1. Incivility: Disclosing and Disarming the Incivility Elephant in Academic and Practice Nursing The University of Southern Mississippi PhD Program of Nursing

2. Participants Sheila P. Davis, PhD, RN, FAAN Mary Friend – PhD Student Charlotte Gore- PhD Student Danny Tige Lantrip- PhD Student Melissa Martin- PhD Student Sharon McDonald- PhD Student Melinda Sills – PhD Student

3. Incivility – Dr. Davis

4. Objectives

5. Incivility – the Elephant Definition – any action that is offensive, Intimidating, or hostile that interferes with the Learning and/or practice environment (CRLT). Such behavior may be increasing, thus jeopardizing the welfare of the educational and/or practice setting of nurses.

6. A Student’s Account “I was typing my patient assignment on the computer and began humming to myself. The instructor approached me angrily and told me that if I hummed again, she would kick me out of clinical. .. She really let me have it in front of other students……inside, I was ready to burst.” (Clark, 2008)

7. Faculty Experiences “ Faculty who realize that they will likely face inappropriate behavior during lectures may begin devoting time and energy to planning coping ( survival) strategies rather than focusing on lecture material. Further, faculty who dread going to a particular class and having to deal with particular students can become demoralized and disillusioned with the overall teaching process.” (Morrissette,

8. How Bad is the Problem in Nursing ?Luparel( 2008) Moderate problem in nursing ( Clark & Spring, 2007) Tardiness, talking in class, and other inattentiveness was experienced by 100% of faculty One half of faculty reported being yelled at in the classroom 43% of faculty reported being yelled at in clinical setting Faculty report having serious emotional and physical consequences

9. Incivility in the WorkplaceJane Legacy Incivility appears to be an increasing dilemma for organizations. Incivility is getting worse and more exaggerated Incivility is a business issue – expensive $$ Victims suffer from increased stress, anxiety, exhaustion, sleeplessness, depression, anger and embarrassment. Lost of work time, sickness, extreme reactionary actions, and lawsuits can result from incivility.

10. Bullying

11. Incivility – Workplace Bullying According to Gary and Ruth Namie, authors of The Bully at Work, bulling is ‘the repeated malicious, health-endangering mistreatment of one employee (the target) by one or more employees (the bully, bullies). The mistreatment is psychological violence, a mix of verbal and strategic assaults to prevent the target from performing well. It is illegitimate conduct in that it prevents work getting done. Thus an employer’s legitimate business interests are not met.

12. End Result of Extreme IncivilityWorkplace Violence Almost 38% of shootings in the workplace happened in "white collar" situations. This makes up over 30% of all fatal shootings at work. Florida and California were the most dangerous states involving shootings on the job. 24% of workplace shooters were laid off or fired. about 9% of those shooting showed warning signs beforehand that were commonly ignored when others noticed them. There were about 13% of shootings in the workplace that involved a former or current intimate relationship. Over 13% of cases revealed the workplace shooter had a history of mental health issues

13. Melissa Martin, MSN

14. What do you think of ? Patients yelling, using vulgarities at the nurse and throwing things? Physicians being discourteous and obnoxious? Experienced nurses leaving new nurses to fend for themselves? Anger, jealousy and strife between nurses or units? School/College /University shootings/ most recently faculty on faculty- February 2010

15. YES The previous are all blatant acts of Horizontal Incivility and Violence! But incivility is not always that easy to identify.

16. So what really constitutes incivility?

17. Incivility can be ‘discreet’ Arriving late to a meeting or leaving early. Sending an e-mail without a greeting. Not using uncivil words- but using accompanying harsh tones or body language. Dismissing or ignoring co-workers concerns, thoughts, or input.

18. Please don’t answer Just Think… Have you ever been guilty of any of these?

19. Then…. Perhaps incivility is more common than we think. Perhaps incivility exist in places we are afraid to consider. In fact, incivility has permeated all areas of society and nurses are no exception.

20. Charlotte Gore RN, MSN Objective 3 Provide input into a conceptual model for recognition and reduction of incivility in nursing.

26. Lindy Sills, MSN

27. ‘Dance of Incivility’ ….. A dynamic interaction between faculty and students. When viewed as a ‘dance’ rather than a struggle for power and control, the potential for healing is enhanced. (Clark 2008)

28. Facilitating Factors Crowded working conditions Overworking conditions Too many demands Fundamental mistrust between students and faculty that faculty are trying to “weed them out” Fundamental mistrust between subordinate and supervisor Ineffective classroom and/or practice management skills ( Luparell, 2008)

29. Civil Workplace Requires Nurses Students Faculty Administration

31. Clear communication

32. Non-threatening environment

33. Shared involvement

34. Self-reflection

35. Cooperate

36. Collaborate

37. Monitor for bullying groups

39. Measures to Address Student to Faculty Incivility Zero-tolerance Clear communication Role-models Shared involvement Self-reflection Criminal background checks Act on warning signals

40. Measures to Address Faculty to Faculty Incivility Zero-tolerance Clear communication Self-reflection Cooperate Collaborate Carefully select faculty Refuse to be a victim Monitor for bullying groups

41. Measures to Address Administration to Subordinate Incivility Zero-tolerance Clear communication Self-reflection Respect subordinates Listen Educate subordinates on incivility and civility Acknowledge warning signals Evaluate organizational structure

42. Resources for Addressing Incivility in the Workplace Louanne Friend, MN,RN University of Southern Mississippi

43. Legal Protection Anti-bullying legislation was enacted in Sweden in 1993, Great Britain in 1997, Belgium in 2002 and Australia in the mid- to late-1990’s (Leymann & Gustafsson 1996; Namie 2004). Targets in the U.S. find few avenues of legal redress available.

44. Federal Statutes

45. Title VII Civil Rights Act Case law associated with Title VII of the U. S. Civil Rights Act of 1964 has established employer liability for the consequences of a hostile work environment. Title VII prohibits discrimination on the basis of “race, color, religion, sex, and national origin” which renders it inadequate to protect against generalized workplace bullying.

46. OSHA The U. S. Occupational Safety and Health Act of 1970 (OSHA) was primarily designed to respond to physical hazards in the workplace (Yamada 2000). OSHA’s protections do not generally extend to psychological or stress-related hazards in the workplace.

47. Workers Compensation Few, if any, States recognize psychological or stress-related claims as compensable under their Workers’ Compensation programs. Because the vast majority of workplace bullying is verbal in nature, there is often no direct physical injury to the target.

48. Healthy Workplace Bill New York is the only state that forbids abusive conduct in the workplace. In May 2010, the New York State Senate passed the Healthy Workplace Bill, a measure that would allow workers to sue for physical, psychological, or economic harm from abusive treatment at work.

49. 17 States since 2003 have introduced the HWB There are many ways that you can contribute to the Healthy Workplace Bill Campaign, from a simple letter to the editor or become a state coordinator, everything helps Citizen lobbying as opposed to professional lobbying is appreciated by most politicians. Gary Namie, PhD Director of the Healthy Workplace Bill Legislative Campaign.

50. Joint Commission Taking the perspective that bullying is a safety issue, in 2008, the Joint Commission issued a standard on intimidating and disruptive behaviors at work, citing concerns about increased medical errors, poor patient satisfaction, adverse outcomes, higher costs, and loss of qualified staff.

51. American Nurses Association The ANA Code of Ethics states nurses have a responsibility to establish, maintain and improve health care environments and conditions of employment conducive to the provision of quality healthcare.

52. AACN American Association of Critical Care Nurses’ Healthy Work Environment Initiative (2004). AACN’s Healthy Work Environment initiative is a multipronged, multiyear effort to engage nurses, employers and the nursing profession in recognizing the urgency and importance of working collaboratively to improve the environments in which nurses work.

53. AONE The American Organization of Nurse Executives has stated that collaboration and communication are some of the characteristics that are needed in a healthy workplace.

54. American Organization of Nurse Executives (AONE)

55. AONE

56. Healthful Work Environment Tool Kit The National League for Nursing has focused on work environments in academia and has published the Healthful Work Environment Tool Kit© that can be used by applicants for faculty positions, current faculty members, and nurse administrators to assess an academic work environment.

57. Toolkit The tool kit addresses the following nine work-related areas: salaries, benefits, workload, collegial environment, role preparation and professional development, scholarship, institutional support, marketing and recognition, and leadership. These areas are used to frame the discussion of how nursing faculty and administrators can work together to assess and enhance the health of nursing academic workplaces

58. Center for American Nurses Center for American Nurses. Lateral violence and bullying in the workplace. 2008. It is the position of the CENTER that there is no place in a professional practice environment for lateral violence and bullying among nurses or between healthcare professionals. All healthcare organizations should implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior.

59. Nurse Educators In the NLN/Carnegie Foundation Survey, Nurse Educators: Compensation, Workload and Teaching Practices, nurse educators reported working just over 56 hours per week while school was in session.

60. Nurse Educators To maintain a healthy work environment, nurse administrators should ensure that faculty members have options for nine, ten, and twelve month contracts. Another benefit could be joint-appointment contracts allowing faculty to fulfill both education and practice role responsibilities.

61. Policies Are A Must! First, it is important to develop a code of conduct describing the types of behavior that are considered disruptive .The code needs to address all workers in an organization, including employees, such as nurses, and nonemployees, such as physicians (Barnsteiner, Madigan, & Spray, 2001).

62. Code of Conduct In order for a code of conduct to be effective, it must be applied in all circumstances where there is a possible breach. Without this enforcement, the code is meaningless. All team members, including hospital administrators, chief nursing officers, and other nursing leaders, need to be accountable for modeling and enforcing the code.

63. What to Do?

64. Cognitive Rehearsal Techniques Griffin (2004) reported that newly licensed nurses who had been taught about the use of cognitive rehearsal techniques to address disruptive behaviors were better able to confront nurses who displayed lateral violence.

65. Call a Code One strategy that has been used by nurses to show support for other nurses is by calling a “Code Bully” or a “Code Pink” (Childers, 2004; Namie & Namie, 2009). If a nurse is being yelled at by another healthcare worker, a code can be called by word of mouth or by a more formal method, and the nurses can unify by physically standing behind the nurse so as to let the disrupter know that the disruptive behavior is unacceptable (Childers, 2004).

66. Online Resources for Developing Code of Conduct American Medical Association: www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/organized-medical-staff-section/helpful-resources/disruptive-behavior.shtml HC Pro: www.strategiesfornursemanagers.com/ce_detail/225618.cfm

67. Center for American Nurses For those nurses wishing to learn more about disruptive behaviors, the Center for American Nurses (CAN) has a free webinar titled 10 Tips for Addressing Disruptive Behavior at Work that can be accessed at www.centerforamericannurses.org/displaycommon.cfm?an=1&subarticlenbr=195.

68. Conclusion

69. Desk Rage: Do you need a policy to deal with workplace Incivility? Employers can reduce risks by identifying and controlling workplace incivility before it gets out of hand. Have a civility in the workplace policy that requires the exercise of self-control at work and professionalism in dealing with coworkers. Make sure employees are aware of any anti-stress programs you have. Walking paths, exercise rooms and anger management classes are examples

70. Desk Rage Provide a quiet area that employees may use to get away when needed. Make sure that employees are aware of job related resources Keep in mind that ignorance is not bliss where desk rage is concerned and have a good plan for dealing with it. http://del.hrtools.com/policies_and_procedures/articles/desk_rage_do_you_need_a

71. References American Association of Critical-Care Nurses (2005). AACN Standards for establishing and sustaining healthy work environments. Available: www.aacn.org Center for American Nurses. February 2008. Position statement on lateral violence and workplace bullying. http://www.centerforamericannurses.org/positions/lateralviolence.pdf (accessed July 15, 2010).

72. References American Organization of Nurse Executives (2006). AONE guiding principles for excellence in nurse/physician relationships. Retrieved June 17, 2009, from http://net.acpe.org/services/AONE/Index.htm

73. References Center for Research on Learning and Teaching (2010). Teaching strategies: Incivility in the college classroom. Retrieved September 30, 2010, from www.crit.umich.edu/.../Incivity.php Childers, L. (2004, April 26). Bullybusters: Nurses in hostile work environments must take action against abusive colleagues. Nurseweek. Retrieved August 19, 2009, from www.nurseweek.com/news/features/04-04/bullies_print.html

74. References Clark, C. (2008). Student voices on faculty incivility in nursing education: A conceptual model. Advances in Nursing Science, 31 (4), E37-E54. Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing,35, 257-263. Grover, S.M. (2005). Shaping effective communication skills and therapeutic relationships at work. AAOHN Journal, 53(4), 177-182

75. References Healthy Workplace Bill. Available at: http://www.healthyworkplacebill.org/ Accessed July 20, 2010. The Joint Commission. Sentinel Event Alert #40. Behaviors that undermine a culture of safety. July 9, 2008. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm Accessed September 22, 2010.

76. References Lazoriz, S., and P. J. Carlson. 2008. Don’t tolerate disruptive physician behavior. American Nurse Today 3 :http://www.americannursetoday.com/ME2/dirmod.asp?sid . Legacy, J. , Incivility in the workplace. Retrieved July 7, 2010 from http://www.publicvirtues.com/Incivility_Study.html. Morrissette, P. (2001). Reducing incivility in the university/college classroom. Retrieved, July 7, 2010 from http://www.ucalgary.ca/iejll/morrissette/ Yamada, David C., Crafting a Legislative Response to Workplace Bullying (2004). Employee Rights and Employment Policy Journal, Vol. 8, p. 475, 2004. Available at SSRN: http://ssrn.com/abstract=1303725

77. Questions?

78. Contacts The University of Southern Mississippi 118 College Drive, #5095 Hattiesburg, MS 39406-0001 601-266-5457 www.nursing.usm.edu