Toxic Nursing, 2nd Ed. Cheryl Dellasega

free of clutter. He identifies nurses who “leave a mess” at the change of shift and lectures them publicly.

      After an especially busy evening shift, Deb, who juggled an extra patient due to short staffing, is preparing to go home—30 minutes late. Ron comes down the hall with a frown on his face. “Deb, I hope you’re not leaving! Your patient in 670 has dirty linen all over his room!”

      Rather than argue with Ron, Deb goes back to the room and discovers a used patient gown on the bathroom floor where the patient had left it after changing. She puts it in the laundry, but the next day she complains to the nurse manager about Ron’s “pickiness” and public harassment.

      nurse leader insight

      Observing the behavior of a single nurse within an organization is diagnostic of the style, needs, and wants of that individual and how their personal and professional aspirations are being met (or not). It is also a window into an organization and how well it functions overall. The leadership expectations, the management accountabilities, and the social culture of the unit as well as of the organization on a larger scale are transmitted to employees, patients, and the community. All these elements reflect the values and expectations of the micro unit and macro organization and are embedded in every behavior that staff display. That is why, in looking at the behavior of a single nurse, we must consider not only that individual but also the larger context in which that person is living, much like we would in considering the role of family dynamics in family therapy. There may be a “patient,” but there is also the family that tolerates the individual and often, consciously or unconsciously, reinforces defiant or deviant behavior, therefore disrupting the entire family unit. Let’s look at how these play out in practice.

      Every employee has strengths and stresses from various areas of their life. Work can often be a stage for living out the drama of one’s own life. In reading this example, I wonder if Ron has teenagers who are also leaving a mess at home? The difference between an unhealthy work environment and one that allows staff to work out conflicts in a healthy and productive way is that the unhealthy environment allows individuals to project blame, vent anger openly, and give license to an overall sense of lack of control. In essence there are no guidelines for conflict management that serve to solve problems and reinforce open, honest communication.

      In this example, Ron appears to be the agent of control. On one hand, his desire to keep rooms free of clutter is a good thing, but is it a shared value for the team? When he roars, people tolerate the bad behavior but quickly lose sight of the fact that what he is trying to achieve may be worth considering. It is all in how the group decides to set expectations and share in the decision-making and accountability for making decisions reality.

      What are the options here? Let’s look at each role:

      • Deb: Deb could talk to Ron directly, focusing on how Ron is inflating the problem—how she agrees with his objective, but not his method of communicating it. This could also offer the opportunity to have a broader discussion about room clutter at the next staff meeting. Deb does not react to the behavior but can focus on the patient-centered objectives and how to create a more orderly environment for the benefit of all.

      • Ron: Ron could identify room clutter as less of a personal objective than one that is focused on the patient from an aesthetic, quality, and infection-control perspective. He could take a leadership role with staff and explore with others the reality of how room clutter detracts from a professional environment that is aiming to provide patients and families with a four-star environment.

      • Unit manager: The unit manager should listen to Deb without taking sides, instead seeing the situation as an opportunity to practice conflict-management techniques. He or she could use this example in a follow-up discussion with the entire team on how to resolve the issue and set expectations that are fair, achievable, and attainable for all. By remaining non-reactive, the manager functions as a facilitator rather than an agent of control forcing the team to come to terms with each other. After a discussion on the issue of room clutter, staff-to-staff interactions, techniques to settle conflict, and how to respect each other, the manager in essence has moved the group to a different level of communication. The manager has also made expectations clear. Both have a role in making the unit a harmonious place to be. This serves as a baseline for future interactions between Ron and other staff.

      If the behavior persists, Ron may need individual coaching to recognize his responsibilities to his teammates. A determination may need to be made as to whether he can remain on the team. At the same time, the group must take joint responsibility and not let their reactions go underground, thus reinforcing his negative approach. Ron must learn that his behavior is not acceptable, and everyone needs to understand the steps involved in how to handle such issues in the future. Ron will find he gets more cooperation from his peers when he approaches them as a peer rather than as a critical, harping superior. And the team will feel more in control, knowing that when conflicts arise, it is their responsibility to deal directly with each other and to work out problems together.

      –Nancy M. Valentine

      Nurse managers must deliberately practice good listening skills to all complaints pushed up to them by their employees. Pushing a problem up the chain of command isn’t easily done by nurses. The culture has taught them to be silent or vent within their “safe” coworker groups. However, your main goal is to provide exceptional, safe patient care by empowered nurses. Keeping communication channels open will alert the nurse manager to problems brewing in the unit before a battle between shifts or units, or escalating nurse conflict, occurs. Open lines of communication are important.

      Confronted with the report of Ron’s behavior, the nurse manager knows any past attempts between peers has failed. Ron’s peers have exhausted their tools to stop the behavior. Frustrated and angry about Ron’s public cacophony, these nurses may avoid Ron at shift change. Peer communication has stopped as well as any information required on change of shift.

      Before acting, investigate! Speak to observers and targets of Ron’s behavior. Begin a private discussion with Ron from his perspective and to coach him on his behavior. A first-time complaint or observation may not require disciplinary action. A private conversation and coaching may uncover the basis of Ron’s behavior and a gap on a professional communication standard between shift changes. Document your coaching interventions with Ron.

      As a nurse manager, you should meet with each shift. Coaching and disciplinary action require your active involvement to change behavior. As a nurse manager, speak to all staff on your expectations at shift change. Create a policy and procedure with a checklist for shift change to ensure a consistent approach. And, as their manager, model the professional behavior you want to see in your staff. Unprofessional behavior disappears in the manager’s presence, so be prepared to continue surveillance and keep communication open.

      Formal disciplinary action is required if Ron’s behavior continues. To continue coaching or disciplinary action, consult with human resources and employee health services. Human resources will counsel and strengthen your approach on coaching or progressive disciplinary action according to policy. Employee health services can schedule psychological counseling for the employee or unit, if needed.

      –Peggy Ann Berry

      reflections

      Do you think Ron’s behavior counts as bullying? If not, why not? Identifying bullying can sometimes be difficult—and can feel like drawing an arbitrary line in the sand. Where do you draw that line in your unit? What do you do when a behavior might be right on the line, but not clearly over it?

      As a nurse manager, what strategies can you use to work with Ron?

3.2 Passing Judgment

      scenario

      The nurses on the Labor and Delivery floor know that Tessa is openly critical of the ER and calls the nurses who work there “lazy and sloppy.” One day, an emergency admission arrives on L&D just as Tessa is returning from lunch. As everyone hustles around the patient, Tessa grabs the chart and