February 21, 2017

The Culture of Safety - Part 1: No Innocent Bystanders

The Culture of Safety - Part 1: No Innocent Bystanders

By Beth Boynton, RN, MS

When I attended graduate school in 2003, I studied organizational development and behavior, group dynamics, coaching, and emotional intelligence, all of which added depth and breadth to my understanding of individual and organizational behaviors and cultures.

In that program, I learned about a “no innocent bystanders” strategy as part of my research in developing a model that used theater games to build emotional intelligence in children.

One of my resources was a book called Caring Classrooms: The Social Emotional Education of Young children by Jonathan Cohen, PhD. The book placed a significant emphasis on addressing bullying and the need for system-wide, long term, K-12 programming that included a policy known as “No Innocent Bystanders“. 1

This is a policy in which everyone who witnesses inappropriate behavior is held accountable for taking action, and I believe this is a model that we truly need in healthcare.

There are no innocent bystanders in nursing practice

As nurses, we are aware that disruptive behaviors undermine a culture of safety. The Joint Commission’s Sentinel Event Alert, Behaviors that Undermine a Culture of Safety, 2 links intimidating and disruptive behavior to medical errors, poor patient experience, increases in the cost of care, and staff turnover.

We intuitively know that these outcomes are interrelated; medical errors, hiring, and training new staff are likely to increase costs, and turnover of staff can contribute to medical errors and poor patient experiences. Creating cultures of safety where communication is respectful, effective, and efficient is in everyone’s best interest; yet, toxic cultures and behaviors are a pervasive and persistent problem in healthcare.

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The good news is that nurses are the largest workforce in healthcare and the most trusted profession in the United States. It makes sense that we should take a leadership role in creating positive change by championing a “no innocent bystanders” strategy to support the change we wish to see.

The Benefits Of A ‘No Innocent Bystanders’ Approach

To understand why we need this kind of approach instituted in healthcare settings, consider these three benefits:

1. Organization-wide accountability will become a cultural norm.

Our collective status quo has allowed and promoted a mindset wherein witnesses to disruptive behavior look the other way, justify the behavior, or offer support to victims off the record. The rules for a “code of silence” are generally implicit, and involve complicated combinations of tradition, fear, and power combined with a lack of knowledge, skills, and support.

Integrating a “no innocent bystander” approach into a policy that addresses workplace conduct will help organizations infuse respectful, open, and honest communication into workplace culture. This can translate into speaking out against bullying, providing feedback about breaches in protocol, and taking concerns up the organizational ladder. We can turn around the tacit “code of silence” that keeps blaming and bullying cultures alive, creating a new norm of accountability that will make patients and providers safer.

Related: Nurse Bullying: Stand Up And Speak Out

2. The shift in power will support respectful interactions.

The unwritten rules and fears that keep us silent are extremely powerful; worries about job loss, retribution, or uncertainty about appropriate behavior are very real factors in maintaining silence. Regardless of their intention for keeping quiet, silent witnesses give more power to bullies and promote more fear in victims.

When bad behavior occurs in workplaces and no one speaks up, there is a sense that the inappropriate conduct is collectively accepted; this acceptance inadvertently condones the bullying and isolates the victim. And typically, looking the other way doesn’t feel good. Can you envision how an integral power shift could occur when witnesses become part of the equation? Here are a few examples:

Doctor to doctor: “Joe, you’re out line. Take five minutes and cool off.”

Nurse to nurse: “Barbara, you broke the sterile field. I’ll get you another dressing kit.”

Supervisor to nurse: “I overheard your tone with Mrs. Smith and want to discuss how you can take a more compassionate approach next time.”

Nurse to physician: “Dr. Jones, stop it! I’m not going to stand by while you yell at my colleague.”

In each of these situations, clear, confident, and respectful communication is used to steer behavior in a positive direction. How might they have played out adhering to the old “code of silence”?

3. Action provides feedback and opportunities for growth.

Speaking up about another person’s perceived inappropriate behavior makes a statement about what is not acceptable; this can lead to many important learning and growth opportunities for everyone involved.

If I ask a colleague for help and he rolls his eyes, smirks, and says, “You need more help than anyone else I’ve ever worked with,” I might wonder if I am more needy and inferior to other nurses; I might also be reluctant to ask him for help in the future. Imagine how a bystander colleague could intervene by saying, “Hey, Stan, I saw that look; no need to be snarky. If you can’t or won’t help her, I will.”

This intervention would help me to see more clearly how inappropriate my colleague’s behavior is; this is more likely to contribute to a sense of confidence about speaking up, setting limits, and honoring my own experience. If other staff are around, they will get the message that the offending nurse’s remarks and behavior were inappropriate and how his behavior has a negative impact on others. It would be great if he cares, but if he doesn’t care or won’t work to change his behavior, there will be a clearly identified pattern for a supervisor to address.

Also, if I am requesting help more often than others and working in a culture with open, honest, and respectful communication, this will present opportunities for feedback that will pave the way to becoming more independent (or possibly trying a different nursing specialty that’s a better fit for my skills and temperament).

It is also important to mention that inappropriate behaviors are not always black and white; being yelled at may be more intimidating to some than to others. Yelling may be a bullying tactic, but not always; it may vary with one’s perceptions, or it may be a strategy for overcoming a noisy environment, hearing deficits, or distance.

There are also times when intentions of abuse are not present despite someone feeling mistreated. In such situations, someone with a tendency to shout can work to be a little calmer, and another person can work to take yelling less personally. Teasing out these gray areas requires respectful conversations and active, non-defensive listening.

Apply The Strategy Where You Work

In summary, communication is by nature messy, gray, and imperfect. A “no innocent bystanders” policy and approach can play an integral role in creating cultures of safety. Such workplaces hold much promise in terms of improving safety, job satisfaction, quality of care, and patient outcomes.

What do you think about a “no innocent bystanders” rule? Does your organization have one? In Part II, I’ll share ideas on what staff nurses and nurse leaders can do to promote a “no innocent bystander” strategy.

Next Up: We Used to Work Together But Now I’m Her Boss!

Beth Boynton, RN, MS specializes in communication, collaboration, and workplace culture.  She is a Medical Improv Practitioner and author of Confident Voices (CreateSpace 2009) and Successful Nurse Communication (F.A. Davis 2015).  Her third book,  Medical Improv: A New Way to Improve Communication is scheduled for release in 2017.  She can be reached at beth@bethboynton.com,  Twitter @bethboynton, or through her Confident Voices in Healthcare Blog.

1. Phillips, Suzanne, Psy.D., ABPP. “No Innocent Bystanders: The Role We Play in Reducing Violence.” PsychCentral.com. Web. 21 Feb. 2017.
2. The Joint Commission. (2008). Sentinel Event Alert, Issue 40, Behaviors that Undermine a Culture of Safety. Web. 21 Feb. 2017.

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