A Critical Building Block for Successful Good-Conduct Policies

This past January, the Joint Commission’s new standards addressing behaviors that undermine a culture of safety went into effect. Health care professionals and organizations are being called upon to develop, promote and maintain cultures where zero tolerance for abuse becomes the norm — a daunting task because it requires behavioral changes that are complicated by unhealthy power dynamics, mixed messages, self-esteem issues and old pervasive patterns. And yet this culture change is critical to key nursing issues like quality, safety and job satisfaction.

Organizations that are seeking to develop and maintain a culture of safety should consider integrating a “no innocent bystanders” rule for three compelling reasons. As background, “no innocent bystanders” is a rule that many school systems are using to address bullying, and the same principles apply to our workplaces. In fact, the American Academy of Pediatricians recommends a similar approach in their new policy statement that defines the role of the physician in youth violence prevention.
What follows are three compelling reasons to integrate this idea into conduct policies addressing disruptive behavior in health care workplaces.

1. Organizationwide accountability becomes a cultural norm.

A survey by the Institute of Safe Medication Practices found that “40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator,” according to a recent patient safety alert from the Joint Commission.

Promoting a “no innocent bystander” policy is a strategy that will help organizations infuse a zero-tolerance-for-abuse standard into its culture. Such a policy requires everyone to participate in, and be responsible for, workplace dynamics.

Our collective status quo has allowed, and perhaps promoted, a mindset where witnesses to disruptive behavior look the other way, justify the behavior or offer support to victims off the record. The rules for a “code of silence” are generally implicit and involve complicated combinations of tradition, fear and power mixed with a lack of knowledge, skills and support.

Setting clear expectations for witnesses is an important motivation for changing these old patterns. Even thinking and talking about this idea is worthwhile. Organizational leaders can examine the concept and facilitate important dialogues. Questions like the ones that follow will surely get people talking:

How do individuals respond to toxic behaviors now? How has bad behavior impacted them? What do employees need in order to feel safe when intervening in disruptive incidents?

Tough, honest and safe conversations can contribute to successful long-term cultural change.

 2. The shift of power supports respectful interactions.

The unwritten rules and fears that keep us silent are extremely powerful. Worries about job loss, retribution, or uncertainty about appropriate behavior are very real factors in maintaining silence. Silent witnesses, regardless of intention, give more power to bullies and more fear to victims. When bad behavior occurs in workplaces and no one speaks up, there is a sense of acceptance for the inappropriate conduct. This acceptance inadvertently condones the bullying and isolates the victim.

If you put aside, for the moment, the complications of achieving a “no innocent bystander” standard, can you envision how an integral power shift could occur when witnesses become part of the equation? Here are a few examples of how witnesses might participate in bullying situations.

Doctor to doctor: Joe, you’re out line. Take five minutes and cool off.

Nurse to nurse: Barbara, talking about Sally behind her back is disrespectful, and I don’t want to participate.

Nurse to doctor: Dr. Jones, stop it! I’m not going to stand by while you are yelling at my colleague.

Whether silent or voiced, bystanders have a lot of power. Doesn’t it make sense to channel this power constructively?

3. Intervention provides feedback on appropriate and inappropriate behavior.

Speaking up about another person’s perceived inappropriate behavior makes a statement about what is not acceptable. This can lead to important learning and growth opportunities for everyone present.

The victim may have confusing feelings of fear and anger, and hearing an observer’s opinion may help the victim to see more clearly how inappropriate a bully’s behavior is. This is likely to contribute to a sense of confidence about speaking up, setting limits and honoring his or her own experience. The bully may find out that her behavior has a negative impact on others and, more importantly, perhaps learn that there are consequences for bullying. Other witnesses can compare their own reaction to that of the one intervening.

Inappropriate behaviors are not always black and white. Being yelled at may be more intimidating to some than to others. Yelling may be a bullying tactic, but not always. It may vary with perceptions, or be a strategy for overcoming a noisy environment, hearing deficits or distance. Teasing out these gray areas requires open and safe discussions in supportive environments.

In summary, changing the status quo is challenging work. Yet how exciting will it be to work in environments where respect is mutual and pervasive? Such workplaces hold much promise in terms of improving safety, job satisfaction and quality of care.

Beth Boynton, RN, MS, author of Confident Voices: The Nurses' Guide to Improving Communication & Creating Positive Workplaces, is a consultant, speaker and teacher. [bbbboynton@earthlink.net]