RSSArchive for December, 2017

Q & A: Ending Nurse-to-Nurse Hostility

Editor’s Note: Strategies for Nurse Managers recently sat down with Kathleen Bartholomew, RN, MSN, author of Ending-Nurse-to-Nurse Hostility, Second Edition to discuss strategies to end hostility in the workplace. The following is an edited version of our conversation.

Strategies For Nurse Manangers: What inspired you to write Ending Nurse-to-Nurse Hostility?

Kathleen Bartholomew:
I wrote “Ending Nurse-to-Nurse Hostility” because of my deep love and respect for Nursing. The intimate and poignant moments that nurses share with their patients as well as their high level critical thinking skills have always blown me away. Yet I also witnessed occasions when nurses took each other down – mostly in subtle ways. I wanted to understand why. I wanted to discover and illuminate these unconscious learned behaviors so that we could all lift each other up and show the world the best of humanity.

SFNM: What is nurse-to-nurse hostility?

KB: A formal definition is: “…any behavior that interferes with effective communication among healthcare providers and negatively effects performance and outcomes.” (The Center for American Nurses)
An informal definition would be: Any interaction or behavior that leaves you feeling ‘less than’ the capable, skilled, caring person that you really are – like eye-rolling. Some people unconsciously try to make someone feel smaller so they can feel bigger (remember middle school?).  Some other examples would be: raised eyebrows, making faces behind someone’s back, withholding information, bickering, fault-finding, back-stabbing, intimidation, put downs, ignoring someone’s greeting, blaming or an unfair assignment. These are all unconscious behaviors.  No one thinks to (themselves, “I’m going to roll my eyes at her right now”. The insidious nature of these hostile behaviors is what makes them so dangerous because we don’t even realize that we are taking each other down.

SFNM: How does it differ from regular bullying? 

In the United States, bullying is a term used to describe someone a power level above you like a manager or physician who uses overt and covert behaviors to ‘put you in your place’. “Horizontal” hostility refers to the way your peers try to take away or under-mine each other’s power. It is more common in a unit where the manager has an authoritarian or laisse-fare style of leadership and where nurses do not have the resources or staffing to do their job.

SFNM: What are some examples of hostility in the workplace that are often overlooked?

Many nurses don’t recognize that talking about someone when they are not present is a form of hostility. Gossip erases trust as the underlying message to our psyche is “If they are talking about people who are not here, then they are probably talking about me when I am not here. “
Other covert forms of hostility are withholding information (let’s see how good she/he is), refusing to work with other people, and cliques. If you have cliques in your department, then you are not a team – and high reliability standards have consistently proven that only collegial teams can keep patients safe. People join cliques for two reasons: to elevate their own self-esteem, and/or to stay safe. So become inclusive by letting everyone belong, look for the good in each other, and compliment freely.

SFNM: What can a manager do to prevent bullying and horizontal hostility in their department?

KB: These three strategies and tactics set the foundation for trust and therefore civility:

  1. Say what you see.  If you see someone rolling their eyes, stop and say, “I noticed that you rolled your eyes…”   These covert behaviors lose their power when we call them out into the open.
  2. Dismantle the hierarchy. We may have different roles, levels of education and paychecks, but each and every single person is a critical member of the team.  The fastest way to even the power play is to ask for feedback by individually asking his/her staff: What do you like that I do well? And what would you like to see more of?

    Another way to equal the playing field (which is critical to Millennials especially) is to job shadow. This sends a strong message that you care about their world when you ‘walk in their shoes.”  And if you walk onto the unit and everything is chaotic, ask the charge nurse what you can do and then do just that.

  3. Nothing About Me, Without Me. Gossip undermines trust. If someone comes into your office to complain about someone else, ask them to go get that person and explain that you would do the same for them. This is the most fundamental leadership behavior because it sets up the conditions for trust. Furthermore, it emphasizes that we are adults who should be able to bring our concerns or observations to each other. The AACN standards say that we must be as competent in our communication skills as we are in our clinical skills – but we are not. Encourage, roll play and coach staff to speak with each other about the important stuff.

SFNM: Do you have any suggestions for a manager that suspects their staff is experiencing hostility?

Yes! I can’t tell you how many managers ask their staff is a problem and the group says “no”. Group think doesn’t allow it. The best way to evaluate the presence of hostility is to send out a simple Survey Monkey (there are two short surveys in “Ending Nurse-to-Nurse Hostility”). After you have compiled the results, share them at a staff meeting. As managers, we need to hold up a virtual mirror so that staff can see how their behaviors affect each other and patient care.

The second step would be awareness training. There are three free educational videos, each only ten minutes long on my website complete which end with a question for the group. Show one each month at a staff meeting; or include in your annual education and new hire curriculum.

SFNM: What advice would you give someone who was experiencing horizontal hostility in the workplace?

KB: Every month someone emails me with a story expressing the shear pain of being rejected from the group. Their letters are heart breaking. It is difficult to understand how in a profession based on caring, how nurses could be so downright mean.

My advice is to know without a doubt that it’s not about you. Horizontal hostility is a symptom of an unhealthy group. If you quit, they will just do the same thing to the next person. If you are different in any way, you become a vulnerable target. When humans work closely together under stressful conditions, have low self-esteem, have a bully for a manager, or a manager that doesn’t care what they do, or plays favorites, you can be certain that staff will be hostile.

About Kathleen Bartholomew
Kathleen Bartholomew, RN, MSN is the author of HCPro titles: Ending Nurse-to-Nurse Hostility, second edition, Speak Your Truth: Proven Strategies for Effective Nurse-to-Physician Communications, along with the Team Building Handbook: Improving Nurse-to-Nurse Relationships. Additionally, Bartholomew has recently published “The Dauntless Nurse: Communication Confidence Builder” with co-authors Martha Griffn and Arna Robins along with the Dauntless Communication Tool app on iTunes.


Why Do Healthcare Workers Report to Work When Sick?

By John Palmer
This article originally appeared in PSQH.

It’s no secret that that healthcare can be a dirty profession. So why is it that despite the warnings about the dangers of not wearing appropriate protection around hazardous drugs and infectious diseases, workers still choose to put themselves in danger?

It’s an interesting conundrum, and wearing the proper Personal Protective Equipment (PPE) is just as much for the protection of the patient as it is for the worker. In fact, a report published in the November 2017 issue of the American Journal of Infection Control found that as many as 4 out of 10 healthcare professionals show up at work even when they are sick with flu-like illnesses.

The study makes the assertion that illness transmission by healthcare employees represents a grave public health hazard.

Lead researcher Dr. Sophia Chiu called the findings “alarming” and cited an earlier study that showed patients exposed to a medical worker who is sick are five times more likely to get a healthcare-associated infection. “We recommend all healthcare facilities take steps to support and encourage their staff to not work while they are sick,” she added.

The survey of nearly 2,000 health workers during the 2014-2015 flu season interviewed doctors, nurses, nurse practitioners, physician assistants, aides, and others who self-reported flu-like symptoms at work such as fever and cough or sore throat.

“Healthcare personnel (HCP) working while experiencing influenza-like illness (ILI) contribute to influenza transmission in healthcare settings,” the report’s authors wrote. “Influenza infections are associated with thousands of deaths in the United States each year. Transmission in healthcare settings, where there is a higher concentration of elderly persons and individuals with immunosuppression or severe chronic disease, is a major concern.”

According to the report’s findings, of the people surveyed 414 (21.6%) of the workers reported flu-like symptoms, and 183 (41.4%) reported working with the symptoms for at least three days at a time. Pharmacists (67.2%) and physicians (63.2%) had the highest frequency of working with symptoms suspected to be the flu.

By work setting, hospital-based workers had the highest frequency of working with flu symptoms—more than 49%. The most common reasons given for working while sick included still being able to perform job duties and not feeling bad enough to miss work. Among workers at long-term care facilities, the most common reason was inability to afford lost pay.

Suggested solutions

So, what does this mean? Well, perhaps most revealing about the study is the prevalence of healthcare workers who think it’s acceptable to show up for work when they aren’t feeling well.

“Training to change social and cultural norms of HCP, such as the expectation to work unless experiencing severe symptoms among clinicians, might address these misconceptions,” the authors wrote. “Different strategies for modifying norms might be needed for different healthcare occupations. For example, physicians develop their sense of professional identity and adopt professional norms and values over a long period of training, which may differ from the experience of nonclinical HCP.”

In addition, the authors of the study came up with several suggestions that healthcare facilities can use to try to fight the problem of workers coming to work sick.

Make workplace policies clear. After listening to the reasons workers gave about why they came to work sick, including the ubiquitous “I could still perform my job duties,” and “I wasn’t feeling bad enough to miss work,” it became clear that individuals may not be the best ones to make the decision about whether they should work. For that reason, the authors stressed that there should be a clear policy and culture that stresses the importance of infection control in the healthcare workplace.

“Employers can convey that the perspective of infection control at the institutional level is important for HCP to consider when deciding whether to work during (an illness),” according to the report. “For example, one academic medical center instituted a triage system requiring HCP with fever or upper respiratory symptoms to undergo evaluation and viral testing. This system provided symptomatic HCP with more information regarding their risk to others. This institution also instituted mandatory absence from work for at least 7 days if testing was positive for influenza.”

Make it easier to take sick time. Many healthcare workers interviewed in the survey said did not take time off from work when they were sick because they were could not afford to lose pay for time off. This may mean that you need to consider a change in policy for sick time. The reports authors suggested institution-level resources to accommodate sick leave, including a “jeopardy system” in which some workers are held in reserve to back up sick colleagues.

This “may help reduce common perceived barriers to taking sick leave when the risk of transmission to others is taken into account,” the report said. “Such barriers include difficulty in finding coverage and desire to not burden colleagues.”

Make the flu shot mandatory, but remember that it isn’t a guarantee. Many facilities encourage their workers to get the flu shot every year, and in fact some make it mandatory. The report’s authors claimed that the fact that a worker received the flu vaccination at any time during the 2014-2015 influenza season may have contributed to the decision to come to work, even with symptoms. In other words, their perception is that there is no way they could have the flu if they’ve gotten the shot, which of course is not the case. Workers should be educated about the flu vaccine, and again, should be encouraged not to come to work if they feel sick.

In many places, it’s still not legal to require flu shots for employees, and if unions get involved it’s a much more complicated issue. Many people still have religious requirements, or moral protests against required flu shots. But the truth is that the flu shot has been proven to be safe and extremely effective.

Therefore, employees who work with patients should be encouraged to get a flu shot each year. In most cases, the flu vaccinations are free, and they really will make things healthier in your facility. Statistics show that those who get the shot stay healthier with very little risk of side effects. That translates to healthier workers who can come to work and not get patients sick. At the very least, there must be a very strict policy in place preventing patient contact when workers are sick, and in all cases, they must wear face masks when working anywhere around patients with compromised immune systems.

During the winter months, you should encourage workers to stay healthy. Your staff cannot help patients when they are not well, so encourage them to keep healthy by living a healthy lifestyle. They should be washing their hands regularly, eating well, and getting plenty of sleep—and staying home when they are sick. They should be getting plenty of exercise, downtime, and time to spend with their families and pursuing hobbies.

Make PPE mandatory, and train more. It should be common sense, and common practice, for anyone who works in healthcare that PPE is part of the job. Yet for some reason, workers still come up with every excuse not to use it.

Over the years, PPE—and standards from OSHA and other regulators—have been developed to help reduce and prevent workers from getting hurt or sick on the job. Yet, every year, we hear more about how healthcare workers have some of the highest workplace injury rates in any industry in the United States. To make things worse, every so often an illness rarely, if ever, seen in the U.S. makes its way into the country’s healthcare facilities (think MERS in 2012 or Ebola in 2014) and changes the way the healthcare community looks at PPE. In addition, training often takes a back seat because of shrinking budgets and lack of time.

“PPE does not remove the hazards; it protects the individual,” says Marjorie Quint-Bouzid, MPA, RN, NEA-BC, who currently serves as vice president of nursing at Parkland Hospital and Health System in Dallas. “Healthcare organizations must continue to attempt to mitigate potential hazardous situations or practices as the first line of defense.”

The trouble doesn’t stop with infection control. Pharmacists who handle hazardous drugs, and the nurses who then administer them, are at high risk of occupational exposure. These exposures can cause acute health effects, from sore throats to hair loss; allergic reactions; cancer; and reproductive toxicity—including an increased risk of miscarriage.

A 2011 National Institute for Occupational Safety and Health (NIOSH) survey reported that the most common reason given for failing to wear gloves was that “skin exposure was minimal”—an opinion at odds with various biological measures of worker exposures.

In 2011, NIOSH surveyed 2,069 healthcare workers—most of them nurses—who had administered one of more than 90 specific antineoplastic drugs in the previous week about their adherence to safe work practices. According to the survey, which was published in the Journal of Occupational and Environmental Hygiene in 2014, workers reported that they had engaged in risky activities or been exposed to hazardous drugs by incidents that included:


  • Failing to wear a nonabsorbent gown with closed front and tight cuffs (42%);
  • Priming intravenous (IV) tubing with the antineoplastic drug (6% had done this themselves; another 12% reported that this was done by the pharmacy);
  • Taking potentially contaminated clothing home (12%);
  • Spills or leaks of antineoplastic drugs during administration (12%);
  • Failing to wear chemotherapy gloves (12%); and
  • Lack of hazard awareness training (4%).

When NIOSH asked healthcare workers why they did not wear their personal protective equipment (PPE), including double gloves and gowns, while compounding or administering hazardous drugs, it found that workers were essentially shrugging off the risk. “Skin exposure is minimal” was the most common answer to the question, followed by “not part of our protocol” and “not provided by employer.” The researchers concluded that “there is a perception among respondents that chemotherapy drugs pose a minimal exposure risk.” In addition, workers reported that employers failed to implement safe work practices and provide PPE in many cases.


The dangers of compassion fatigue

Nurses are the frontline of patient care, making them the most susceptible to compassion fatigue, a state of mental exhaustion caused by caring for patients and their family through times of distress. It’s important that nurse managers are aware of the risks, identify the signs in their staff, and provide guidance to nurses that need it. While the increase in stress and unhappiness caused by compassion fatigue are evident, some of the other consequences are less obvious:

Increased medical risk: Compassion fatigue can lead to an increase in medical errors due to a lack of communication or inability to react. Nurses suffering fatigue can become unsympathetic, self-centered, and preoccupied, to the detriment of a patient’s care. To read more about this connection and how to counter it, check out Reduce Nurse Stress and Reduce Medical Error from HealthLeaders Media.

Decreased retention: The increased stress and potential trauma associated with compassion fatigue can drive new nurses away from the field. The American Association of Colleges of Nurse reports that 13% of newly licensed RNs work in a different career within a year of receiving their license, and 37% said they were ready to change careers. Many reported that the significant, ongoing emotional stress was a factor in their dissatisfaction.

For more information on combating nurse fatigue, check out the Health and Wellness section of the Strategies for Nurse Managers Reading Room:

Don’t underestimate damage caused by burned out nurses

Preventing nurse fatigue
Beat nursing stress and stay calm and collected

3 tips to resolve staff conflicts

Nurse managers often find themselves in the middle of conflicts, including personal conflicts between staff, nurse-patient conflicts, and interdepartmental conflicts. These issues can be disruptive, and lead to a decrease in productivity and staff morale. This makes the ability to resolve conflicts an essential skill for nurse managers, but nurses rarely receive formal training in conflict resolution. Here are some three tips to manage conflicts in your unit in a stress-free and effective manner.

Active listening: When faced with a conflict, it’s important to listen to what a person has to say and understanding their perspective. This means meeting face-to-face, asking open-ended questions, and listening without interrupting. Observe important nonverbal cues and make sure each side in a conflict understands the other’s perspective.

Keep calm: Emotions can get heated in the midst of a conflict; work to recognize your own emotions, as well as the feelings of those involved. Try to maintain a compassionate understanding for those involved, and acknowledge their feelings when analyzing a problem.

Stay positive: The negativity of some disputes can sometimes seem overwhelming. If you can manage to maintain a positive attitude and a calm demeanor, you’re well on your way to resolving most conflicts.

Source: Minority Nurse

For more about communication and conflict resolution, check out our educational articles from the Strategies for Nurse Managers Reading Room:

Hone your skills as a nurse mediator to manage staff conflict

Improve communication with these teaching strategies for the classroom