I had a really bad annual review. It was terrible. So I wrote an 11 page rebuttal. You know me
Tess:Classic Rebecca right there.
Narrator:This episode of Friends of Flo is brought to you by NCLEX Mastery. If you're a nursing student and you're about to take your NCLEX you need to go to the App Store right now and download NCLEX Mastery.
Tess:All right welcome folks this is Friends of Flo and you're talking to Dr. Tess Judge-Ellis and I have with me...
Andrew:Dr. Andrew Whitters DNP
Rebecca:and Rebecca Porter, uh...
Tess:No keep going.
Rebecca:Okay, I'm Dr. Rebecca Porter
Tess:And we actually brought on so we're the Friends of Flo which means that we are nurses and nurse practitioners, researchers and clinicians who like to get together and talk about nursing subjects.
Rachel:Correct
Tess:And we're lucky today we brought on Rachel Hedren with us today. So go ahead and say hello.
Rachel:Hi my name is Rachel Hunter and I'm a medical psychiatry nurse at the University of Iowa hospitals and clinics.
Tess:All right. So the big question today is...
Andrew:Nursing violence. Why do nurses eat their young?
Tess:Do the nurses eat their young? And so to do that, Dr. Rebecca is an expert in this content. So give your background just a little bit, Rebecca. I've known Rebecca for 20 years.
Rebecca:Tessie and I go back a long time when I used to be a nurse practitioner and we've spent a lot of time talking about why do nurses some nurses behave the way they do. And some people call it...historically it's been called nurses eating their young. And I did some looking back in the literature cause that's what I do and I wanted to know when did this all start. And actually the term was coined in the early 1970s and it really began because nursing started over 120 years ago in the United States in a very patriarchal society and the people called to nursing were asked to be demure, quiet, reserved, well-behaved women.
Tess:Oh my gosh we should not be in the profession.
Andrew:I don't think I knew that, I really don't think I knew that specific part of you know American history.
Rebecca:Yeah, so my piece is in ethics and I of course love the history of nursing ethics. And there was a book I found written in 1905 by a nurse ethicist whop put in the requirements to, entry requirements to nursing school. And so you bring those Victorian morals support forward into the early 20th century and things like that die hard. And the role of women began to really change probably in the 1970s after the sexual revolution of the 60s. But, nursing is primarily a women's profession. There are man in there now, but nurses have never been empowered to do what they do. And I think, sidebar, that when you ask people what does a nurse do? My answer is you know when they don't do it.
Andrew:Yeah, that makes sense
Rebecca:So you look at the patriarchy and you look at the power grid. The power gradient in a hospital and in society it's men sliding down to women. Old sliding down to young
Tess:Sure what's valued versus not valued in society. Targeted identities.
Rebecca:Right. So you put a group of women intergenerational women, people who are late baby boomers who have held onto that role of women that they grew up with of not questioning, of doing what you're told, of working with older boomer men, physicians who are used to telling people what to do.
Andrew:Do you think that's still prevalent in today's society that same gradient?
Tess:In society?
Andrew:Well I guess within the profession of nursing, excuse me, within the profession of nursing do you think that there's still that that gradient of...
Rebecca:I think that there's oppression. I think that people in positions of power, unless they are very self aware, unless they're practicing with moral leadership with kindness and generosity as leaders...are not aware of what they're doing to people who are following them. And so I think that power gradient sets up a place of oppression...
Andrew:And to take that just a step further in my head, I look at a lot of nurses and I've been practicing for over ten years as a nurse and a nurse practitioner and I think that oftentimes nurses will make sacrifice professional sacrifices and that's almost an expectation at the sort of the corporate level, the business level within hospitals and perhaps even in private practice. It's expected that you stay past a certain time past your regular shift time to get down with your chart and you're expected to do X, Y, Z for your patients because that's what good nurses do. And I think that can be problematic because nurses give so much of themselves and so much of their time that once that becomes this expectation it almost becomes self-demoralizing if that makes some sense. So comment on that. I mean how does it fit in with that model?
Rebecca:Okay, I'm going to be really political here. I think that's a very pink collar, blue collar attitude. If you look at white collar workers, if you look at corporate executives, if you look at physicians, if you look at attorneys they're not saying uh-oh my shift is over, I got to get out of here. They're saying there's a job to do. This is my client, this is my patient. I'm going to stay here because it's my responsibility. That's just a counter argument. So I think it's how we are socialized into our role. I think it's the environment that we work in and I think it's a product of our society as well. Just because it's 3:30 in the afternoon. And if your patient is still having chest pain or a psychotic episode or is in a cold are ethically, morally, are you going to walk out the door? Are you going to feel that you've sacrificed something. You know what is sacrifice in the face of somebody suffering. What does it mean to suffer and what can we sacrifice to meet that person, that patient at their moment of suffering....Oh! It's 3:30 got to get out of here.
Andrew:Of course. So let's talk about that translation then from that sort of model. And the historical model that you just mentioned. How does that translate then into what we see within the nursing profession and this this idea that we"eat our young".
Rebecca:I think if we put this disrespectful behavior or lateral violence whatever word that you want to put onto it into a theory. And if we use that theory of human behavior we can begin to separate that there are three different components to this kind of behavior and we look at people, their own psyche, their own psychology, their own behavior. And if somebody already has a propensity towards violence or towards being rude and that's their normative behavior or they are a narcissist. We can see that in our world today what happens with a narcissist and the bullying that that creates. Then a second component of that is the organization. What does the organization value? What's the socialization that we're put in into that organization where we're working and is oppression allowed. Is that hierarchy protected? Are people in power protected and everybody else is kind of just get your job done and be quiet. And it doesn't matter how you're being treated. The third component of that human behavior are the values of the organization. So it's the human psyche, the values and socialization of how we're treated and what we expect.
Andrew:So how does a new nurse come into a situation. Perhaps a nurse is being interviewed, coming to an organization and find out about those types of variables in an organization.
Rebecca:I think it's hard to get to that question. Let me just pop out a statistic. Up to 85% of nurses are bullied in a hospital. And that's been going on for decades. A huge proportion of those brand new nurses are going to leave within the first year because of bullying.
Andrew:And doesn't that drive you guys nuts? Because I mean the first podcast that we did you alluded to the idea that we're the most trusted profession. And then I hear stuff like this and this is embarrassing for me as a provider and as a nurse because we had this caring desire to do what's right for people, but we can't seem to take care of ourselves. It really makes me mad.
Rebecca:It really is really frustrating. But I think if you add up all of those issues of gender issues, intergenerational issues, funding cutbacks...Rachel can talk about the high pressures at work of acuity increasing. It's normal now. So you're working in a pressure cooker and then you add on top of all these other issues. And when we're talking about...it's OK to have an angry outbursts. We all have those. You know we all have moments of anger but I think what we need to get at is what is the definition of bullying? What is the definition of abusive behavior? I'd like to know what your thoughts are what do you guys think? Rachel hasn't had a chance to talk yet.
Rachel:I would say the biggest thing that I've noticed is the gossip goes on and when you come into a new environment and you don't know anyone there's not really anything to say. And if you don't say anything people sometimes can ostracize you for that for not really having an opinion about someone or something, whether it's systematic, whether it's management, whether it's just some kind of procedure that's protocol to the unit.
Tess:They're looking to see whether or not you're part of the club. Can you join in on that gossip...
Andrew:That's a lot of pressure. I mean there's just in general that seems like a lot of social pressure to fit in.
Rebecca:I just watched the movie Mean Girls. I had to rewatch that.
Andrew:Is that the one with Rachel McAdams and...
Tess:Lindsey Lohan
Rebecca:So it is really hard to be in your person. It's really hard as you brought up to....Andrew you asked, how do you find out about what a unit is like. And I think it was a couple weeks ago we talked about how do you interview for your first job. Where are the questions you ask about your first job, that it's your market you know you can get a job pretty much wherever you want. And so where do you want to work and you should have your criteria set down. You want to work in a place where scholarship is valued
Rachel:Like higher education going on to school that needs to be supported. I was told before I interviewed not to talk about potentially going to grad school because it could limit my potential on the unit. They would not see me as management material because they knew I was going to leave
Rebecca:Wow
Rachel:But I didn't really take that advice to heart. And luckily that was well received by my assistant nurse managers. But it's something that's out there that a lot of new nurses here that I think is...
Andrew:That alone seems like there's a desire to press you into a have the peg fit its hole, you know? And I think that just sounds very forward and it sounds it doesn't sound like an environment that would be made attractive to especially a new person coming out of school.
Tess:Did you have something else to say about that Rachel?
Rachel:No, not really. I'm just glad at least where I interviewed that I didn't have feelings that I couldn't express my own educational goals. I thought that made me more marketable and if they didn't see it that way I knew it wasn't going to be the place for me.
Rebecca:Right and so another question that you could ask is, how is conflict handed in your unit.
Tess:You know before we go onto that and the new thing I wanted to get back to something that you said early that resonated with me, Beccers, hat was when you said something about well behaved well-behaved nurses. You know you had to be a well-behaved woman. And so consequently I think when I run up against resistance that it's easy for me to fall back and say I'm being such a bitch. Can we cuss on the podcast Dougie C? He says, yes we can. You know as a person who was raised and I'm not quite a baby boomer I'm at the tail end of the baby boomers.
Rebecca:You're up there Tessie
Tess:I was born in'65 which means the last day of 1965.
Rebecca:Yeah, you're barely a boomer.
Tess:But I guess my thought is that you come up, they assume of course I'm a nice person and I was raised in nice Iowa and I'm moving forward and and then I come up against a, like, I want to say my mind about something and I sound to myself kind of bitchy and I have an internal conflict about this and how it's accepted. And maybe this is just revealing myself a little too much. But I think it resonated with me when the culture out there is we're still supposed to be nice. And where does the point of being assertive and in ownership of that it's just simply that's me and I'm being assertive versus oh my gosh they're going to think I'm a bitch. Oops, Dougie C is saying we're off to a break.
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Tess:Okay, so lead on Mcduff.
Rebecca:Oh, I was at McBeth last night. Anyway, Rachel you brought up the thing about gossiping and gossiping is so much fun. It really is. It really is fun. Until somebody gets hurt and so you have to be able to exercise some street smarts and be able to discern whether this is just fun gossip about something fun or is it destructive or is it whining and what's it accomplishing? When you get into a kind of gossip that is mean or divisive or the mean girls are trying to split a group. Or there's a clique being formed and you're not part of it. It takes a lot of courage. I was going to say moral courage, it is the same thing. To say, I don't know all the facts about this and I don't think we should be talking about this and when you have all the facts I'd love to have a conversation about it. There aren't any facts here. We're just speculating and I'm not going to be part of this and walk away.
Andrew:But that's being done at this predication that that yes it's it's courageous to say that, but then the person who says that is also putting themselves out there to be destroyed socially by gossip
Rebecca:What does it feel like Rachel? You do psychiatry. What does it feel like to know that you're sitting and listening and laughing when you know you shouldn't be, but you're going along to get along. And then you go home and you just think what the heck have I been hanging out. Who the heck am I becoming here.
Andrew:That's difficult
Rebecca:What's it like to be new which like to have that happen. How hard is it to just walk away?
Rachel:I think for me my role is a little bit different because I had been a student there before so I knew people. But hearing from other new nurses that are very good friends of mine. It has really destroyed them psychologically. They can't really handle it and they don't feel like they can talk to people above them like their assistant managers or nurse managers some of them have chose to either move on to different roles or move to different institutions.
Tess:But this gets into your second part of your theory. I mean it's the moral you know your own sense of self and your own courage I suppose. And then knowing yourself, but then the organizational supports around you and then what's supported in the organization.
Rebecca:Exactly. So part of being able to take a stand and the healthy response is to say I can't do this anymore, but then having a courage to say to a human resources I am leaving because of the intrepid gossip. I'm being bullied for the last six months. And that's one of the definitions of bullying is that there's a target. It's purpose is to isolate and separate and humiliate another person or group of people. And it has to be a pattern that has to go on usually for about six months before it's really called bullying.
Andrew:So let's expand for a little bit. What else can be done besides going to H.R. or going to management or even the people the people that are conducting the bullying. Because this could be a lone rider situation where a nurse might feel completely on his or her own and that right there takes a tremendous amount of energy and courage.
Rebecca:So let me tell you a story. My very first job I was bullied by my nurse manager. This is a long time ago, but I was I was isolated. In retrospect, I realized only after many years did I realize what had happened to me. And this nurse manager had bullied me. She started off my first day of work saying I hate nurses from two year and four year programs. This was at a time when there used to be three year hospital based programs. And I was from a"4 year" program and I knew things weren't going to go well from there. And she kept giving me really horrible assignments and I told her on the first day for instance I've never had any training in emergency room care. In the University of Calgary we didn't do emergency room or critical care that was considered. You had to have a separate education certification to work in those areas. And it was considered post-graduate education. First day on a job where did I get assigned it was a small rural hospital. First case in the morning multiple vehicle accident and there I was. And I asked for help. And I was told that I was weak and stupid and inept. And so I told the physicians that I've never done this before. Tell me what you need and I will do my best. There is another day there was a code. And I started to do CPR and she bumped me out of the way and said Get the hell out of the way you're of no use here. And next time you're shackled. It was just awful. And just like you find in the literature. That kind of bullying can be covert. Like getting really bad assignments repeatedly. It can be people targeting you without warning signs reading notes about you. Or it can be very overt like she knew she was brushing me aside. But no matter what it is we have our responses are so breaking. Rachel you talked about friends who have left her unit and they're doing that to protect her own health. And we know that this kind of behavior affects us physically. That people got chest pain, chronic illness flare. So as a nurse practitioner is when you see nurses coming into your practice with these inexplicable symptoms that you could say tell me what's going on at work. And mentally depression, clinical expression needs psychiatric intervention. Loss of faith, loss of friends, getting into bad coping strategies like drinking too much. So what do you do when your manager is a bully. I had a really bad annual review. It was terrible. So I wrote an 11 page rebuttal, you know me.
Tess:That's classic Rebecca right there.
Rebecca:And I sent that letter to the chief of medicine and the director of nursing and then I quit and and she followed me into my next job. She wrote a really horrible evaluation, but my next job saved my life. Well saved my professional life. So this has been going on for decades. And what do you do. We can talk about things that you can say towards different things and Tess will have lots of perspective lots of things to add from her psychiatry training, but ultimately we have to look after ourselves. As we look after ourselves and after regain some seniority where we are, we have to spread our kindness and generosity to one another. You have to stand up. You have to walk into your unit on that first day with your shoulders back and your head held high. And look people in the eye and let them know that you're not going to be one of their targets. You're here to work. We're not here to be best friends. We're not here to be in a clique. We're here to care for patients and what we hold in common may not be our personal values, but what we do hold in common are our professional values.
Tess:Bravo! Bravo Rebecca
Rebecca:And so part of that code of ethics is that we care for ourselves as we care for our patients. We care for one another as we care for our patients.
Tess:This is why we're a trusted profession, right?
Rebecca:So what do you say when they're gossiping. What do you say when they are rolling your eyes. I didn't get that bath done today, Rachel, I'm sorry I have to leave that bath for you. And you roll your eyes at me or I roll my eyes at you and say, I've got to start my shift already ten minutes late cause I have to go do a bath and I roll my eyes. Can you think....
Tess:Oh I can think of a lot of first things I'd say
Rebecca:I know, but this is...we have to be professional.
Tess:Exactly. We do have to be professional.
Rebecca:So think for a second. What would you say to somebody who rolls your eyes at you?
Rachel:I think a lot of it comes back to education before we even step on the floor at our first job. I think it comes from this is the reason we have nurse residency programs. I think they need a lot of work. And these are the things they should be helping us learn is how to handle ourselves.
Rebecca:So were you ever taught what to do what to say.
Rachel:No
Tess:Don't you think this gets at leadership, individual leadership. And I think when you think you're the lowest man on the totem pole as a new nurse or whatever your new job is then you don't think you're a leader. To me leadership it's personal leadership not just like taking a position to be a leader.
Rachel:Right
Tess:So I do think that going through vocabulary I think and I mean Rebecca gave us three or four articles that we were to read in preparation for this and we could put up those citations on the Facebook site if people are really interested. Okay so here's some ideas when somebody is rolling your eyes at you. You can say, I see from your facial expression or I saw your eyes roll and that indicates to me that you have something to say to me and it's OK to talk to me. I'm safe to talk to and and when somebody says, oh you're just a newbie no wonder you didn't get everything done tou guys are all the same. You can say, I know I have a lot to learn. I'm in my first year, but I learn best from people who respect me. I learn best from people who treat me with respect. And how could you reframe rephrase that would help me learn.
Andrew:That's a great response
Rebecca:What you also have to remember is that sometimes people who are mentoring or precepting appear to be really critical. And it can be A, your personality, B, they've got standards, but C, they want to be sure that you know what you're doing and you can perceive this as overbearing, but they're also saying I'm responsible for what you're doing right now. So I'm going to be on your case while this is getting done.
Tess:So kind of a little thicker skin.
Rachel:And I think that's something I got a lot of on my unit and it was the best thing for me. That I got all that constructive feedback that made me strong from the beginning.
Rebecca:Was it hard?
Tess:Do you have an example, Rachel?
Rachel:I think the biggest thing was being a medical and a psychiatry unit. Some of the medical stuff really we just didn't have a lot of experience in a nursing school. However, I learned quickly, but they would...e0ven if they saw me struggling they let me struggle through it. And they were you know constructively criticizing like, OK next time do it this way next time do it that way or if you think you have a better way let's come up with something together. I think that feedback is what what made me better. And if somebody was just like OK, do it however you want I I wouldn't be a good nurse.
Andrew:And I think the key word there is being constructive with nurses and with new people. I think to your point that when you're calling someone names that just punctures their competence. And it's demoralizing. And so I think there is a big difference between being constructive and then just being angry to say, well that was just dumb you know. Because that in a way can be construed as, wow, I guess I was just called stupid right there.
Tess:Actually we need to quit. I'm sorry we have to end this we maybe need to have another session at some point.
Rebecca:I'm going to be really interested to see what kind of comments people have.
Tess:Please send them in. Twitter, I don't know what we're doing.
Rebecca:Share your story and and give us some examples that we can pick up on next time.
Tess:Keep your eye on the patient.
Rachel:Be the change you.
Tess:Be kind to one another.
Andrew:I'll watch you if you watch me.
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