Incivility in the Healthcare Work Environment

Nurses work closely with physicians, and this relationship has a long history of conflict. Often it is stereotyped as “us versus them,” which is an unhealthy approach. With greater emphasis on teamwork, nurses and physicians are slowly being forced into improving their work relationships. This change in attitude really needs to begin at the student level. Academic programs and HCOs need to stand behind efforts to improve team collaboration, coordination, and communication among their healthcare profession students and staff. One area that has received special attention is verbal abuse from physician to nurse. Unfortunately, this is also a problem nurse-to-nurse-incivility or bullying among nurses is now found in HCOs as well as in nursing education programs.

In schools of nursing, incivility is found among students and faculty, in faculty/staff-faculty/staff, student-faculty, and student-student interactions. Students may also experience bullying with nurses during their clinical experiences or observe it. In 2008, the National Student Nurses Association (NSNA) published an article about incivility in its journal, and this behavior continues to be a problem (Luparell, 2008). Involvement in this type of behavior may lead to physical and emotional responses, even causing the victim to feel traumatized, powerless, or stressed; lose sleep; and develop anxiety and depression. People may try to avoid one another for fear of another negative encounter leading to distrust. When students and faculty are in situations where evaluation occurs, distrust on both sides may prevent objective faculty evaluation of students and student evaluation of faculty-impacting trust. This behavior can be disruptive in the classroom (face-to-face or e-learning) and in clinical experiences, interfering with student learning both for the students directly involved and for the students on the sidelines. The community of learning then becomes a place where no one wants to be.

Incivility demonstrates disrespect. When this type of behavior occurs, decreasing the escalation of the behavior is critical. Many times, incivility occurs from misunderstanding, so trying to talk about the issue-in a calm manner-is important. Students may feel that they have no power. If the issue cannot be worked out directly with those involved, all schools should have a process for discussing difficult issues, and these guidelines should be followed.

Before you talk to a person (another student or faculty member) about a situation that you found unacceptable, think about what you will say and even practice before the discussion. Doing so will help you cope with your emotions because you do not want to have a repeat of the uncivil behavior. Another method for dealing with verbal abuse is to try to remove the emotion from the situation-step back for a breather and then discuss the issue or problem on a factual basis. This strategy may require a third party to act as a neutral mediator in the discussion. This is not easy to do when parties are emotional and often tired and stressed, but it does make a difference. Such an approach provides time to gain a more objective perspective.

When students observe or are involved in uncivil encounters in clinical experiences, this has a negative impact on their professional socialization and learning. Such behaviors are all connected to communication, the ability to compromise and listen, and respect and trust, which in turn affect the ability to work collaboratively as a team member. Students should begin to learn about healthy interactions with others when they are students, lessons that then should be carried into their practice to reduce incivility in the workplace.

Organizations associated with health care have made statements about the problem of incivility. In 2008, The Joint Commission issued a sentinel alert on incivility for its accredited healthcare organizations. Since the problem increased in HCOs, the Commission now requires that their accredited HCOs have standards in place to address this type of behavior, as they recognize it interferes with teamwork and quality care. The Commission (2023) views workplace violence as “an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.” Its accreditation standards require HCOs to manage their safety and security risks routinely, monitoring and collecting data about risks and incidents, and provide education and training about workplace violence for all staff.

Nursing organizations have also spoken out about these problems, demonstrating similar concerns as The Joint Commission. The American Association of Critical Care Nurses issued a statement about healthy work environments (AACN, 2021). The ANA also published a position statement on incivility in the workplace. It emphasizes the ANA Code of Ethics as a basis for preventing and resolving incivility so that the workplace is one in which healthcare organizations can “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (ANA, 2015a, p. 4). The position statement examines incivility, bullying, and violence in the workplace (ANA, 2015b). A 2017 and 2018 ANA survey noted that 29% of the more than 9,000 nurses and student nurses participating in the survey had experienced verbal and nonverbal peer aggression. Other studies examining workplace bullying “suggest the incidence of nurses experiencing it at some point in their career is much higher, and it can involve coworkers, administrators, physicians, and others. In our survey, however, 64% of respondents said they felt comfortable reporting instances of bullying. Reporting is key to ensuring that necessary culture changes are made” (Grant, 2019). All of this affects the nursing practice. It also has financial ramifications because incivility reduces productivity and may have a negative influence on staff retention as well as recruitment. This can also lead to health problems for nurses and interfere with career development.

Concern has also emerged about the impact of verbal abuse and disruptive behaviors among patient care team members. Examples of disruptive behaviors include verbal abuse, negative behavior, and physical abuse (for example, profanity, innuendo, demeaning comments); reprimanding or insulting another person in public and inappropriately; threatening others; telling racial or ethnic jokes; undermining team cohesion; scapegoating; silence (not speaking to a team member); and assaulting another person, throwing objects, and outbursts of rage (Lower, 2007). One study sought to explore the impact of work relationships on clinical outcomes (Rosenstein & O'Daniel, 2005). This research was published in a nursing journal, although a physician and a healthcare administrator conducted the study. The study was a follow-up to an earlier study that examined the impact of disruptive behavior on job satisfaction and retention (Rosenstein, 2002). These studies are older, indicating that incivility is not a new problem, and it continues.

Given that this chapter discusses the need for greater use of effective interprofessional teams to provide quality PCC, it is easy to see how team problems like this may be perceived as disturbing. Disruptive behavior may adversely affect patient safety, patient mortality, the quality of care, and patient satisfaction. These concerns further emphasize the need to improve teamwork and professional relationships. HCOs need to support open, safe communication among all staff members. To ensure this occurs, staff members require education about the problem of disruptive behavior and how to respect and communicate with one another even during stressful situations. HCOs must ensure that collaboration, communication, teams and teamwork, and conflict management are part of the culture, and this content is included in ongoing staff education. To augment these strategies, policies and procedures need to be developed and effectively implemented to guide staff in their actions when they need to respond to difficult interpersonal situations. There are also strategies that individual staff should consider when they respond to or work to reduce incivility, for example (Gessler et al., 2012, p. 11):

• Be assertive and confront the person(s) who is involved in the uncivil behavior.
• Use “I” language when talking to the involved person(s).
• If direct conversation about the situation does not work, then staff should report the occurrence as expected in the organization process. Identify critical information, such as date, time, who was involved, and what occurred.

Other nursing experts recommend the following (Moorehead, 2022):

• Conduct annual worksite analyses that help identify vulnerabilities within the hospital campus (dead-end corridors, inadequate lighting, multiple or uncontrolled building access points).
• Take action to mitigate or abate issues identified in the analysis.
• Collect and analyze information about workplace violence obtained through incident reporting.
• Act on trends and opportunities for improvement as identified via reporting and information analyses.
• Provide staff with training and education on the organization's workplace violence prevention program (when hired, annually, and when significant program changes occur).
• Include prevention, recognition, response, and reporting of workplace violence during training.
• Create programs developed by a multidisciplinary team and led by one designated expert.
• Report incidents of workplace violence to the organization's governing body.

Many organizations now have zero-tolerance policies related to this type of abuse. Some HCOs, as well as schools of nursing, have identified codes of conduct that staff or, in the case of a school of nursing, faculty, students, and staff are expected to follow (Lewis & Malecha, 2011). However, the existence of a written policy does not guarantee on its own that attitudes and behaviors will automatically improve. Staff members need to know about the policy content and the consequences of violating the policy, and these consequences must be applied when necessary. Some HCO policies ask nurses to use the term “Code Pink” when they experience incivility to alert others to these negative experiences and ask for support (MacLean et al., 2016). It is important for staff to have a structured method to ask for help as it makes it easier for staff to communicate if a problem exists. Nursing leaders, as well as other leaders in the organization, need to commit to reducing these problems (Lewis & Malecha, 2011). In addition, as noted earlier, this is not just an issue for the workforce. Students experience incivility in the school environment and need to know how to ask for help. Given these concerns, the ANA website has resources for students and also for use after they enter the workforce (ANA, 2020).

In summary, it is very easy to say that poor attitudes and abusive behaviors are all the physicians' fault when, in fact, they are not. Many nurses enter the profession with a negative attitude toward physicians and feel that they do not want to be controlled by physicians. The better approach is for new nurses to enter the profession with a positive attitude toward nursing as a profession, knowledgeable about the nursing role and responsibilities, competent, possessing a reasonable level of self-esteem, and willing to collaborate with others, whether they are nurses or other staff. Nurse-nurse incivility is all too prevalent and a serious problem; thus, the problem involves more than just nurse-physician incivility. What is needed to prevent incivility is someone who wants to work with others, not against others, and someone who approaches issues and problems with an open mind and not tied to an “I know better” mindset. If all healthcare professionals approached practice in this manner, then collaboration, coordination, and communication would improve. There would also be less incidence of verbal abuse, and the work environment would be positive and healthy for all team members.

Delegation

Delegation is part of the nurses' daily work. Care is planned and coordinated to meet patient needs, but at some point, the RN may need to delegate work to others. Much of the work is done in a team model. It is not cost-effective for all care to be provided by the RN. Delegation involves giving another staff member the responsibility and authority to complete a task or activity and distributing tasks or assignments to be efficient and effective. Before an RN can delegate, the RN needs to have responsibility and authority or power over the activity or task. An RN cannot delegate something that is outside approved nursing practice as determined by the nurse practice act in the state where the nurse practices. An extreme example is that an RN cannot delegate prescriptive authority (prescribing of medications) because an RN typically cannot do this activity. An advanced practice registered nurse (APRN), however, may have prescriptive authority because this nurse has met special requirements, and the state may allow the APRN to prescribe. However, even the APRN cannot delegate prescriptive authority as this activity is only approved via state regulations to specific persons.

When an RN delegates to another staff member, such as assistive personnel (AP) or an LPN/LVN, the RN is not avoiding work and is still held accountable for the outcomes, but this delegation may provide more efficient care. Accountability is part of this process, which means “being responsible and answerable for actions or inactions of self or others in the context of delegation” (ANA, NCSBN, 2019). AP are unlicensed staff members who are trained to function in an assistive role to the licensed nurse in the provision of patient activities as delegated by the nurse. AP may have several different titles, such as nursing assistant or nurse's aide. There is no national standard that is accepted and enforced in every state as to employment requirements, training, or position descriptions for AP. The RN (the delegator) is still responsible for supervising the work (activity, task) that the other staff member (the delegatee) will do. Delegation is dependent on the RN's judgment and the patient's needs, staff competence, and the amount of supervision required.

“Supervision” and “assignment” may be confused with “delegation”; however, they are not the same but related to one another. When a nurse is monitoring patient care and work performance, this is supervision. The nurse may be in a formal management position, such as a nurse manager, a team leader, or an RN staff nurse who has delegated work and then ensures that a task is done effectively. Assignment is the process that identifies who will do work activities. For example, the nurse manager might assign an RN to lead a team or to administer medications to patients. An assignment can be given only to staff who have the required qualifications to complete the task and can assume responsibility and accountability. The accountability is still shared in that the person doing the activity has the accountability for the actual action or activity, and the person who made the assignment, such as the nurse manager or team leader, is responsible for the assignment decision.

Importance of Delegation

Why is delegation important, and why is it part of care coordination and teamwork? One RN or one team member cannot always do everything that is required for a patient. There must be an effective use of staff resources-expertise and time. Delegation is a critical part of providing cost-effective, quality care. In some situations, if an LPN or AP can provide the required care safely, this is more cost-effective when salary levels are considered, with the RN providing overall supervision. Quality care requires that patient outcomes are achieved with no harm to the patient. Through delegation, the RN determines the tasks that should be done, by whom, when, and how. In 2019, the delegation guidelines were revised and applied to (ANA & NCSBN, 2019):

• APRNs when delegating to RNs, LVNs/LPNs, and AP
• RNs when delegating to LVNs/LPNs and AP
• LVNs/LPNs (as allowed by their state/jurisdiction) when delegating to AP.

These guidelines do not apply to the transfer of responsibility or handoff of care from one licensed provider to another.

Communication and information are critical elements of delegation. If communication is not effective, or there is inadequate information, delegation may then be ineffective. This can, in turn, lead to problems for the patient and interfere with the team's ability to achieve the desired patient outcomes. It is often difficult to provide clear communication in rushed, stressful healthcare environments, but improved care requires this type of communication. Mindfulness-staying alert to key information and evaluating and updating information as necessary-is an active process that can improve communication during delegation, as was discussed earlier. The goal is not to share as much information as possible but rather to share the critical information clearly-that is, information that has meaning in the situation. Anthony & Vidal (2010) comment on mindful communication and delegation,

Mindful communication practice is recognizing the significance of the facts and how they pertain to the patient situation. When nurses engage in mindful communication, information processing is redirected, resulting in a unique set of decisions and actions. Historically, RNs have relied on job descriptions and delegated skills lists to guide delegation practices . . . hospitals value standardization to improve safety through consistent practices.

The National Council of State Boards of Nursing (NCSBN) has identified delegation standards and described the delegation process. It defines “delegation” as “transferring to a competent individual authority to perform a selected nursing task in a selected situation. The nurse retains the accountability for the delegation” (NCSBN, 2023; ANA, NCSBN, 2019). This definition really describes the following:

• Transferring means the RN can do something that will be passed on to someone else to do. The RN has the right to transfer tasks; however, the RN cannot delegate something that the RN has no right to do as an RN. (For example, suppose a patient needs a bed bath. The RN can do the bed bath, but it is more efficient to have the AP complete the bed bath, while the RN assesses the patient's overall status at the beginning of a shift.)
• The RN transfers the activity to a competent person-someone who can complete the task because that person has the skills and experience to do so. (For example, the AP has been trained to give bed baths and report any problems encountered to the nurse.)
• In the delegation process, the delegator, or RN, is giving the delegatee the authority or power to do the act or task. (For example, RNs have overall responsibility and authority for all nursing care-from basic care, such as a bed bath, to complex care needs. The RN determines who is the best staff member to complete a task. In some cases, the RN may decide that because of the patient's critical status and the need for intensive interaction and assessment, the RN should complete the bed bath; alternatively, the RN may decide that the AP is best suited to handle this task.)
• The delegatee must then do something-this action is specific and attached to a specific situation. (For example, the AP completes the bed bath for a patient, completes required documentation, and informs the RN whether there is anything unusual to report.)

Five Delegation Rights

It is natural to wonder who is responsible for the care in delegation. The delegatee is responsible for the care that the delegatee provides or the delegatee's performance, and the delegator is responsible for the delegation process. This process is not simple and requires experience. The RN must consider the five rights of delegation (ANA, NCSBN, 2019).

• Right task: The task must be delegated for a specific patient or situation. If the RN or delegator is not clear about what the task is, the RN will not be able to clearly identify what needs to be done and by whom.
• Right circumstances: The appropriate setting, available resources, and other relevant factors need to be considered. Perhaps the RN needs to tell the delegatee where to complete the task and identify supplies, equipment, and other resources needed to complete the task effectively.
• Right person: The right person delegates the right task to the right person to be performed. The RN must consider the best staff member to complete the task (type of staff, experience and skills, availability of time to complete the task without negatively impacting other work, and so on).
• Right direction/communication: Providing a clear, concise description of the task, including its objective, limits, and expectations, is part of effective delegation. The delegator must explain to the delegatee what is to be done, how to do it (if that is not already clear), the time frame, outcomes, and so on. The delegatee needs to feel comfortable asking questions for clarification or expressing concern about the possible inability to complete the task. The delegator must be an effective communicator and sensitive to concerns and issues needed to establish a communication environment that allows for open discussion. This is critical to ensure patient/person-centered care that is focused on quality. If the delegatee is afraid of speaking up and saying, “I do not know how to do something” or “Would you explain more about what you want done?” then this is an ineffective delegation process that may harm the patient. The delegatee may need help in organizing work and setting priorities, or the delegatee may need to be told what to report to the RN and when. The delegator needs to ask directly if there are questions or concerns and be open to the response. All of this is part of providing clear directions and guidance.
• Right supervision: Appropriate monitoring, evaluation, intervention (as needed), and feedback are part of delegation. The RN, as a delegator, does not just delegate a task and then forget about it. Instead, the RN needs to supervise as required. Monitoring methods include observation, verbal feedback, written feedback, and review of records in which the delegatee documents what was done. In some situations, supervision is minimal; in other situations, there may be a greater need for monitoring. Factors, such as the expertise of the delegatee, the patient's status, the complexity of the task, and timing, may all affect the monitoring process.

The following information should be applied by team leaders and members during delegation and support the five rights (Shnur, 2023).

• Identify tasks for delegation based on needs.
• Ensure appropriate education, skills, and experience of persons performing delegated tasks.
• Assign and supervise work provided by others (e.g., LPN/VN, assistive personnel, other RNs, and others, such as community health workers).
• Communicate tasks to be completed and report concerns/problems immediately.
• Organize the workload to manage time effectively.
• Utilize the five rights of delegation noted above.
• Evaluate delegated tasks to ensure the correct completion of the activity.
• Evaluate the ability of delegatee to perform assigned task(s) for the position (e.g., job description, scope of practice, training, experience, team member role and responsibilities, team leader role and responsibilities).
• Evaluate the effectiveness of time management skills.

Another factor that should not be ignored during delegation is how comfortable the delegator feels in delegating and how well the delegator knows the delegatee. New RNs may be nervous about delegating; trusting another person to complete a task can be risky. Some new RNs may be overly concerned because they feel that they could perform the task better. In both situations, the result could lead to excessive hovering or over-monitoring. In this case, the delegatee may interpret the delegator's behavior or attitude as indicating a lack of confidence in the delegatee. This message can have a negative impact on team relationships. Finding the right balance takes experience. New RNs need time to learn how to delegate effectively and seek guidance from their own supervisors or mentors to assess their delegation competencies. Figure 10-8 highlights the five delegation rights that all who delegate need to apply.

Figure 10-8 Five rights for effective delegation.

An illustration outlines the five key principles for effective delegation, arranged in a circular flow. The rights include right task, right circumstances, right person, right directions forward slash communications, and right supervision forward slash evaluation.

Delegation Principles

The ANA and the NCSBN collaborated to identify the key delegation principles that continue to be relevant for every RN during delegation. The RN must effectively use critical thinking and professional judgment and assume responsibility and accountability. The following are also important principles for the nurse during delegation: (ANA, NCSBN, 2019):

• Direct care and determine the appropriate utilization of assistants.
• Delegate components of care but not the nursing process.
• Delegate or assign based on the RN's judgment of the patient, nursing team members' competence, and degree of required supervision.
• Delegate only tasks other healthcare workers have the knowledge and skill to perform based on practice requirements.
• Communicate clearly and completely regarding delegation and patient needs, verifying comprehension and acceptance of the responsibility, allowing questions and confirmation of expectations.

The HCO chief nursing officer should ensure that the delegation process is effective and communicate the importance of delegation to quality care. This also means that the HCO and its administration need to ensure that all staff have the resources they need to provide care and follow the delegation principles and provide staff education to improve delegation.

It is important for the RN, as the delegator, to thank the delegatee and recognize the work that the delegatee has done. The RN, as a delegator, should provide positive feedback when work is done well and constructive feedback as needed. The delegator should not criticize work negatively but rather discuss the work and outcomes privately with the staff member and make recommendations for improvement. It is easy to take things for granted and not recognize team members' work. It really takes little time to give positive feedback and a “thank you,” and this step can go a long way toward building teams and individual staff competence.

Will there be times when the RN, as delegator, must change a decision about delegation? If so, why would this occur? In the monitoring process, the delegatee may ask for help. The RN needs to listen to this request and respond. There may be times when the patient's condition changes, and someone else, including the RN, may be better suited to complete the task. The RN may recognize that the delegatee is not as qualified to complete the task as originally thought. The RN must be aware of the need to avoid being negative, damaging the delegatee's self-confidence, or embarrassing the delegatee in front of others. How the RN communicates and intervenes can make the situation a positive learning experience for the delegatee and support a positive work environment. In addition, the RN must recognize the impact on the patient-how the patient views the change of assignment and if the patient wonders what is going on with the changes.

Supervision is a critical part of delegation. The ANA and the NCSBN have similar definitions of supervision. The ANA defines “supervision” as the “active process of directing, guiding, and influencing the outcome of an individual's performance of a task,” whereas the NCSBN defines it as “the provision of guidance or direction, oversight, evaluation and follow-up by the licensed nurse for the accomplishment of a delegated nursing task by assistive personnel” (ANA, NCSBN, 2019). It is important to note that supervision does not necessarily mean the RN is in a management position. RNs who are not in management positions must also supervise when they delegate.

Evaluation of Effective Delegation

How does the RN evaluate delegation? The first focus is the role of the delegator. Were the right tasks delegated, and why were they delegated? The second concern is the directions. Were the directions clear? The RN should consider to whom the task was delegated and the delegatee's strengths and limitations. Did the delegatee have the resources to complete the task? Did the delegatee have the time to complete the task? What impact did performing the specific task have on other responsibilities that the delegatee may have had? Were the expected outcomes met? Was the delegator available to the delegatee if questions arose or problems occurred? This availability is more than just physical; it concerns not only whether the delegatee is able to reach the delegator but also whether the delegator is able to listen and hear the delegatee and then respond effectively. RNs want to be effective delegators, and all new RNs struggle with how to delegate. The following are some characteristics of effective delegation that continue to be important (Milgram et al., 1999, p. 245):

• Do not give employees menial tasks; include tasks that offer opportunities for learning and growth.
• Distribute tasks with an understanding of each employee's position description and job status, abilities, and total workload.
• Delegate when there is someone skilled available or when the task can be completed by a subordinate whose time is less expensive.
• Use benchmarks to monitor progress along the way; having only a final deadline can be overwhelming. (This applies to activities or tasks that take a longer time to complete.)
• Do not micromanage subordinates. Experienced employees usually have the skills necessary for managing complex tasks on their own (particularly if the tasks are typically done by them).
• Establish what needs to be done, and then provide support to the employee so that the employee can decide how to accomplish the activity or task effectively.

The focus of this discussion thus far has been on RNs delegating to other nursing staff-not RNs. It is important to recognize that RNs may assign work or tasks to other RNs. A team may include several RNs, and one may be the team leader. The nurse manager or nurse coordinator of a unit assigns work to RN staff routinely.

Effective delegation takes practice; it does not “just happen.” There are barriers to delegation. Staff may be uncomfortable with delegating and with criticism, depending on whether they are the delegator or the delegatee. This can interfere with effective delegation and positive outcomes. RNs typically delegate to APs. Consequently, RNs need to know about AP roles and job responsibilities. APs cannot do the following or be delegated these activities: health counseling, teaching, and activities that require independent, specialized nursing knowledge, skills, or judgment. The evaluation of delegation needs to consider the types of activities that were delegated. The ANA (2007) identified AP direct and indirect patient care activities as follows:

• Direct patient care activities assist the patient in meeting basic human needs (settings may be hospitals, home, long-term care, and other). Activities include assisting with feeding, drinking, ambulation, grooming, toileting, dressing, and socializing. Collection, reporting, and documentation of data related to these activities are important. APs need to report data to RNs; data then are used to make clinical judgments about patient care.
• Indirect patient care activities support the patient and the patient's environment, such as providing a clean, efficient, and safe patient care milieu. Activities might include companion care; simple meal preparation; housekeeping; providing transportation; and clerical, stocking, and maintenance tasks. Many of these activities would take place in the patient's home, where APs may be working one-on-one with patients through a home healthcare agency or some type of community agency.

Generally, tasks that can be delegated have the following characteristics (ANA, NCSBN, 2019):

• Frequently occur.
• Are considered technical by nature.
• Are considered standard and unchanging.
• Have predictable results.
• Have minimal potential for risks.

Stop and Consider 9
Effective delegation is not easy to learn.

Change

Change can be discussed in relation to changes in the healthcare delivery system, but change is also a part of collaboration and coordination, which are difficult to accomplish without some change, for example in individual team members, the entire team, a unit, or the HCO (Finkelman, 2022). “The healthcare landscape is facing dramatic changes. Transformation is being driven by unprecedented mergers and acquisitions, new technologies in the marketplace, and the volume, variety, and velocity of available data. Change is occurring with phenomenal speed across the healthcare ecosystem. We must harness this change to address the serious health challenges we continue to face” (HHS, AHRQ, 2019). Patients are asked to change all the time, and staff must adjust to changes, too.

Why do team members often not like change? They may be fearful of the results, particularly of the unknown; they may fear losing something of value, such as control, job responsibility, and so on; or they may believe change will not make things better. The other view of change is it may be an opportunity for improvement. Sometimes, however, change does not lead to positive outcomes. This type of situation must be dealt with, recognizing that not changing may mean stagnation and limit improvement. Some changes require a structure to support planning, implementation, and evaluation or a project team that would then use the change process, following these steps:

• Identify the issue or problem/need for change and factors that influence the need for change.
• Engage relevant staff, when possible, in the planning process.
• Gather information to better understand the need and possible solutions.
• Identify stakeholders and barriers.
• Describe solutions to solve a problem or improve.
• Select the solution to implement.
• Prepare staff for the change (inform them about the change, the reasons for the change, the timeline, planning and implementation, and train staff, if needed; engage them in the implementation).
• Implement the change (the solution).
• Evaluate the results (including staff feedback).
• Determine whether any adjustments are needed (ongoing); ideally, include relevant staff early in the process to enhance staff commitment.

There are barriers to effective change that need to be considered early on so that they can be avoided if possible. One of these is resistance to a specific change or even to change in general. This may come from one stakeholder or a group of stakeholders. It is important to listen to comments about change as one can better develop prevention or solutions to address issues for which there is resistance. Groupthink may also occur, which blocks innovation. This is a situation in which all group members think alike. This makes it appear as if this is a positive situation, but ideas are not expressed that might not support the group/team view. This often means there is a loss of new ideas that might be useful. Effective change requires effective planning and then evaluation; if not done well, this is a barrier. Another barrier is ineffective change spread, which means a change or innovation is not expanded and does not become part of the HCO. Most changes should not remain isolated but used in other areas of the HCO (IHI, 2023b). For example, a change in the admission process, if it is only applied in one unit when it is needed in other units, acts as a barrier to improvement and change.

The plan-do-study-act (PDSA) cycle is used more today by healthcare professionals and teams to assist in decision-making, make changes, and ensure better-coordinated care (IHI, 2023c). This cycle is used to test changes. During the first step (plan), the team identifies the objective(s)/outcomes and predictions as to what might happen and why; the team then develops a plan to implement the change. In the next step (do), the team institutes the change and collects outcome data. In the third step (study), there is more in-depth analysis of the outcome data and relationship to the problem. In the last step (act), the change may be modified and then fully initiated.

What methods can be used to decrease barriers to change and increase team involvement in change? Explanation and education about the issue or problem and the need for change is the first step. Including team members (staff) in the discussion about the need for change and possible solutions increases members' commitment to the change process. They will participate more fully and be more invested in the results. Change is stressful. This stress needs to be recognized, and when possible, implement interventions to reduce stress, as discussed in other content. Experiencing too many changes at one time or too quickly can make effective change difficult. Sometimes there are situations in which change is dictated, for example, a change in laws about a healthcare delivery issue informing hospitals that they cannot deny emergency care to patients in critical conditions even if reimbursement is an issue. When this occurs, team members still need an explanation and should be included in the change process. Asking for feedback and listening are important. Change is risky-and sometimes it will fail. Teams need to learn from their errors and ineffective decisions and then move on. Effective collaborative teams do not place blame on individuals; rather, they look at results in an objective manner and realize that the team works together. Sometimes the team makes mistakes, and then team members must work together to resolve the issues, learn from the mistakes, and improve.

Stop and Consider 10
Change can be positive or negative.

Conflict and Conflict Resolution

Conflict is inevitable; however, what is important is how it is handled. In some cases, conflict can be prevented. It is natural for misunderstandings to occur among people who work together, such as in teams. Often, causes of conflict relate to inequitable sharing of resources; insufficient explanation of expectations; questioning someone's performance; unexplained changes that disturb routines and process, for which team members are not prepared; and stress resulting from changes that team members do not understand and may see as threatening or ineffective. Each of these causes can be prevented from becoming a conflict. Engaging in clear, timely communication and including team members in the process can reduce conflict.

Another cause of conflict that is more difficult to manage is an individual's personal responses and behavior, which may increase team conflict. Examples include team members who did not complete expected work, are late to meetings, do not listen to others, complain, are overly critical of others, do not know how to communicate effectively, want to be the “star” and take all the credit, and so on.

Conflict resolution requires leadership and participation from team members. When difficult issues or problems arise, it is best to deal with them rather than postpone decisions, which usually means that the problem has time to get worse. Using threats and negativity with little positive feedback can lead to more conflict, so these approaches need to be avoided. Listening can go a long way toward preventing conflict, and if conflict does occur, this can help to resolve it. When team members treat one another with respect and communicate clearly, conflict can be decreased. Respect means to recognize another's right to have opinions, listen, and then discuss these opinions. Nonverbal communication can provide important clues about increasing conflict. When teams or individual members experience stress, the risk of conflict increases, so it is important to monitor individual and team stress.

Open communication is key to conflict resolution and may also have a major impact on preventing conflict from developing. When conflict occurs, it is important to provide opportunities to identify the facts, determine the purpose of the actions or activities at the time, and review team member's perspectives. When members are emotional, this factor can interfere with effective resolution, so sometimes, the best first approach is to step back and allow some time for all parties involved to control their emotional reactions. However, the issue still needs to be resolved, so this time period needs to be monitored-it should not go on too long. Sometimes, one or two members need to be persuaded to reexamine the issue. This effort may or may not be successful. Teams need to understand that individual team members do not always get their viewpoints accepted by all. Compromise is required; however, when this occurs, it must be done in a manner that respects divergent opinions and does not use negativity or reduce self-esteem. All of these facets of conflict resolution require leadership-on the part of the designated team leader and from the members who commit to the team and its effectiveness.

Describe-express-suggest-consequences (DESC) is an example of a structured approach to addressing a conflict. The goal of using DESC is to arrive at a consensus and keep the discussion on track. The DESC script includes the following elements (O'Keeffe & Saver, 2014, p. 12):

• Describe the specific conflict situation or behavior using concrete data.
• Express how the situation made you feel or identify your concerns.
• Suggest alternatives and seek agreement.
• State consequences in terms of effects on team goals; strive for consensus.

Stop and Consider 11
Nurses encounter conflict in the workplace.

Power and Empowerment

As people work together, the issue of power arises. Simply put, power can be described as when healthcare provider A wants something that healthcare provider B has and may or may not need or want as much; healthcare provider B then has more power in the relationship. Typically, there is not a balance of power in a team, particularly when it is first formed. This is most seen with nurses and physicians; physicians typically have more power because of their profession, experience, and history. This balance, however, can shift and should change as the team develops, with members recognizing one another's value and experience. Nevertheless, an imbalance can be difficult to overcome and makes the work situation stressful.

How a person feels about his or her work has an impact on how that person functions on a team. Herzberg's theory, as described in Figure 10-9, identified job maintenance factors or extrinsic factors that influence job satisfaction, which are still considered important; however, there is more to job satisfaction than these hygiene factors, as Herzberg called them. The motivator factors (intrinsic factors) must also be considered. Herzberg suggested that because of these factors, organizations that increase accountability, create teams, remove controls, provide feedback, introduce new tasks, allocate special assignments, and grant additional authority might increase staff motivation (Michalopoulos & Michalopoulos, 2006). Staff may then feel increased personal achievement and more empowerment. The same authors noted that the factors to increase staff motivation are part of the need for nurses to “increase responsibility, control over their work, and the opportunity to use their own initiative, all of which are offered in team nursing and the nursing process” (pp. 54-55). Exhibit 10-3 describes the types of power.

Figure 10-9 Herzberg's theory on job satisfaction.

An illustration explains Herzberg's theory.

This includes job maintenance factors, extrinsic factors, such as job security, salary and benefits, supervision, status, working conditions, and policies and administrative practices. Satisfactory level 5 hygiene factors indicate that work gets done and improves, while unsatisfactory level 5 hygiene factors indicate dissatisfaction and that work does not get done or improve. Motivators to improve performance intrinsic factors include responsibility, advancement, recognition, achievement, and growth.

Exhibit 10-3 Types of Power

Type of Power Description Legitimate/formal power Power that originates from serving in a formal position (for example, a team leader, nurse manager, or chief nursing officer). Referent/informal power Power that originates from others' recognizing that an individual has leadership qualities and choosing to follow that person. Informational power Power that originates from information a person has and others need. Expert power Power that originates from a person's expertise, which can be useful to others and enable the person to provide guidance (for example, a nurse clinical specialist). Reward power Power that originates from a person's ability to reward others (for example, the ability to grant a salary increase, promotion, or assign an interesting project) if they agree to do something. Coercive power Power that originates from a person's ability to punish others (for example, the ability to assign an unpleasant task or project, or deny a promotion) if they do not do what is asked.

Empowering teams means that the team leader needs to become less assertive over time and gradually allow the team to lead itself. The team needs to find the best solutions by using the expertise of all the members and then assuming more leadership. This strengthens the team leader's leadership-with the result of better team outcomes. Power and empowerment are discussed in other content in this text, particularly in content related to nursing leadership.

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Empowerment allows you to practice fully as a nurse.