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Home , Bullying in nursing, Nursing management, Turnover (employment)

Creating Healthy Work Environments 2019

Bullying in : Implementing Solutions for Practice

Matthew S. Howard, DNP, RN, CEN, CPEN, CPN Emergency Department, Eskenazi Health, Indianapolis, IN, USA Jennifer L. Embree, DNP, RN, NE-BC, CCNS Nursing Administration, Eskenazi Health, Indianapolis, IN, USA

Background and Significance:

Incivility and in nursing is a widespread issue. In the hectic and stressful environment of an emergency department, the incidence of violence has a negative cumulative effect on nursing staff (Angland, Dowling, & Casey, 2014). When situations become volatile, when tempers rise, and situations become unbearable, emergency nurses can use learned skills to hold critical conversations and prevent additional disruptive and harmful behaviors. This proposal describes the necessity for and development of an asynchronous provider-directed, learner-paced e-Learning educational activity designed to encourage productive communication and sustained dialogue between nursing staff. To mitigate and bullying behaviors, the following PICOT question was developed.

In a high-acuity, high-stressed environment, such as the emergency department, what is the effect of a provider-directed, learner-paced educational activity designed to encourage open discussion on new (in orientation) nurses compared with no educational activity, on the Clark Incivility Index® within the first year of hire?

Workplace violence and bullying are issues many nurses deal with daily. Nurse leaders and advance practice nurses are often called upon to develop policies which speak to this issue. Facility policies related to bullying should provide structure and ultimately empower nurses to combat issues and the effects of bullying (Evans-Agnew, Johnson, Liu, & Boutain, 2016). Lachman (2014) notes that “is correlated inversely with ” (p. 58). Bullying is ultimately an attempt by an aggressor to remove someone else’s power. Providing an avenue to return this power back to the individual may lower the levels of incivility and bullying (Blackstock, Harlos, Macleod, & Hardy, 2015).

Methods/Procedures:

The project is based on the conceptual framework developed by Ren and Kim (2017). It is hypothesized that an intervention designed to disrupt the bullying experience with an educational activity with disrupt the framework and prevent the subsequent , self-esteem issues and satisfaction issues (Ren & Kim, 2017). As such, the Johns Hopkins Nursing Evidence-Based Practice Model was employed. The practice model comprises three components, inquiry, practice, and learning (Dearholt & Allan, 2018). The inquiry and learning phases noted the need for the project through literature reviews and discussions with nursing staff. Best practices were reviewed, and it was determined that an educational activity designed to promote communication may be an effective intervention to decrease the incidence and effects of bullying and uncivil behaviors. The PDSA model (Deming, 1994), was utilized to developed and operationalized the practice improvements.

To measure success, the Clark Workplace ‘Civility Index’ was used. The Clark Workplace ‘Civility Index’ is a validated evidence-based questionnaire constructed to assess nurses’ personal civility and increase personal awareness related to personal actions and intentions (Clark, 2017). The index will be completed by both the control and experimental groups before initiation of and after completion of the educational activity.

The Negative Acts Questionnaire-Revised (NAQ-R), a validated 22-item instrument developed to measure perceived exposure to bullying and while at work (Einarsen, Hoel, & Notelaers, 2009) was also utilized. The personal awareness of bullying and incivility may assist the nurse in becoming more conscious of his or her actions and reactions to harassment, violence and bullying techniques (Charilaos, Michael, Chryssa, Panagiota, George, & Christina, 2015; Einarsen et al., 2009; Tsuno, Kawakami, Inoue, & Abe, 2010).

A pre-test post-test quasi-experimental design study was used with the intent to improve nurse communication. IRB approval was obtained, and participants were recruited. The control group consist of nurses who have recently, within the past calendar year, completed general nursing orientation. The experimental group consist of nurses who are currently in nursing orientation. Both groups completed the Civility Index and the NAQ-R. The experimental group then completed an asynchronous provider- directed, learner-paced e-Learning educational activity. The educational activity was developed in conjunction with an international nursing association, and designed to improve attitude toward, and effectiveness in, holding difficult conversations with other staff members.

Once the educational activity was completed, both groups completed a second Civility Index. It was expected that control group participants Civility Index scores would remain relatively unchanged while experimental group participants Civility Index scores would increase after the educational intervention.

Major Outcomes:

Success of the pilot project was identified by the participants meeting two specific outcomes. One; it was hypothesized that within sixty days of completion of the educational activity, more than 80% of experimental group participants would have implemented at least one positive conflict management strategy effectively. Two; within ninety days of completion of the educational activity, more than 80% of experimental group participants would have increased their Clark Workplace Civility Index© score.

Sixty-two nurses participated in the pilot project (response rate: 29%). From these, 30 met criteria for the experimental group and 32 met criteria for the control group. Both quantitative and qualitative data were analyzed. Based on the pre- and post-test scores, the pilot project proved successful meeting both specified outcomes.

Civility Index scores can range from 20-100. A low score, less than 50, means the participant exhibits very uncivil behavior where as a score of 90-100 exhibits very civil behavior. The average Civility Index pre-score for the experimental group was 92 with a post-score average of 98. In contrast, the average pre-score for the control group was 88 with a post-score average of 81.

The NAQ-R scores range from 22-110. A score lower than 33 notes an employee that is not bullied, whereas employees with a score between 33 and 45 may be considered as being bullied occasionally. Employees who score above 45 are considered victims of . The average score for both groups was 32. In the experimental group, 70% of participants are not considered bullied. For the same group, 17% may be considered being bullied at work and 13% are considered victims of workplace bullying. For the control group, 63% are not considered bullied, 31% may be considered being bullied at work, and 6% are considered victims of workplace bullying.

Conclusion:

Incivility, lateral and horizontal violence, and bullying have been an issue for decades (Coile, 2016; Wilson, 2016). One way to the cycle of violence is through awareness and (Vagharseyyedin, 2016). The development of a provider-paced, learner-directed asynchronous educational activity did prove useful in increasing personal awareness related to personal actions and intentions related to civil behaviors. The essence of the pilot project was to develop an educational intervention that would provide nurses with the knowledge and tools to appropriately react to crucial conversations when under stress. Nurses stated a perceived comfort level with creating a safe environment to hold conversations and facilitate true dialogue.

Title: : Implementing Solutions for Practice

Keywords: Bullying, Communication and Crucial conversations

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Abstract Summary: As the issue of incivility, lateral and horizontal violence, and bullying continue in nursing, strategies are needed to address and eliminate hostile work environments. Educational activities not only raise awareness of these issues, but often provide skills, training, and knowledge of how to reduce the frequency and impact of incivility.

Content Outline:

1. Introduction to issues of bullying and incivility in nursing 2. Discuss causes of incivility 1. General causes of incivility 2. Specific causes in a fast-paced, high-stressed environment, such as: 1. Burn unit 2. Critical care (i.e. intensive care units) 3. Emergency department 4. Interventional suites (cath lab, endo, etc.) 5. Operative suite (OR, PACU, etc) 3. Present the use of educational activity as a performance improvement intervention 4. Discuss the methods used in the study 5. Provide a review of the procedure used for the study 6. Discuss the outcomes 1. Describe the quantitative results of the study 2. Note the themes gathered from qualitative data of the study 7. Discuss implications for nursing practice

First Primary Presenting Author Primary Presenting Author Matthew S. Howard, DNP, RN, CEN, CPEN, CPN Eskenazi Health Emergency Department Staff Nurse II Indianapolis IN USA

Professional Experience: Matt Howard is currently the Director of Educational Resources at the Honor Society of Nursing, Sigma Theta Tau International. Mr. Howard also works part time as a staff nurse in the Emergency Department at Eskenazi Health in Indianapolis, IN. His nursing career has taken him from stretcher-side nursing to academia. He has served as an Assistant Director at a School of Nursing, Manager of Trauma Services and Clinical Manger of Operations of an Emergency Department and as a . Prior to these appointments, Mr. Howard worked as a staff nurse in several Indiana and Kentucky Emergency Departments and has worked as an Injury Prevention Coordinator and a Trauma Registrar. He began his nursing career as a basic EMT in rural western Kentucky while working through his nursing degree and is currently working towards his doctoral degree in nursing. Author Summary: Matt Howard currently serves as the Director of Educational Resources at Sigma Theta Tau International (STTI). Mr. Howard’s career has taken him from stretcher-side nursing to academia. His clinical background includes emergency department and flight nursing, and management. He currently serves on several national nursing associations including STTI and the Emergency Nurses Association.

Second Author Jennifer L. Embree, DNP, RN, NE-BC, CCNS Eskenazi Health Nursing Administration Magnet Coordinator Indianapolis IN USA

Professional Experience: Coordinator of the MSN and DNP Nursing Leadership and Health Systems Program. Nurse Faculty Scholar-Sigma Theta Tau, 2014-2015.Committee member: Research and Scholarship Committee, DNP Curriculum and Student Affairs Committee and DNP Evaluation Committee. Indiana State Nurses Association Immediate Past-President. Centerstone of Indiana Board Immediate Past-President. Have been a faculty member teaching aross the curriculum of RN-BSN, BSN, MSN- Clinical Nurse Specialist, MSN Nursing Leadership in Health Systems and DNP Leadership Programs. IU School of Nursing Clinical Faculty Leadership Mentoring Program 2015-2017. Steering Committee Member-Indiana Action Coalition. Past Executive Board Member Indiana Center for Nursing. Board Member at Large-Indiana League for Nursing. Board Member and Past President-Indiana Organization of Nurse Executives. Author Summary: Jennifer Embree is a former NFLA Scholar and working in partnership with Indiana University School of Nursing and Eskenazi Health System as their Magnet Coordinator