|  Despite codes of conduct and zero-tolerance rules, disruptive workplace behavior happens. People become sarcastic, demeaning, or verbally abusive. Others gossip or form exclusive cliques. Sometimes, incivility and psychological aggression can explode into physicality. As workplaces, hospitals aren't immune from this kind of disruptive clinician behavior; nor are nurses or other healthcare team members who work there.
That's where Hopkins nurses Jo M. Walrath, PhD, MS, RN; Deborah Dang, PhD, RN, NEA-BC; and Dorothy Nyberg, MS, RN, enter the picture. They've been exploring the causes of, reactions to, and impact of hospital-based disruptive behavior through a series of focus groups with almost 100 nurses working in an acute-care hospital. Reporting on these structured interviews in "Hospital RNs' experience with disruptive behavior," Journal of Nursing Care Quality [online, November 2009], the researchers give voice to nurses' experiences with disruptive clinician behaviors. Walrath, an associate professor at the Johns Hopkins University School of Nursing, says, "Our exploration provides evidence that disruptive behavior can affect not only the safety of patients but also the cohesiveness of the healthcare team and the long-term health of the nursing workforce." The research team created a taxonomy that synthesized 168 different disruptive behaviors into three key categories: incivility, psychological aggression, and physical violence. The most frequent adverse behaviors were found to be triggered by issues related to personal char-acteristics, stress, fatigue, or competency. According to Dang, Director of Nursing at the Johns Hopkins Hospital (JHH), "Disruptive behavior is so ingrained in interprofessional relationships, nurses often don't recognize behaviors as disruptive." That may explain why, when confronted by rude, insulting, or condescending behavior from peers, staff, physicians, or administrators, many nurses do not speak up, despite their longstanding role as patient advocates. Some hunker down; others choose to leave. Much can and must be done to promote more emotionally healthy workplaces for nurses, notes Nyberg, a program coordinator at JHH. Walrath observes, "Because disruptive behavior can fracture the relationships that make up the healthcare process, it must be recognized by clinical care leaders, openly discussed and equitably addressed for the safety of all, particularly for that of our patients."
--Teddi Fine
Nursing students are exposed to a broad array of clinical situations and settings as an integral part of their education. Since patient safety is a foremost consideration, students manage a limited number of patients and do so under close supervision. Hands-on educational opportunities ebb and flow with the patient census. Participation in challenging, high-risk clinical work often is a matter of timing and circumstance. As a result, the students' clinical experiences can vary widely. Often, their first exposure to a particularly complex case may occur after graduation in clinical practice, when their patient loads can triple or quadruple and supervision may be minimal. But have they been well prepared to meet new situations head on with solid decision-making acumen and an eye toward patient safety?  It's an issue of considerable concern to Pamela R. Jeffries, DNS, RN, FAAN, ANEF, associate dean of academic affairs at the Johns Hopkins University School of Nursing. She has been searching for ways to better assure that new nurses are well-prepared to juggle multiple competing demands requiring attention to detail and to assess their ability to transfer clinical competencies from the classroom to the clinical setting. Her solution: the increased use of simulation experiences to model the high-risk clinical environment. From manikins and role-play to interactive media and standardized patients, simulations can help students learn, test clinical skills, and, perhaps even more importantly, develop decision-making skills for difficult-to-manage situations.
"The value of simulations cannot be overstated," Jeffries observes. "Simulations help students safely hone skills and problem-solving that, down the road, can help them save lives in virtually every service setting and patient population." Most recently, Jeffries has been assessing the use of simulations to provide a non-threatening environment in which students' nursing skills can be learned and tested. Writing in "Fostering patient safety competencies using multiple-patient simulation experiences" [Nursing Outlook November/December 2009], Jeffries describes the results of a study testing a simulation that helps assess nursing students' ability to manage complex, even ambiguous, patient safety-related decisions while juggling a large patient load. She found that this type of simulation helps students master patient safety skills and, ultimately, better safeguard their patients' health and lives. Jeffries says, "Simulations allow us to expose students to high-risk nursing situations they may not see in their clinical rotations, making it possible to bridge gaps and provide an opportunity to prepare our students for real-world clinical situations."
--Teddi Fine
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