1

Issues in Educating Our Healthcare

Workforce

Deborah Anderson

Principal, PivotPoint

pivotpt@mac.com

&

Patricia M. Schoon, MPH, PHN, RN

Distance Clinical Instructor, College of Nursing

University of Wisconsin Oshkosh

patschoon@gmail.com

Upon completion a participant will: 1. Identify the preferred characteristics

for individuals entering health professions.

2. Describe the methods of training future health professionals.

3. List the characteristics of a healthy medical work place.

2

Provide context and build awareness that workplace behavior is a significant problem

Discuss selecting and educating healthcare workers

Define a healthy workplace and methods of improving workplace behavior

Personal Life

Experiences

First

Professional

Degree

First Year of

Professional

Employment

Role Expectations and

Performance

3

Academic ◦ Students report experiencing and/or observing

interpersonal abuse

◦ Students of color report being alienated

◦ Students, faculty, staff and administrators all report

experiencing or witnessing interpersonal abuse

Clinical ◦ Students report experiencing and/or observing

interpersonal abuse between and among staff, students,

preceptors, clinical faculty

Workplace ◦ Primary reason new nursing graduates leave acute care is

interpersonal abuse in the workplace

8

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Student Faculty Administration Staff I choose not

to answ er

this question

N = 534

RR = 35%

411

65 2 18 11

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

1

Nursing

PT/PTA

OS/OT/OTA

Did not answer

Radiography

Other Health Programs

Other Minneapolis Programs

AA Non-Health & LAS

2 Uncounted

Schoon & Dols, 2007 Survey of Health Professions Departments at a Private Midwestern University, unpublished

Question: Who has experienced or

observed interpersonal abuse?

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

Stude

nts

Facul

ty/p

rofe

ssors

Don’

t kno

w

No one

Staff

(in A

dmis

sion, R

e...

Peopl

e at m

y cli

nica

l or..

.

Direct

ors

or d

epar

tmen

...

Every

one

Deans,

Pre

side

nt a

nd ..

.O

ther

N = 514

Schoon & Dols, 2007 unpublished data

4

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%

Stu

dent

s

Faculty/p

rofe

ssors

Don'

t kno

w

Sta

ff (in

Adm

ission

, ...

Eve

ryone

No o

ne

Oth

er

Peo

ple a

t my clinical ..

Dire

ctor

s or

dep

artm

e..

Dean

s, P

reside

nt a

n...

Schoon & Dols, 2007 unpublished

11

1.3 1.4 1.5 1.6 1.7 1.8

Yelling or using a loud voiceBehaving depressed, negative,

Any actions that destroy self-esteemBeing un-supportive, uncaring,

Not communicating, using silenceAllow ing unresolved disagreements

Demeaning of another personCursing and sw earing

FavoritismBlaming

Constant complaining

Mean

Schoon & Dols, 2007 unpublished data

Complaining

Belittling Ignoring

Lack of communication Not listening/walking away

Talking behind someone’s back Laziness

Gossip Blaming

Anderson 2012 unpublished data

5

Medical students experience a variety of abuses ◦ 80.6% of senior respondents reported abuse by

their senior year Silver & (1990)

◦ Medical students report experiencing verbal abuse, sexual and racial discrimination, harassment, and physical abuse

Rees et al (2011)

◦ Little has changed since 1990

50% to 97% experienced or witnessed abuse Clark & Springer 2007, Cox 1991, Thomas & Burk 2009

Nursing students experience or witness abuse across academic settings

Abusive behaviors include: incivility, verbal abuse, rude behavior, and physical violence

Curtis et al. 2006, Lashey & Meneses 2001, Long 2000

Perceived frequency of abuse ◦ 16,000 respondents

◦ 95% of surveyed staff experienced or witnessed abusive behaviors

◦ 62-96% experienced or witnessed abuse in the last year

◦ 3-25% experienced or witnessed abuse daily Anderson 2004 unpublished data

6

Anderson 1999 unpublished data

Anderson 2004 unpublished data

New York Times May 8, 2011

7

90% of health care workers report experiencing or observing harmful behaviors at work

Olson, 2007

27 – 85% of nurses report being bullied or harassed or experiencing incivility from nurses and physicians

Hutton 2008; Wilson, Diedrich, Phelps, & Choi 2011, Spencer 2013

30 – 60% of new grads change employment locations within the first two years

Bowles & Candela 2005; Beecroft, Dorey, & Wenten (2008)

Individuals experienced digestive problems, insomnia, long-term sickness, and more psychological distress than individuals who did not experience abusive workplace behaviors.

Anderson 2004, Schoon & Dols 2007, Spencer 2012.

Health issues identified in medical students include depressive symptoms, escapist drinking, cynicism about the profession, and low self-confidence

Rees & Monrouxe 2011

Headaches, migraines Anxiety. Stress Sleep disorders Anger, hostility Fatigue Stomach problems, ulcers Irritable bowel disease Depression Aggressive behavior ( suicide, murder) Eating disorders, obesity Alcohol and drug abuse physical discomfort Back pain Hypertension Sick days

Anderson 2014 unpublished data

N = 79 No medical problems 56 (74%) Medical Problems 15 (20%) Not sure 6 (8%)

8

85,000 respondents

25-45% report medical problems related to abuse at work ◦ Sleeping problems (80%) ◦ Headaches (56%) ◦ Fatigue (44%) ◦ Depression (33%) ◦ Anxiety attacks (30%) ◦ GI problems (28%) ◦ Neck, shoulder, arm pain (27%) ◦ Alcohol/substance abuse (16%) ◦ Physical injuries (9%)

Anderson 1991-2012 unpublished data

23

0.00%

10.00%20.00%30.00%

40.00%50.00%60.00%

70.00%

Hea

dach

es

Sleep

ing

prob

lem

s

Dep

ress

ion

Fatig

ue

Stom

ach

ache

s

Anxie

ty a

ttack

s

Men

tal h

ealth

con

cern

s

Get

sick

easily o

r ofte

n

Eating

diso

rder

s/ob

esity

/...

Top 9 Medical Problems

N = 65

Range = 11 = 45

No Yes Not sure

12.5 % Yes

N = 521

85.6% No

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Oth

er

Back

pain

Alcoh

ol o

r dru

g ab

use

Hig

h bloo

d pr

essu

re

Sore

achi

ng ja

w

Ulcer

s

Suicida

l tho

ught

s

Hea

rt di

seas

e

Sexua

l pro

blem

s

N = 65

Range 1-9

Schoon & Dols, 2007 unpublished data

Abusive environments are associated with negative patient outcomes, decreased patient satisfaction, increased adverse events, and increased mortality

Institute of Medicine (IOM) 2004, Spencer 2013, The Joint Commission 2008

Increased costs to organizations ◦ Staff turnover, dissatisfaction, loss productivity,

absenteeism, and negative patient outcomes.

9

Incivility &

bullying

victimization

Shame

Anger

Self-blame

Self-attack

Revictimization

Hostile

workplace

Felblinger, 2008

Change and

Complexity

Lack of

Support

Reduction in

Funding and

Staffing

Interpersonal

Abuse and

Incivility

Safe Environment

Personal respect

Open, honest communication

Trust and responsibility

Adequate resources and training

Constructive direction and feedback

Recognition

Meaningful work

Personal growth

Fun and Enjoyment Park Nicollet Institute

10

Self-respect, self-esteem

Self-control, discipline

Respect for others

Tolerance, understanding

Teamwork, cooperation

Caring, empathy

Fairness, justice

Peaceful conflict resolution

Social responsibility, caring for others

Generosity, altruism Park Nicollet Institute

Starts with the education ◦ Create a culture of respect; improve listening skills,

team work, collaboration, and sensitivity to cultural diversity

Requires organizational commitment

Students model faculty

There is a demand for improving healthcare culture

What to look for What to look out for

Inquisitive

Seeks strong role models

Learns tacit rules

Punctual/prompt

Responsible

Insightful

Instant expert Seeks power and

influence Poor boundaries Chronic tardiness Blames and blameless Unable to see or use

feedback

11

What to look for What to look out for

Seeks & uses feedback

Truthful

Humble

Courageous

Commitment to improving human condition

Obfuscating Arrogant Critical under stress Avoids truths Commitment to career

Admission criteria to nursing schools ◦ Varies depending upon organization

GPA, admission testing, essay, interviews

◦ Essential abilities include

cognitive, sensory, communication, psychomotor, and behavioral/emotional/spiritual health abilities.

Principles Actions

Caring, collaboration, and teamwork are cornerstones

Empower students, faculty, staff

Promote respectful relationships

Address problematic behaviors before they escalate

Realistic workload Clear and honest

communication Healthy teamwork is an

expectation.

◦ Assess relationships and environment

◦ Role model and champion respectful behavior

◦ Establish healthy academic culture

◦ Work toward zero tolerance

◦ Acknowledge and address unhealthy behaviors and situations

◦ Address concerns and stressors

◦ Establish and disseminate standards for cooperation and communication

33

12

Student

Clinical

Culture

Academic

Culture

Patient

Healthcare

Administration

Healthcare

Workforce

Five Stage Process to Organization Change (18-24 month process) ◦ 1. Team building –

Governance concurrence

Leader identification – find a champion

Representative workgroup selection

◦ 2. Assessment – Organizational survey – all levels

◦ 3. Implementation Informational sessions, posters, defining healthy and

harmful behaviors, training in conflict resolution

◦ 4. Evaluation ◦ 5. Infusion/Sustainability

13

Principles Management Actions

Caring, collaboration, and teamwork as cornerstones

Empower staff and victims Promote respectful staff

relationships Target potentially

problematic behaviors before they escalate

Realistic workload grounded in respect and cooperation

Clear and honest communication

◦ Assess workplace relationships and environment

◦ Role model and champion respectful behavior

◦ Establish healthy unit culture

◦ Create zero tolerance ◦ Acknowledge unhealthy

behaviors and situations ◦ Address staff concerns

and workplace stressors ◦ Establish and publish

standards for staff cooperation and communication

Ongoing Journey

Change does not occur overnight

◦ Time

◦ Energy

◦ Commitment

THINGS CAN IMPROVE!

Anderson, D. (2014). Unpublished data. PivotPoint@mac.com

Beecroft, P., Dorey., & Wenten, M. (2008). Turnover intention in new graduate nurses: A multivariate analysis. Journal of Advanced Nursing, 62(1), 41-52

Bowles, C., & Candela, L. (2005). First job experience in recent RN graduates: Improving the work environment. The Journal of Nursing Administration, 35(3), 130-137.

Clark, C., & Springer, P. (2007). Incivility in nursing education: A descriptive study of definitions and prevalence. Journal of Nursing Education, 46(1), 7-14.

Cox, H. (1991). Verbal abuse nation-wide, Part II: Impact and modification. Nursing Management, 22.

Felblinger, D. (2008). Incivlity and bullying in the work place and nurses’ shame responses. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(2), 234-242.

Hutton, S. (2006). State of the science. Workplace incivility. The Journal of Nursing Administration , 36(1), 22-28.

Institutes of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Retrieved from http://www.iom.edu/Reports/2003/Keeping-Patients-Safe-Transforming-the-Work-Environment-of-Nurses.aspx

Lashley, F., & Meneses, M. (2001). Student civility in nursing programs: A national survey. Journal of Professional Nursing, 17(2), 81-86.

Luperell, S. (2004) Faculty encounters with uncivil nursing students: An overview. Journal of Professional Nursing, 17(2), 59-67.

Rees C., Monrouxe L. (2011). Journal of The Association of American Medical Colleges [Acad Med] 2011 Nov; Vol. 86 (11), pp. 1374-82.

Silver, H., & Glicken, A. (1990). Medical student abuse: Incidence, severity, and significance. JAMA. Vol 263, pp 527-532.

Schoon, P. & Dols, C (2007). Survey of abusive behaviors in a midwestern university. Unpublished.

Spencer, C. (2013). Healthy work environments: Personal Civility in healthcare. Academy of Medical-Surgical Nurses, 22(1). Retrieved from http://www.amsn.org/sites/default/files/documents/practice-resources/healthy-work-environment/resources/MSM-Spencer-Jan13.pdf

The Joint Commission. (2008). Sentinel event alert: Behaviors that undermine a culture of safety. Issue 40. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.pdf

Thomas, S., & Burk, R. (2009) Junior nursing students’ experiences of vertical violence during clinical rotation. Nursing Outlook, 57(4), 226-231.

Wilson, B., Diedrich, A., Phelps, C, & Choi, M. (2011).