our inter-professional colleagues may mistreat us. Let us decisively address the issues in our own house first. We must commit now, not later, to peace in our time.
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- Benson G, Martin L, Ploeg J et al (2012) Longitudinal study of emotional intelligence, leadership, and caring in undergraduate nursing students. Journal of Nursing Education. 51, 2, 95-101
- Codier E, Codier D (2015) A model for emotional intelligence and patient safety. Asia Pacific Journal of Oncology Nursing. In Press
- Codier E, Kooker B, Shoultz J (2008) Measuring the emotional intelligence of clinical staff nurses: an approach for improving the clinical care environment. Nursing Administration Quarterly. 32, 1, 8-14.
- Holbery N (2015) Emotional intelligence: essential for trauma nursing. International Emergency Nursing. 23, 1, 13-16.
- McQueen A.C.H. (2004) Emotional intelligence in nursing work: Journal of Advanced Nursing 47(1), 101–108
Emotional maturity refers to your ability to understand, and manage, your emotions. Emotional maturity enables you to create the life you desire. A life filled with happiness and fulfilment. You define success in your own terms, not society’s, and you strive to achieve it. Your emotional maturity is observed through your thoughts and behaviours. When you are faced with a difficult situation, your level of emotional maturity is one of the biggest factors in determining your ability to cope.
12 Signs of emotional maturity
Each person has a different level of emotional maturity. It is something which you can consistently work on and improve over time. You can use the following signs of emotional maturity to gauge your own level:
You are able to see each situation as unique and you can adapt your style accordingly.
You take responsibility for your own life. You understand that your current circumstances are a result of the decisions you have taken up to now. When something goes wrong, you do not rush to blame others. You identify what you can do differently the next time and develop a plan to implement these changes.
3. You understand that vision trumps knowledge
You know that you do not need to have all the answers. As long as you can identify the problem, you can visualise a solution and research the best way to implement that solution.
4. Personal growth
Meeting the challenges of tomorrow requires learning and development today. You have a desire to learn and a thirst for knowledge. Learning and development activities form a key part of your schedule.
5. You seek alternative views
Knowing that the way things are done can always be improved, you willingly seek out the opinions and views of others. You do not feel threatened when people disagree with you. If you feel that their way is better, you are happy to run with it.
Variety makes the world a more beautiful place. Even when you disagree with people, you do not feel the need to criticise them. Instead, you respect their right to their beliefs.
There will always be things that go wrong. There will always be setbacks and major disappointments. While you may initially be a little upset, emotional maturity allows you to express your feelings, identify the actions you can take, and move on.
8. A calm demeanour
It’s hard to be calm 100% of the time but you are able to remain calm the majority of the time.
9. Realistic optimism
You are not deluded. You know that success requires effort and patience. You do, though, have an optimistic disposition whereby you believe you can cope with whatever life throws at you. You also believe that there are opportunities out there for you, so you seek them out.
You are usually easy to get along with and people feel comfortable approaching you. Building relationships is never contrived; it comes easy to you.
You appreciate when others praise or compliment you. It feels good when they approve. However, you know that there will always be people who disapprove but you are confident in who you are and what you do. If you believe that a particular course of action is right for you, you will do it, whether they approve or not.
You don’t take yourself too seriously. You are able to enjoy a good laugh with friends and colleagues, even when you are the butt of the joke.