Transcript

Hello, this is Sally Cohen, and it's another episode of Conversations with Sally. This time our topic is disruptive behavior and nursing. And I'm pleased to welcome my guest today, Ron Keller, who is the Senior Director of Nursing at NYU Langone Health. Ron has a PhD in nursing research and theory development from NYU Myers College of Nursing and a master's in public administration from the Wagner School at NYU.

In addition, he is a certified nurse executive. The reason I invited him to be our, guest here today is that he's done a lot of research and work on disruptive behavior and bullying.

Both as a researcher and a nurse leader. I'm going to start out with a fundamental question, which is, what is disruptive behavior in nursing? Or what does it mean to you?  

 It's really any inappropriate behavior that can be a confrontation, conflict, it can range from verbal to physical abuse, it can even go down the path of sexual or other forms of harassment.  What the most common report that I see and we hear in the evidence are verbal abuses. So that can be angry, abusive language any yelling or cursing or belittling.

type tirades but as I said, it could even take the form of some physical mistreatment. What we do see now and we can't forget about is the written forms of disruptive behavior. So now in our health records, nurses and other professionals are texting one another about patient stories. We all use email.

So there's the written component. to disruptive behavior as well.

 When you say written, does it go into the patient's record this way?

No, no, we texting. Some of our more sophisticated electronic health records have the capacity built in for professionals to text through the system about patient care.

So when there's that kind of disruptive behavior about patient care, is it directed. Nurse to nurse in this case. You didn't do this right or something like that.

It also may be an escalation to a provider about patient care and the response.

Didn't you know this, you should have dot dot dot. It can take on a tone of frustration and escalate to what one might consider disruptive.

So we're not just talking nurse to nurse here, we might be nurse to physician or anybody else.

Yes, or an advanced practice nurse.

Okay, right, right.

 So what's the difference between disruptive behavior and bullying?

The key difference is bullying is classically defined with a repetitive nature.

So it's happening over time, there may be an intent or it's repeated behaviors by an individual. They both have the negative effects but certainly when something's happening over time to an individual or it's the practice of someone to display those negative behaviors then there's a consistency there.

I remember reading that in some definitions, even if it was, Unintentional, it could be considered bullying. So, the classic example is the person who makes faces while somebody else is talking at a meeting. Rolling their eyeballs or grimacing while someone else is talking. They might not intentionally do that, but it has an impact. Would you consider a negative impact on another person? Would you consider that bullying?  

If it's happening over and over,

yeah, I would passive aggressive behaviors are very commonly reported whether it's this gesturing that you're describing or agreeing to do something and really not.

taking it on wholeheartedly. And we see that in nursing quite frequently, or as it's reported because We need to precept other nurses and bring them into the profession and that experience is critical to the success of becoming a nurse. All of us have had to do it in our lifetime as clinical nurses.

Let's face it, not everybody does it with the same gusto and in the same way that you would want them to.  

 So is there is that the behavior manifestation of resentment?

Yeah. What? What?

The underlying causes for some of these actions, well,  that, that's a tough nut there,  there are certainly environmental factors, , the work environment that may contribute to some of these behaviors, but what's underlying there that motivates one to accept it, a precept or assignment, and not.

Nurture someone in that experience sometimes can be quite baffling.

We've seen a lot of that. 

It falls under the umbrella that even a few experiences are ones that we want to prevent. I'd like to think these are not happening every day everywhere, and we've taken some steps to help improve the environments and support a healthy workspace.

But they do happen.

So if someone tells you that they've experienced that, what do you do? In the preceptor, I'm specifically referring to the preceptor situation.

As a nurse leader the first thing is that investigation phase. So you're listening to the experience of the person that's sharing what happened. And then I would go to the preceptor as well and hear there.

Perception

I think it takes a lot on the part of the precepted. individual to speak up. Either they have to have reached a point of emotional pain or, maybe not.  Maybe not everybody has to suffer before they speak.

What are your thoughts or concerns about that individual and how to handle them? This is all about hearing stories.

There are certainly two sides to every coin here. And so if this is a new hire, and this is the first report of an experience, and it's with a preceptor hypothetically that you have some known and relied upon. And this would sound like something totally aberrant in their everyday practice.

Well, well, then you're putting your lens to this investigation. Sometimes it's everyone has a bad day. It's when you're saying to yourself, wow, this is not the first time I've heard this story.

What do you do? We do give leaders. some tools on how to address this, and I even role-play some of these exercises with leaders.

If you're down to that, I start to set up a verbal contract with somebody.  Let's both agree That If somebody was to be onboarded on our unit and the preceptor was consistently rolling their eyes,  if a preceptor was not giving the orientee the information they needed to perform their job, or if they provided insults, can we both agree that that would be disruptive behavior?

 You're setting up this contract with someone, and then should it happen again, it's on March 7th, I sat down with you, and we both agreed that these types of behaviors weren't accepted in the workplace. And now we're sitting down again.

 You've got to hope that for some of these individuals, it's bringing the awareness to them that they can change their behavior.

Are there some groups or characteristics of nurses who are more vulnerable than others to being bullied?

Well, the most common would be those new to the profession they may be clinically naive as they're developing their practices, might be younger. They haven't integrated into that team.

What do you do next if they, if there's a third and fourth time, what can you do about this?

Do you,  you might put it in there? HR record, but then do they go for counseling? Do they get warnings?  

Behavior is, is part of performance. As clinicians,  it's also the way we interact with the team. So if somebody needs to improve, you may set forth a performance improvement plan with that person.  Now you're putting that verbal contract on paper and  that moves along the line of progressive discipline setting forth those expectations  and setting quite clear deliverables at a timeframe

okay, now let's switch to another aspect of this, which is the organizational culture or the factors in the organization that might promote disruptive behavior unintentionally or that prevent it in some way. And I'm also thinking about having been through COVID and the tensions that we all experienced in providing care during that time.

What makes for a supportive culture

yeah, I'd first like to just acknowledge what you said in there about the lead in of since COVID.

You know, that's a statement that we hear a lot as leaders these days. Since COVID, things are different.  There's a lot of people attributing the change in our patients, change in visitors, and sometimes our professionals.

I don't know what the evidence there is to correlate that, but as leaders, we have to act upon it nonetheless. , in my initial studies of my doctoral program, Where I was looking at verbal abuses in different organizations, and there were some key factors  that stood out, you know, those environments that have high work group cohesion demonstrate less reports of disruptive behaviors.

Those environments where there's less constraints and constraints are,  those things that where you have the information you need to perform your job, there's less reports. And another was justice. Do people feel like reward and, and recognition is being distributed for the work done?

I recently received a complaint about the way assignments were being performed on a unit.  And the experiences of varying acuity on this particular unit, which by their very nature, one of the one of the attributes of bullying are unfair sanctions, which can come in the form of an assignment.

Wow.  

from nurse to nurse. So we started to measure the way assignments were done and the experience. So if it's a unit that was caring for patients of a particular population.

We made sure that everyone was going to get that experience or if charge nurse assignment needs to be rotated. Are we creating an environment as equitable for everyone?  

What'd you find out?  
 

In some circumstances where someone else had reported it. We were able to say, wait, hold on a second. Here's what you have done since hire date, which is exactly the same as what the other members of your cohort are doing.

And they were like, Oh, okay. That's good to know.

I will share that in our organization, myself and some colleagues put together a task force to address what to do when in the moment. We developed a program where we give people some tools using the bystander to upstander concept.

I understand.

So if you were to be the one who's observing this interaction by two between two people we ask people,  and this is not linear, but we apply four essence.

Go stand by the person who's the recipient for this. You're aligning yourself with them. You're demonstrating to others that they're not alone. And sometimes just the presence of another individual can make that person who's yelling aware, like, well, whoa, what's going on? And stop.  And then a key one is support.

We want you to provide that support to that individual. So whatever emotions are being triggered, someone's there to help. Put a stop to that, to that and stop that . We talked earlier about when do you speak up to the manager? When do you bring it to the next level?

And you know, I'd argue you bring all of it. Yet you speak up all the time. Doesn't mean every event warrants a progressive action,  but you want it to be known. And the other S is sequester to do things in private when, when possible.  We have a very successful program. It's voluntary. So, so nurses sign up to do this program , to date.

We've probably had about 300 nurses go through this. And we do a similar program for leaders. Where it changes for the leader is they have to do the next step of the follow-up.

So I think it's important to do that because if you don't, it festers and it just makes it worse.

It becomes like.  It's contagious in a way, and it becomes the way that people behave. It's how to stop it that's really difficult once it starts.

 Changing behavior is difficult. Yes.  So this is why we're still talking about this. Right. Time and nursing, because changing behavior is hard.

So a leader, I can teach you how to administer this medication in 40 seconds.  To bring a change in behavior in an environment takes time.  

 We're human beings and we've got a whole repertoire and bunch of things in our brain that interact to make us behave a certain way in certain situations. We're complex human beings.  You know, I hear all over the world, nurses saying, people saying, nurses are, are leaving. They're leaving the hospital. They're leaving the profession. They don't want to do this anymore.

Does disruptive behavior have an impact on nursing retention?  

Well, I will speak from the evidence there that yes, it does. And many of the studies that you look at report someone's intent to leave that have higher experiences of disruptive behavior and, and nursing.

And that should matter to everyone.

I will say, you know positively for our organization, our, our vacancy rate and retention our vacancy rate is low. Retention is better. So we are seeing some positive, all the emphasis on recognition, on wellness, while it hasn't been studied anecdotally I hear positive reports so it shows working on, consistently working on that culture and providing the support and resources might make a difference.

In a perfect world.  What would be your wish list for addressing disruptive behavior or for just disruptive behavior in nursing as a nurse leader?

Well, I'll answer that with a quote from Maya Angelou,  who said, do the best you can until you know better. Then when you know better, do better.

Thank you. That's a good place to end and to look to the future so that one day we won't be discussing this. Who knows? Thank you very much.

My pleasure, Sally.