Toxic Nursing, 2nd Ed. Cheryl Dellasega

skills training for all staff, creating opportunities for practicing and rewarding new behaviors, coaching individuals who may have a tougher time, and disciplining those who refuse to practice respectful behaviors. It is also crucial to have senior leadership support, no double standards, and a policy of “no innocent bystanders,” making everyone accountable for respectful dynamics.

      Ultimately, it is the nurse manager who will control the climate of an individual unit—often without much training in conflict management. Hopefully, working toward civility and away from conflict can be an approach that leads both patients and staff to communicate and interact respectfully, in a way that makes everyone feel valued.

clearing toxicity: scenarios, insights, and reflections

1.1 Too Loud

      scenario

      I sometimes work double shifts. On the 1600–2400 shift, there is an LPN who is well into her 60s. She has days where she is not as spunky and on top of things as other days. If it is a day where she needs more guidance, I try to be patient with her.

      There is an RN who becomes frustrated and has a short fuse with this LPN. I have witnessed on more than one occasion the RN degrading and yelling at the LPN, often in the hallway where the patients can overhear. Most times, the LPN did not do anything to warrant the verbal abuse the RN bestowed upon her. The only outcome of the relational aggression as far as I can see is the LPN becomes more frustrated and less alert to tasks she is to do for patients.

      One night, I was assigned to work with the LPN, and the RN was on the other team. There was an incident that involved the LPN with me and a volunteer. The RN tore down the hallway after the LPN and yelled at her. As soon as the RN returned to the nurse’s station, I approached her. I pointed out to her that her behavior was inappropriate and she had crossed the line and disrespected the LPN. The LPN didn’t want to hear about it, though, and she just walked away from me.

      –Anonymous BSN, RN-BC

      nurse leader insight

      In this situation, it is right to be concerned about the RN’s pattern of aggressive behavior toward the aging and possibly slower LPN. Any time such behavior is tolerated, it is given silent permission to continue. The message goes to all stakeholders that such behavior is OK.

      The most effective and direct way to address the incident would be for the concerned nurse to intervene while the hostile behavior is happening. In a clear and firm voice that everyone involved can hear, say, “Stop yelling at her right now. Your behavior is inappropriate!” In this case, the offending RN, LPN, and volunteer all get the same message about the behavior. This type of intervention gets easier, although not necessarily easy, with practice and a supportive organizational culture. Later, take a quick, private moment with the LPN and volunteer to see if they are OK, and convey the message that no one deserves to be treated like that.

      A private moment with the offending RN later in the shift would also be necessary. If the concerned nurse is a colleague, she might say, “I’ve been concerned about your yelling at the LPN for a while. It is harmful to all of us. If you continue, I am going to talk with the unit manager. If there is some way that I can be helpful, please let me know. If you have concerns about her performance, maybe you should talk with her or the unit manager. Do you understand what I am talking about?”

      If the concerned nurse is a supervisor, a more authoritative tone and approach are warranted. She might say, “Yelling at the LPN is inappropriate. I am aware that I have tolerated your behavior for a while and I was wrong to. I’m sorry if I have given you any ideas that abusive behavior is OK. It is not. Beginning now, I am going to call you on it and document it in your record. Do you know what I am talking about? Is there something that you need from me to behave more respectfully?”

      Given the ongoing pattern of behavior witnessed by staff, patients, and volunteers, the nurse manager should be concerned about the organizational culture on the unit. This pattern of behavior includes multiple missed opportunities for the concerned nurse to give constructive feedback to the offending RN, LPN, or nurse manager and the LPN’s unhealthy coping pattern of just walking away (a passive-aggressive action in its own way). In addition, there is the possible question of the LPN having performance issues. All these issues should be addressed.

      –Beth Boynton

      In this situation, the LPN who had been bullied by the RN is not spunky enough to stand up to the perpetrator. Although the LPN was warned by another nurse who witnessed the bullying, she still did not have the courage to stand up or even discuss the matter with the third person. I believe that by staying indifferent to her perpetrator, the LPN strengthens the RN’s hand, which makes things even more miserable. In this case, the best thing is to inform the superiors and administration about the situation by a petition. That being said, the attitude of the administration is highly important to prevent these hostile behaviors. If the administration is determined enough to solve the LPN’s problem, they will also prevent future bullying episodes.

      –Dilek Yildirim

      reflections

      Think about the “civility quotient” of your unit—what behaviors do you observe, and how does your team rate? Are they more or less civil than others within the institution?

      How far should a nurse manager go in intervening with interpersonal communication problems? Is it your job to make sure everyone on your unit “gets along,” or are there times when employees need to figure things out for themselves?

1.2 Rude Docs

      scenario

      Hector, a nurse on the rehabilitation unit, graduated from school the week before he started work. He is well received by his nurse coworkers, but the physicians give him a hard time. “You new nurses are all the same. No common sense!” fumes one doctor, Dr. Monroe, when Hector doesn’t realize he is supposed to have his patient in bed when the physicians make rounds.

      “If you had half a brain, you’d know that it’s your job to make sure these patients take in enough calories to help them get through rehab!” says another doctor, Dr. Carter. “It’s hard work to go through therapy all day.”

      Hector feels totally incompetent, even when the other nurses reassure him and try to run interference with the physicians.

      nurse leader insight

      In this example, at least two doctors are known on the unit for berating new nurses. Sadly, many of us have experienced a transitional shock coming from a rigorous academic environment with a sense of accomplishment, excitement, and commitment to practice to this hostile and disrespectful “welcome” to the real-world nursing environment.

      Stopping this disruptive behavior is crucial for collaborative, safe care and for rewarding, long-term careers. Ideally, the nurse manager would have spoken with these physicians individually prior to Hector’s starting on the unit. A quick chat in private about the expectation of respectful behavior, sentinel event data related to poor communication, the cost of recruiting and retaining qualified staff, and an invitation to look at teaching opportunities as they arrive may be all that is needed. Because that didn’t happen, the nurse manager should speak with Hector privately and explain that she is working on addressing this behavior with the physicians, that Hector should try not to take it personally, and that she would like to help Hector be assertive with these doctors the next time an incident occurs. They could use a scenario to role-play a response.

      This would provide Hector with language and leadership support for the next time he is attacked by these doctors. Using a clear, firm voice and confident body language, Hector might say, “Dr. Monroe, your comments about all nurses lacking common sense are offensive. My goal is to work with you collaboratively for the safest and best care of our patients. I am happy to hear feedback on your preferences and concerns, and I expect you to treat me with respect. Can I count on you for this?” Or, “Dr.