Cleveland Clinic is LEADing the Way to a Civil and Respectful Nurse Culture

Added on Oct 20, 2016

Cleveland Clinic is LEADing the Way to a Civil and Respectful Nurse Culture
By Audrey Doyle
From Industry Edge October 2016

At Cleveland Clinic, strong communication, teamwork and leadership skills are the keys to preventing and eliminating uncivil behavior among the nursing staff. Through an innovative program called LEAD (Leadership, Enrichment and Dialog) and other initiatives, the Clinic has built a systemwide culture of civility and respect that is advancing nurse engagement and the patient experience.

“High-quality, safe patient care is our number-one priority,” said Kelly Hancock, MSN, RN, NE-BC, the executive chief nursing officer of the Cleveland Clinic health system. “We’ve found that developing and promoting respectful, cohesive relationships among our nurses instills a strong sense of community that has resulted in engaged, high-functioning, highly reliable teams of caregivers who are dedicated to advancing the patient experience.”

The Price of Incivility

Incivility is generally defined as rude, disruptive, undesirable or intimidating actions that may or may not be intentional. A common issue in the business sector today, incivility can range from low-risk behavior such as sarcastic or condescending comments, eye rolling, gossiping and social exclusion to high-risk behavior such as bullying, sabotage, physical aggression and assault. According to Hancock, when incivility occurs among nurses it’s typically one or more of the low-risk behaviors, and although it can be experienced by nurses in all stages of their careers, it’s often directed at new or novice nurses.

Regardless of whether it’s intentional or unintentional or to whom it’s directed, uncivil behavior can be harmful. Hancock still remembers how she felt, when as a novice nurse working in critical care, she was often excluded by the group of seasoned nurses she was working with. “I wanted to be considered one of their colleagues, an effective and contributing member of the caregiving team. Instead, they made me feel like they were an exclusive group that I wasn’t good enough to be included in,” she recalled. “It stopped after a while, but I still felt like I had to earn my badge all over again and I ended up questioning and second-guessing myself for a long time.”

The incivility in Hancock’s case resulted in a bout of low self-esteem. However, it also can cause nurses’ productivity to drop and feelings of resentment and anger to rise. And when the behavior is overt, ongoing, hostile and/or threatening, it can cause nurses to leave the nursing profession. This can exacerbate already troubling forecasts that predict the United States will experience shortfalls of up to 1 million nurses by 2030 due to an aging workforce, an aging baby boomer population and increasing demands for health care services.

Although inflicted on fellow caregivers, uncivil behavior can potentially have a negative impact on the patient experience. Intentional behaviors directed toward new or novice nurses, such as blocked learning opportunities, withholding of help or important information, and patient overloading, are some examples that can impact patient safety.

Even if uncivil behavior among nurses doesn’t actually cause patient harm, it can give rise to the perception that patient safety and quality of care are not top of mind among the hospital staff. “Patients and their families see and hear what goes on in a hospital and pick up on the stress and anxiety incivility can cause,” said Hancock. “When this happens they may start to question whether they should trust their caregivers: ‘They’re not behaving like leaders, they’re not communicating with one another and they’re not working as a team, so who’s watching out for me?’”

For all of these reasons, Hancock said, it’s essential for nursing staff to maintain respectful, caring relationships with their colleagues. “Nursing, especially in high-risk environments like critical care, the ICU, the ER and the OR, can be stressful; it’s the nature of the work and of the job,” she said. “But that doesn’t mean that [stress] needs to be carried over into our relationships with our co-workers.”

A Culture of Communication, Teamwork and Leadership

According to the American Nurses Association (ANA), nurse incivility has become such a serious issue that its Professional Issues Panel on Incivility, Bullying, and Workplace Violence developed in 2015 a new ANA position statement asserting that the nursing profession “will not tolerate violence of any kind from any source” and that registered nurses and employers must collaborate to “create an ethical environment and culture of civility and kindness” in which colleagues, co-workers, employees, students and others are treated with dignity and respect.

To support its nurses in cultivating and maintaining civil, respectful relationships with one another, Cleveland Clinic has established several programs that promote communication, teamwork and leadership development among its nursing staff.

Chief among them is the LEAD program. As Hancock explained, nurses generally don’t think of themselves as leaders unless they’re in a management position. “But you don’t have to have a formal leadership title to be a leader,” she said. “No matter what you do as a nursing caregiver you are a leader, whether you’re teaching your patients how to manage their illness or helping fellow nurses manage their patients.”

An interactive clinical leadership course offered to bedside nurses, LEAD was developed in 2013 by Mary Beth Modic, DNP, RN, CDE, a clinical nurse specialist in diabetes at Cleveland Clinic, in collaboration with Joyce Fitzpatrick, RN, a professor of nursing and former dean at Case Western Reserve University’s Frances Payne Bolton School of Nursing.

LEAD has the following main objectives.

  • Orient nurses to their leadership potential for effecting change at all levels of care.
  • Introduce ways nurses can include elements of leadership in patient care.
  • Describe real and perceived barriers to nurse leadership from the bedside to the boardroom.
  • Capture nurses’ voices on leadership in clinical care through personal stories about their experiences with patients and their families.

LEAD participants meet for four hours every other week for 2½ months. According to Hancock, the course emphasizes the impact of empathy on relationship building, the importance of strong communication skills and teamwork, and the effects of relationship-centered care on clinical outcomes. In addition, it explores the use of transformational leadership skills in everyday practice to promote civility and foster a culture of respect, job satisfaction, engagement, trust and support.

“Transformational leaders create positive change in their followers,” Hancock noted. “Through LEAD and the transformational approach to leadership, nurses see the importance of positive leadership behavior and how that can affect relationships with all members of the nursing staff.”

Besides LEAD, several other courses, workshops and programs offered to Cleveland Clinic nurses are centered on the topic of communication, teamwork and leadership skills development.

  • Building an Empowered Team teaches nurses how to delegate and be assertive without being confrontational.
  • Managing Relationships uses interactive learning methods to improve nurses’ skills in building trust and encouraging two-way communication while maintaining accountability.
  • Lead the Super Charge focuses on such key concepts and competencies as the Professional Practice Model, the Just Culture Model and Peer Accountability, as well as the skills of delegation and conflict management.
  • To Act as a Unit brings together nurses and physicians to build skills in leadership, situation monitoring, mutual support and communication to enhance interprofessionalism.

In addition to these educational opportunities, Cleveland Clinic also offers communication, teamwork and leadership development  opportunities through its Nurse Leadership Academy and through clinical simulation sessions held at its Simulation and Advanced Skills Center. The Nurse Leadership Academy, a four-day program offered to nurses each quarter, covers such topics as leadership, quality, safety and the patient experience.

The clinical simulation sessions, also held quarterly, are designed to improve the way nurses interact with one another.“We videotape our nurses as they simulate the different types of day-to-day interactions they may have, and then we do a debriefing,” Hancock explained. “We do this not to point out what they did right or wrong, but to make them aware, in a nonthreatening way, of how they interact with one another. How do they respond to different questions? How do they address their co-workers? Is there a lack of face-to-face communication? Do they walk down the hall looking at their phones instead of at their colleagues? What does that tell a nurse who may need their help?

“Sometimes we can act like we’re not present and we don’t even realize we’re acting this way,” she added. “And when you think about patients and their point of view, they can interact with more than 50 different care providers during a three- or four-day hospital stay. So those care providers should act and interact like a unit or a team to promote an optimal patient experience.”

Relatable Outcomes

According to Hancock, the educational opportunities offered to the nursing team at Cleveland Clinic have been well-attended and enthusiastically embraced. Although outcomes data from the Clinic’s most recent National Database of Nursing Quality Indicators (NDNQI®) survey won’t be publicly available until November, Hancock did share some written reflections provided by nurses who recently completed the LEAD course.

  • “This class has given me the confidence that, even though I am young and new, I have so much to offer and to share!”
  • “…As [many] of the professional skills that I have learned and been acknowledged for have been technical ones, I need to acknowledge the profound gratitude I feel for being reminded that my professional life cannot exist without relationships—relationships that thrive in authentic and vulnerable environments where we are afforded a moment of kindness.”
  • “The validation and empowerment I received have encouraged me to do the same with my co-workers.”
  • “It does not matter your title—anyone can be a leader. We all need to convey compassion, empathy, positivity and understanding that not everyone can be good at everything. Everyone has something special we can share with one another.”
  • “I really didn’t have a perception of clinical leadership. I thought it was just setting a good example. I now know there is so much more that goes into it. I will continue to explore the best way I can be a leader and create an atmosphere of trust, open communication and innovation on my floor.”

All of this bodes well for advancing caregiver engagement and the patient experience at Cleveland Clinic. “We as nurses are dedicated to providing high-quality, compassionate care to patients and their families, but sometimes we need to be reminded to be compassionate and caring to one another,” Hancock said.

“The LEAD program, the simulation exercises and our other educational tools give our nurses that gentle reminder of the importance of effective communication, collaboration and leadership,” she concluded. “The result is a culture of caregiver collegiality and patient safety."