Examples of less resilient response by nurse from scenario 1: “I don't ... I know
that it is important for you to have the instruments in a timely fashion, as the.
A D D R E S S I N G T H E T O P I C O F B U L LY I N G I N H E A LT H C A R E : T H E R E S U LT S O F A P I L O T W O R K S H O P Lee Pietrangelo, M.D.-Patient Safety Fellow
David Eibling, MD - Chief of Otolaryngology/Director Patient Safety Fellowship
PATIENT
SAFET Y-SIMULATION
BACKGROUND OF THE PROBLEM Abstract: Bullying in the healthcare arena is a disruptive behavior, which results in degraded quality of patient care, increased medical errors, and decreased patient and staff satisfaction. The ability of victims and targets to neutralize the behavior 1 and thus risk to patient safety can be a learned behavior . Toward that goal, we developed and introduced an antibullying workshop, aimed at increasing the awareness of the link between bullying among healthcare staff and adverse outcomes as well as teaching, under lower-fidelity simulation, a specific communication technique for countering the behavior of bullying. Scope of the Problem in Healthcare Today: Bullying is a human behavior from which healthcare workers are not 2 3 immune. Among nursing staff in both Massachusetts and Washington state , nearly one-third reported being bullied by 4 other healthcare staff in the hospital. Rates reported in the literature of bullying directed at medical students place the 5 6 numbers of bullied anywhere from one in four to one in two . Those groups most cited as the abuser (bully), in general, 7, 8 were physicians followed by nurses themselves . The adverse effects of bullying on hospital nursing have been 9, 10 documented to include staff physical health problems as well as long-term costs such as increased staff absenteeism, increased turnover, and reduced commitment to the organization.11 Unlike other workplace bullying, bullying in the healthcare arena has second– and third-order effects that may include medical errors and other adverse outcomes that reach beyond the intended victim onto the patient and family. In a 2004 ISMP study of pharmacists, nearly half of respondents reported that intimidation interfered with the performance of their patient care duties, while a staggering 7% 12 reported they committed an actual medication error. Similarly, in a study of more than 1200 O.R. nurses, the adverse 13 outcome most closely linked with the behavior of bullying was retained surgical instruments in the patient. Strategies to Improve Healthcare Workers Ability to Counter Bullying: While the topic of bullying in the workplace, and, more recently, the topic of bullying in healthcare have been described in the literature, little evidencebased literature exists on strategies to decrease their prevalence and impact on patient and healthcare worker safety. 14 Stevens demonstrated a 6% increase in job retention rates of nurses with focus groups and nurse leadership workshops, 15 16 while, in separate studies, Griffin and Stagg demonstrated improvements in knowledge (Kirkpatrick level 2) and performance (Kirkpatrick level 3), respectively, against bullying, utilizing cognitive rehearsal training. Training healthcare workers to neutralize the unwanted and unsafe behavior of bullying is only one tactic of an overall set of strategies which must include hospital management buy-in as a stakeholder, zero tolerance for disruptive behavior, maintaining a culture of justice and respect, recruiting the ‘bystander’ to act on behalf of the victim and patient, etc. Cognitive Rehearsal and Simulation: Cognitive rehearsal training can be used to teach historical or potential bully victims an established way of responding to future bullies and bullying events, by developing and practicing both a general technique of communication as well as specific scripted reply or replies. Simulation provides a psychologically safe and consequence-free environment in which to then test this technique and scripted replies against a ‘practice’ bully. Real-life bullies both create and count on the adrenaline bomb in their victims, and the desired simulation must have enough fidelity to provide a level of background adrenaline to ensure that the competency gained in neutralizing or countering bullying is not lost at first contact with a real-life bully. Simulation can generated using low to moderate fidelity methods such as role-playing or standardized patients. Key Points: Bullying exists in the healthcare workplace and is complex behavior, with real costs and consequences for patients
and staff. Bullying is a disruptive behavior which degrades patient care quality and safety. The technique of scripted replies can be learned through cognitive rehearsal. Citations: 1
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. Simons, S. (2008). Workplace bullying experienced by Massachusetts registered nurses and the relationship to intent to leave the organization. Advances in Nursing Science; 31: 48-59. 3 Johnson, S. (2009). International perspectives on workplace bullying among nurses: A review. International Nursing Review; 56: 34-40. 4 Stelmaschuk, S. (2010). Workplace bullying and emotional exhaustion among registered nurses and non-nursing, unit-based staff. Senior Honors Thesis. The Ohio State University. 5 AMA Section on Medical Schools Presentation, moderated by Rappley, M. (2011). Optimizing the learning environment: Exploring the issue of medical student mistreatment. American Medical Association. 2
6
Chen, P. (2012). The bullying culture of medical school. NYT Blog.
7
Rosenstein, A and O’Daniel. (2005). Disruptive behaviors and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing; 105: 54-64. Stelmaschuk, S. (2010). Workplace bullying and emotional exhaustion among registered nurses and non-nursing, unit-based staff. Senior Honors Thesis. The Ohio State University. 9 Quine, L. (2001) Workplace bullying in nurses. Journal of Health Psychology; 6: 73-84. 10 Stelmaschuk, S. (2010). Workplace bullying and emotional exhaustion among registered nurses and non-nursing, unit-based staff. Senior Honors Thesis. The Ohio State University. 11 Felblinger, D. (2008). Incivility and bullying in the workplace and nurses’ shame responses. JOGNN; 37: 234-242. 12 ISMP. (2007). Intimidation: Practitioners speak up about an unresolved problem. ISMP Newsletters. 13 Smith, J. (2011). Bullying in the nursing workplace: A study of perioperative nurses. A doctoral management dissertation. University of Phoenix. 14 Stevens, S. (2002). Nursing workforce retention: challenging a bully culture. Health Affairs; 21: 189-193. 15 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. 16 Stagg, S et al. (2011). Evaluation of a workplace bullying cognitive rehearsal program in a hospital setting. The Journal of Continuing Education in Nursing; 42: 395-401.
WORKSHOP DESIGNPROPOSAL AND IMPLEMENTATION
,
Kirkpatrick D. (1994). Evaluating Training Programs. Berrett-Koehler Publishing.
WORKSHOP
EXPLANATION OF SPECIFIC COMMUNICATION TECHNIQUE
Based on completion of the post-workshop assessment with responses provided using a Likert® scale, the following results were obtained from 24 of the 25 participants who submitted their answers to 6 questions: 17
In 2012, the authors, working from within VA Pittsburgh Health System (VAPHS) Patient Safety Fellowship, introduced an one-hour workshop, designed with the dual objectives of increasing the awareness of the phenomenon of bullying within healthcare as well as teaching a specific communication technique for healthcare workers to deploy against future bullying events. We hypothesized that the deployment of the workshop would increase the likelihood that VAPHS employees would be prepared to successfully manage a future encounter with a bully. Twenty-five employees from a single hospital section participated in the 1 hour workshop. The components of the workshop included: 1.Didactic teaching on the background of bullying in healthcare via PowerPoint® presentation, with audience participation (20 mins): Introduction of the concept and definition of bullying, both in the workplace and healthcare workplace, with identification of specific bullying behaviors Connection between bullying and patient/staff safety Review of the current literature Introduction of the concept of personal and professional resiliency as a tool to success in the face of any adversity 2.Explanation of a specific communication technique (10 mins)—see text box to right 3.Practice of the technique under the low-fidelity simulation of role-playing, with the simulation involving: Pre-brief (5 mins) Run of simulation (15 mins), with each participate asked to alternately play the bully, victim, and bystander, utilizing any one of 8 clinical scenarios (see example of scenario 1 in text box below) De-brief (5 mins) 4. Question and answer/discussion; completion of post-workshop assessment (5 mins) Scenario 1 Surgeon Throws Instrument At Peri-Operative Nurse Initial Scenario: Patient with SBO from adhesions is being operated on by Doctor Alpha assisted by Doctor Beta, also assisted by scrub Nurse Charlie, with the surgeons encountering significant adhesions in the abdominal cavity; the surgery does not seem to be going well, as the adhesions are severe Doctor Alpha: (Trying to dissect out tissue planes, but losing patience) These bleepin’ adhesions are just unbelievable…come on! Doctor Beta: Want me to take a shot? Doctor Alpha: (raised voice) No! I got it...If our nurse here would just keep up with handing me the instruments sometime this century… Nurse Charlie: (silent) Doctor Alpha: (Getting frustrated at the course of the operation) Son of a gun!!! Doctor Beta: Let me take a shot. Doctor Alpha: (directed at nurse) (outburst while throwing an instrument at nurse Charlie) would you hand me the frickin’ right instrument in a frickin’ timely fashion—you are going to kill the patient! Nurse Charlie responds… Escalation Doctor Alpha: (angrily responding) You need to zip your mouth—I am operating here, and this is my patient. If you think I am going to tolerate this crap, you thought wrong. Doctor Beta: But Doctor…(cut off in mid sentence by Dr Alpha) Doctor Alpha: Leave it alone, not your fight. Nurse Charlie responds… Further escalation Doctor Alpha: I can hold this surgery all day long until you get on the ball and start handing me instruments in a timely fashion—but Mr. Delta here is waiting on you. Nurse Charlie responds…
1.Consistent with attainment of Kirkpatrick level 2 of education:
Start with this
1. Connect a team centric statement together with a patient centric statement (team + patient): Team centric statement elements
Patient centric statement elements “The Patient”
“We” “You and I”
“The Patient’s” “Mr. or Ms.”
“Our”
Examples of resilient response by nurse from scenario 1: “ I know that it is important for you to have the instruments in a timely fashion, as the
patient’s welfare is at stake.”
or
“We need to work together as a team, or else Mr. Smith’s care will suffer.”
Examples of less resilient response by nurse from scenario 1: “I don’t appreciate your actions.”
22 of 24 participants rated the description of an improvement in their knowledge of bullying as either “agree” or
“strongly agree” 22 of 24 participants rated the description of their feeling prepared to deal with future bullying they might
encounter in their job as either “agree” or “strongly agree” 19 of 24 participants rated the description of their willingness to use the scripted reply technique to deal with future
bullying they might encounter in their job as either “agree” or “strongly agree” 2. Additional findings included: 21 of 24 participants rated the description of the relevance of the workshop training to their day-to-day job as either
“The Team”
or
“Stop that!”
Then try this
Maintain team-centric statement connected to a patient-centric statement, but now include the element of a call for a time-out :
“agree” or “strongly agree” Only 6 of 24 participants rated the description of this training as their first exposure to anti-bullying training as
either “disagree” or “strongly disagree” 3. Conclusions: cognitive rehearsal training under simulation, using this and other communication techniques, may improve the success of healthcare workers in managing the disruptive behavior of bullying from other healthcare staff. Improvements in education and training at Kirkpatrick level 2 may not translate as easily into actual reductions in either the prevalence of bullying or its second– and third-order effects on patient safety or patient and staff satisfaction, as bullying is a complex human behavior for which multiple modes of intervention are required. 4. Future directions: the small sample size of the number of participants in this workshop as well as the difficulties in developing metrics to gauge the success in the clinical arena beyond Kirkpatrick level 2 of training make evidence-based guidelines difficult to establish. The adoption of such counter– or anti-bullying training remains a ’best practice’ as part of a larger intervention strategy to mitigate the effects of bullying in healthcare and to develop a just and safe culture for all healthcare workers and patients. With the deployment of more workshops and as hospitals better focus on the problem of eliminating bullying, more data can be collected to establish the success of cognitive rehearsal under simulation and scripted replies.
“We should take a time out here to ensure that you and I are working in sync on passing instruments for the patient” or “I need to ask you to take a time-out here, as Mr. Smith’s case may be affected by…” Finally, try this
Maintain a team-centric statement connected to a patient-centric statement, but now switch from a call for a time-out to including the element of enlisting back-up from another staff (buddy-aid):
8
17
RESULT S OF COMPLETED
“We seem to be having a problem, I am going to ask nurse Jacobs for help in ensuring that instruments are passed safely for the patient.” or “You and I seem to have a disconnect here, Mr. Smith may benefit from having the nurse manager step in the room.”
Bullying is human behavior that is unwanted, always destructive, the damage from which can be measured in terms of first, second, and, sometimes, even third order victims. Bullying is antisocial, contrary to the good working order of a team, sabotages any mission, and is the antithesis of professionalism. Bullying is never acceptable. Professionalism, on the other hand, is human behavior that is wanted, always constructive, the benefit from which can be measured in terms of first, second, and even third order beneficiaries. Professionalism is prosocial, central to the good working order of a team, enables any mission, and is the antithesis of bullying. Professionalism is always welcomed.
