Years ago, at a National League of Nursing meeting, Loretta Nowakowski, former director for Health Education for the Public at Georgetown University School of Nursing in Washington, D.C., proposed that disease could be best understood by looking at hurricanes. She noted that, like a serious illness, hurricanes occurred only when many factors were present within relatively narrow parameters and that an appropriate intervention could alter the severity or course of a disease or hurricane. This discovery was encouraging to Nowakowski—it meant that an intervention, made at any point, could alter the final outcome.
And so it is with horizontal hostility. History, gender, education, work practices, interpersonal relationships, communication skills, and organizational structure all contribute to horizontal hostility. The “hurricane” of horizontal hostility cannot manifest without these predisposing factors, so to intervene anywhere in this vast array can change the outcome from hostile to healthy.
The good news is that no matter what our current role—whether CNO, staff nurse, director, educator, or manager—we can implement interventions that will decrease hostility. Multiple opportunities are available at various levels.
Framework for leading organizational change to eliminate hostility
Enacting a twofold method (i.e., increasing a healthy environment while simultaneously decreasing hostility) is the most effective approach that managers can take to enact change at the organizational level.
To increase a healthy culture, leaders must:
- Firmly establish board and senior leadership team commitment
- Make harm visible: Frame disruptive behavior as a safety issue; importance of teams:
– Create infrastructures to support managers and staff: Include behaviors in annual reviews for all staff including physicians
- Shift the power structure from a hierarchy to a team/tribe:
– Provide a constructive feedback system for accountability and performance
– Provide leadership training and confrontation skills training for managers
– Provide assertiveness training and confrontation skills training for managers
– Monitor the organizational climate
– Increase social capital—build a strong informal network
To decrease hostility, leaders must:
- Adopt a zero-tolerance policy for all disruptive behavior:
- Same rules for all roles!
- Transform power from a hierarchy to a tribe/team
- Adopt a zero-tolerance policy for horizontal hostility
- Provide leadership and conflict management training for managers
- Educate staff about the etiology and impact of hostility
- Create a system for reporting and monitoring the culture
- Participate with other hospitals to pass state legislation
Increase a healthy culture
Garner commitment from board and senior leadership
Eliminating horizontal hostility at an organizational level begins with a team commitment from the board of directors and senior leadership. Although this may seem obvious, the concept must be restated to prevent the obvious from inadvertently blocking progress when administration attempts to hold staff accountable.
I tried to talk to the surgeon about his obnoxious behavior in the operating room, but he said, “I’m not employed by this hospital so you can’t enforce your silly rules.” How does administration expect me to look my staff in the eyes and tell them not to be rude and disrespectful when they see the same behavior tolerated by surgeons? It won’t work!
The V.P. took this situation to the board of directors, who did nothing. At my last hospital, the board would meet with the physician and explain that if he walked through our doors, and was operating in our hospital, then he must adhere to our core values of respect … if you operate in the hospital, you are the hospital. What a difference!
Commitment should stem from an awareness and understanding of the detrimental effects of hostility to morale and teamwork. Senior leaders also must realize that one of the greatest weaknesses of being at the top of the food chain is that you don’t necessarily receive accurate, honest information. By its nature, a hierarchical top-down infrastructure discourages the upward flow of information. And the longer you are with any organization, the more you assume the beliefs, views, and mind-set of the dominant group in order to politically survive (which many times translates to not saying what you see). With every promotion, the eyeglasses with which we view our own cultures get thicker and thicker.
After hearing that I had received a job offer from another hospital, several physicians called the CEO to complain, who then called me down to his office. Since I already had a job offer, I had nothing to lose by telling the truth. Boldly, I said, “I hate to tell you, but you are naked. It’s like the story ‘The Emperor’s New Clothes’ … you don’t have anything on, but you think you do. At other hospitals where I interviewed, I would have half the staff and double the support, yet you keep saying that this is the best place to work. It’s not.”
Hostile behaviors directly affect patient safety because cognition is impaired when humans witness rude behavior (Porath and Pearson, 2009). High-reliability teams have zero tolerance for any disruptive interactions because they understand that negativity derails communication. The prevalence of this behavior cannot be minimized: An Institute for Safe Medication Practices study of 2,000 clinicians found that 90% had experienced condescending language or voice intonation; nearly 60% had experienced strong verbal abuse and nearly half had encountered negative or threatening body language (Institute of Medicine, 2007). As stated earlier, a direct link has been proven between adverse events, mortality, error, and disruptive behavior (Rosenstein and Naylorf, 2011). Horizontal hostility is not a human resources problem, or a personnel problem, or a personality issue. It is a moral and ethical obstacle to providing safe patient care.
How safe are our hospitals? Medical mistakes (including nosocomial infections acquired in hospitals) are the third leading cause of death in America. Anyone who works in a hospital has received a call asking for a recommendation … “Do you know a good surgeon for my mother?” When trust is low, people automatically access an informal network of information by calling friends who work in hospitals to keep their loved one safe. Proof that administration is aware of this inherent danger is evident in nurse managers receiving a heads up that a member of the board, or physician’s wife, will be admitted to the unit—because everyone knows that once in a while bad stuff happens. If senior leadership has not set the target at zero harm, then the expectation for patient safety in the organization will be the prevailing status quo, which is: We are all good people trying to do the right thing, but we are not capable of perfection … But we have the best policies, procedures, and people here.
I was rounding at a hospital prior to giving a board retreat. Six patients had died unnecessarily in their system the prior year despite medication barcoding, safety huddles, etc. I asked to speak to a nurse for a few minutes off the unit, and she agreed. She was proud of her hospital and her position as a nurse for over 27 years but could not give me one example of an adverse event or error from her unit. I shared with her that the reason I was there was to help the board understand why six people had died. Slowly she reached over and touched my hand and said, “Oh honey, you got to expect some harm. After all, we’re only human.”
Culture is extremely subtle. A fish doesn’t know it is wet.
Before buying an airline ticket, we don’t search out an airline employee and ask, “Excuse me. Do you know a good pilot?”
Other high-reliability organizations like aviation have a different mind-set—because they didn’t have a choice. When 583 people died at Tenerife in 1977, the entire airline industry was in jeopardy; when the Three Mile Island reactor melted down, the nuclear power industry realized they were all hostages of one another, because another accident would shut down the entire industry. More than 32,500 commercial planes fly above the United States every single day—so you’ve got to expect some harm, right?
No! From aviation to high-rise skyscrapers, nuclear power plants, and aircraft carriers, all high-reliability industries but healthcare have set their target at zero harm. These industries have designed reliable systems to catch error in a culture where relationships are perceived as crucial conduits of information and knowledge. Employees don’t have the “right” to speak up. They have a responsibility and an ethical obligation. They understand that as humans they may fail, but by building collegial interactive teams, they can succeed (Nance, 2009). It is the leader’s role to create and sustain the belief that zero harm is possible if we create a high-reliability system characterized by collegial teams.
A lack of transparency around death and injuries in healthcare has been tolerated by the general public to date because the healthcare culture has been able to keep these harmful events secret. But the push for transparency in cost, best practice, and quality will soon be followed by a demand for transparency around harm as the public shares their individual stories in our cyber world; and collective awareness spurns legislation for mandatory reporting.
Keeping the truth hidden has a profound but immeasurable effect on organizational culture. A culture that is built upon secrets produces distorted, inaccurate stories which result in every employee looking out for themselves: a fear-based culture. Making harm visible raises trust. When an organization’s mission, vision, and values match the everyday behaviors, the result is institutional integrity. Only when all employees feel safe will our patients ever be safe.
Kathleen Bartholomew, RN, MN, is an internationally acclaimed speaker and educator who uses the power of story and her strong background in sociology to illuminate and transform the healthcare culture. She is also the author of Team-Building Handbook: Improving Nurse-Physician Communications, Team-Building Handbook: Improving Nurse-to-Nurse Relationships, Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication, Stressed Out About Communication Skills, and Charting the Course,coauthored with her husband, John J. Nance. Today, Bartholomew and her colleagues at The Orca Institute apply best practice principles from the bedside to the boardroom in leadership retreats and on-site presentations.
Institute of Medicine. (2007). Preventing Medication Errors. Washington, D.C.: The National Academies Press.
Nance, J. (2009). Why Hospitals Should Fly. Bozeman, MT: Second River Healthcare.
Porath, C., & Erez, A. (2007). Does rudeness really matter? The effects of rudeness on task performance and helpfulness. Academy of Management Journal, 50(5), 1181–1197.
Rosenstein, A., & Naylor, B. (2011). Incidence and impact of disruptive physician and nurse behaviors in the emergency room. Journal of Emergency Medicine. Retrieved from www.physiciandisruptivebehavior.com/ admin/articles/24.pdf