The Pebble Effect: Stopping Incivility in Clinical Environments

Friday, 25 July 2014: 2:10 PM

Cathleen Opperman, RN, MS, CPN
Professional Development, Nationwide Children's Hospital, Columbus, OH


The Pebble Effect: Stopping Incivility in Clinical Environments is a reporting of an effective educational strategy used to improve the communication patterns and staff engagement of a 400 bed hospital.  Requests in our annual learning needs assessments, as well as feedback from continuing education programs identified a strong desire by interdisciplinary clinical staff to eliminate coworker incivility, horizontal hostility, bullying, lateral violence and intimidation.


The literature review identified incivility as a widespread problem in healthcare.  Whether labeled as coworker incivility, horizontal hostility, bullying, lateral violence or intimidation, it is known to contribute to missed communication, moral distress, preventable errors, low patient satisfaction and staff turnover.  The challenge was that simply inservicing staff to “be nice and patient with each other” is not effective in changing deep rooted behavior.  The literature described numerous educational activities which focused individually on the knowledge, skills and attitudes needed to reshape the culture and therefore change the behaviors.  However, no educational intervention described a combination of all three of these components.  Through the efforts of a small group of clinical Educators, we developed a day-long interactive Workshop based on Kathleen Bartholomew’s “Ending Nurse to Nurse Hostility,” and Martha Griffin’s “Teaching Cognitive Rehearsal as a Shield for Lateral Violence.” 

To encourage nursing staff initially to participate, we provided continuing education credits for the day.  Soon, we realized that providing incentives were not necessary because the demand for the solution to this problem was so high, that we actually had waiting lists of 20 or more and other disciplines were finding the topic and content appropriate and desired as well.  In fact, after participating, some managers were trying to scheduling all their staff to participate.

Design approach:

The teaching strategy was a workshop design because changing behavior not only needed knowledge (through reading before the workshop and lecture during) but practice with the skills and a change in attitude regarding the tolerance of poor behaviors.  The skills needed to respond in various situations include use of cognitive rehearsal and DESC formulated statements for initiating difficult conversations.  These skills are practiced with role playing exercises and case scenarios in the workshop.  The focus on attitudes is the most challenging, yet most essential, in order to make a change in the culture.  With attitude, the educational activities need to help each individual recognize how they contribute to the environment that enables these poor behaviors.  When asked, many staff said that “there are no problems with THAT on our unit,” yet in the next breath they describe how they “work around this person” or “avoid that person.”   With stakes as high as the death of a patient, the first step to changing our culture is raising awareness that poor behaviors are present in our work area and choosing to avoid only condones them.  The educational activities designed to change attitudes regarding incivility include self-reflection, telling stories of targets of incivility, and the “I can/We can” exercises.

A survey was completed before the workshop began and 6 months later to compare the change in perception of incivility.  The survey asked participants to score “respect”, “support” and comfort with “sharing my opinions” with coworkers, charge nurses, supervisors, educators and managers. They scored each individually.  After the first two groups commented on how the workshop day changed their understanding of how much poor behavior was on their unit, many commented that they wanted go give different scores on the survey as a baseline.  From these repeated comments, we started asking the groups to complete the survey at the beginning and at the end of the workshop day.  The scores on respect and support of various members of the clinical team, as well as comfort communicating with each dropped over the course of the day.  The comments explaining this were that at the beginning of the workshop they were not aware of how tolerant of poor behavior they had become and how the culture of the work group was unacceptable in this regard.  One person even stated that when her Clinical Leader was “mean and unapproachable,” she now understands that this is “not a good management style of strength,” but instead is it disrespectful and causes moral distress.  Therefore from the changes in scores from beginning to end of the workshop, we can conclude that awareness was heightened and attitudes open to change.


The first offering of this workshop had over 50 participants with tremendous evaluations and word of mouth spread causing 4 subsequent workshops to be moved into the auditorium to accommodate 120 or more participants in each workshop.  Over 650 interdisciplinary staff participated in the first 5 offerings.  Anecdotal comments from unit managers described situations where they witnessed staff removing themselves from situations when others were gossiping or an increase in overheard compliments and “thank-yous” to coworkers.  This caused one nurse practitioner to comment that “they sure drank the kool-aid.”  Within a week of one workshop, this author received an email from a participant that used the DESC formula to assertively talk with someone about a misunderstanding and now feel a mutual respect for each other.

Conclusions/ value of this presentation:

The 6 month survey results will be available during the presentation along with the agenda for the workshop and description of many of the educational activities.  Clearly, in order to change a culture of incivility to one of inquiry, mutual respect and genuine concern for coworkers and patients, the knowledge, skills and attitudes must be included in educational endeavors.