Toxic Nursing: The Stories, The Solutions

Gossip and Trash Talk

One busy evening, Liandra—who has worked in the ED for many years—makes a medication error, which is quickly caught and corrected by one of her coworkers. Despite the self-limiting nature of the medication mistake, Liandra is consumed with guilt. She can’t stop retracing her steps and trying to figure out what led her to give the wrong dose of medication.

Carrie, Liandra’s coworker, works a double on the night after the mistake is made. She tells the entire night shift about it. By morning, the night-shift workers are convinced Liandra nearly killed a patient and will suffer serious repercussions.

One of them calls Liandra to console her and discovers the incident has been blown out of proportion. This is not the first time Carrie has been caught exaggerating at the expense of a coworker.

The Expert Weighs In:

It’s important to have established a culture in which an error is reported rapidly and the focus is not on laying blame, but on exploring why it occurred and preventing future errors.

The manager needs to talk to Carrie and help her understand how her actions have created a toxic environment: Not only has she created problems for her colleagues, but she has also shifted the focus from prevention of these errors to seeking blame for an error that anyone could make.

The manager should work with the staff to create a culture of trust so errors can be reported quickly and accurately without fear of repercussions.

–Melissa Snyder, DEd, CRNP, Campus Coordinator of Nursing Programs, Penn State Harrisburg

Rude Docs

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 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.

The Expert Weighs In:

In this example, at least two doctors are known on the unit for berating new nurses.

Stopping this disruptive behavior is crucial for collaboration, safe care and for rewarding long-term careers. Ideally, the nurse manager would have spoken with these physicians before Hector started 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 may be all that is needed. Because that didn’t happen, the nurse manager will have to speak with Hector privately and explain that he or she is working on addressing this behavior with the physicians and that Hector should try not to take it personally.

In addition, he or she should role-play with Hector to help him be assertive with these doctors the next time an incident occurs.

Finally, the nurse manager should be aware that staff might be contributing to an unhealthy alignment of “us versus them” with the physicians.

–Beth Boynton, RN, MS, Organizational development consultant, speaker and author, Beth Boynton Consulting Services

Rankism

Rose, a “mature” nurse, takes great pride in being the most experienced employee on the geriatric unit. Whenever a new nurse appears, Rose goes to great lengths to tell him or her that she has been at Grace Hospital since the unit opened.

One busy day on the unit, Tammy, a float nurse who regularly comes to the geriatric unit, is assigned to work with Rose. As soon as Tammy arrives, Rose gives an exaggerated sigh. “Oh gosh, I guess I’ll have to help you all day—again,” she says to Tammy, who thinks she’s joking and laughs.

Rose spends most of the morning telling Tammy how to do basic procedures that Tammy is competent to perform alone. Eventually, Tammy feels as if Rose is condescending and trying to give her the message she’s just not good enough to work on the geriatric unit. “Just because she’s been here 20 years doesn’t mean she’s better than me,” Tammy tells the supervisor. “Please, don’t send me there again.”

The Expert Weighs In:

Rose, through her tenure, perceives herself as the expert nurse on the geriatric unit. This elite self-designation sets the stage for a work environment in which bullying or insidious intimidation can flourish. Rose may perceive a threat to her position and status and has resorted to classic bullying behaviors to maintain her influence—unwarranted criticism and excessive monitoring of a competent and experienced nurse. It’s also likely that Rose will exhibit the same behavior with other nurses if she continues to feel a threat to her status on the unit. Tammy reacts in a manner that relieves the problem for her by requesting not to work on the unit again. However, this doesn’t eliminate the problem that Rose’s behavior creates for the unit and the ability to ensure the recruitment and retention of qualified staff. Once the nurse manager is made aware of the situation, she can continue to assess the ongoing impact of Rose’s behavior on the unit.

–Mary T. Meadows, MS, MBA, RN, CENP, Director, Professional Practice, AONE, Executive Director, AONE Foundation

Politics and CYA (Cover Your Ass)

At St. Clara Hospital, nurse managers must obtain the approval of their nursing supervisor prior to discharging a patient. The policy was created when there was a problem managing empty beds and a physician complained to the CEO. Now, the director of nursing reasons that supervisors will know the status of a particular unit at all times.

“This is ridiculous,” Dolores, one of the new nursing supervisors, tells a coworker. “All I basically do is acknowledge what the nurse managers tell me. The computer could easily do the same thing.”

At the unit level, nurse managers are now requiring all nurses to “check in” with them prior to discharging a patient. “It’s stupid, I know,” says Jill, a nurse manager. “It creates an extra step for everyone, but I guess we’re all paying the price because a doctor blew his stack when his patient sat in the ED for two days, waiting to be admitted when there was really an empty bed.”

The Expert Weighs In:

Top-down change is rarely successful because the people who understand the process the best aren’t involved in the solution. The more input people have in designing the change that affects their work, the more they will own the results.

Forced change is typically met with a cynical response, especially when it creates more work and frustration.

Managing change is difficult and challenging—even when new policies make jobs easier—and leaders must know their roles during these periods of change:

• Listen carefully to what people are talking about. Never make them feel like their comments are silly. Never make promises or try to convince people the change is good; they will come to their own conclusions.
• Allow people time to process the information and vent their feelings and concerns.
• It helps to have leaders highly visible during times of change. People must feel they have direct access to leadership.
• Remain calm and positive. Leadership will set the tone for the change.
• Remember, the people in the organization are the organization—they need to be involved and treated fairly.

–Sherry Kwater, MSM, BSN, RN, Chief Nursing Officer, Penn State Milton S. Hershey Medical Center

Patients as Victims

Aria, an RN with 10 years of experience on a medical-surgical floor at Community Hospital, has worked a double shift after another nurse calls off sick. After 10 hours of caring for difficult patients, she is tired and grouchy.

A patient, Mr. Truman, is recovering from major abdominal surgery. He needs a dressing change and pain medication, but Aria is busy helping another patient who has IVs and mobility problems get to the bathroom. Mrs. Truman searches her out. “My husband really needs you,” she tells Aria. “He’s got a lot of pain.”

“I’ll be there as soon as I can,” Aria replies.

Ten minutes later, Mrs. Truman shows up again, repeating her request. This time, Aria follows her down the hall and tells Mr. Truman she is getting his meds and the supplies for his dressing change. Aria completes her care of Mr. Truman, but is rough and unpleasant as she does so, because she feels stressed and unappreciated. Mrs. Truman later files a complaint with Aria’s nurse manager.

The Expert Weighs In:

The impossibility of one nurse needing to be in two places at once comes up over and over again in clinical practice, and it’s actually an easily solved problem. Answering call lights should be everyone’s responsibility, and there should be enough staff on the floor that Aria could call an aide, another nurse or even the nurse manager to either help the patient get to the bathroom or give the pain medication to Mr. Truman. Managers also need to be tuned in to whether nurses are working a double shift and be prepared to give an overtired nurse more backup.

The real problem here is the chronic one of hospitals not having enough staff to cover call-offs and expecting nurses on the floor to make up the difference without any negative consequences to themselves or patients. Aria is only human; being confronted in the hallway by an irate family member is likely to produce irritation. The nurse manager will need to hear Mrs. Truman’s complaint and then apologize for not staffing the floor adequately and not giving Aria the support she needed to do her job. She also needs to follow up with Aria in a supportive way, admitting Aria was overworked, but making clear that being rough with patients is, of course, not okay.

–Theresa Brown, BSN, RN, OCN, Staff nurse, contributing editor to Scrubs, columnist for The New York Times and author of Critical Care.

The Supernurse Syndrome

When one nurse believes he or she is automatically a better nurse and more skilled than everyone else, chaos ensues. Are there Supernurses in your hospital? On your unit? By any chance, could you be a Supernurse? Answer the following questions to explore further.

Using a scale of 1 to 10, with 10 being “agree as much as possible” and 1 being “disagree as much as possible,” respond to the following:

• I believe that I’m a very skilled nurse.
• My supervisors and other administrators consider me a good nurse.
• I’m the best nurse in my organization.
• The feedback I get from my coworkers about my nursing abilities makes me feel as confident as possible.
• I’m more skilled than most of my coworkers.

These questions are meant to prompt reflection on how you view your own competencies in comparison with those of your colleagues. You could also use them in a meeting of colleagues or staff and start a dialogue on the Supernurse Syndrome.

What do you think? This is a personal, real issue that can affect nurses at some point during their career. Please share your thoughts and your own experiences in the comments section below.

This article was republished with permission from SCRUBS Magazine.