Journal of Nursing Education

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Educational Innovation 

Reader’s Theater: A Teaching Strategy to Help Students Respond to Disruptive Behavior

Jane Hutcheson, MS, RN; Kathleen Lux, RN-BC

Abstract

The seriousness of disruptive behavior among nurses has been documented by professional nursing organizations, nurse researchers, hospital administrators, and the Joint Commission. Disruptive behavior is any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical and sexual harassment. Although the profession recommends development of nursing curricula to address disruptive behavior, the literature on this topic is scarce. Using reader’s theater, an innovative teaching strategy, the 10 most common forms of disruptive behavior were introduced. The scripts were used in a senior-level baccalaureate nursing transition course to increase students’ awareness of and ability to handle disruptive behaviors. Reader’s theater is a scripted, formalized storytelling experience that provides an opportunity for self-reflection and group discussions. After the reader’s theater learning activity, students reported an increased ability to recognize and handle disruptive behavior in the workplace.

Abstract

The seriousness of disruptive behavior among nurses has been documented by professional nursing organizations, nurse researchers, hospital administrators, and the Joint Commission. Disruptive behavior is any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical and sexual harassment. Although the profession recommends development of nursing curricula to address disruptive behavior, the literature on this topic is scarce. Using reader’s theater, an innovative teaching strategy, the 10 most common forms of disruptive behavior were introduced. The scripts were used in a senior-level baccalaureate nursing transition course to increase students’ awareness of and ability to handle disruptive behaviors. Reader’s theater is a scripted, formalized storytelling experience that provides an opportunity for self-reflection and group discussions. After the reader’s theater learning activity, students reported an increased ability to recognize and handle disruptive behavior in the workplace.

Ms. Hutcheson is Assistant Professor, and Ms. Lux is Associate Professor, Capital University, Department of Nursing, Columbus, Ohio.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Jane Hutcheson, MS, RN, Assistant Professor, Capital University, Department of Nursing, 1 College and Main, Columbus, OH 43209; e-mail: jhutches@capital.edu.

Received: February 02, 2010
Accepted: September 08, 2010
Posted Online: March 17, 2011

Disruptive behavior among nurses is a critical issue facing our profession. Disruptive behavior is defined as any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical and sexual harassment (Institute for Safe Medication Practices, 2004; Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005; Rosenstein & O’Daniel, 2003, 2008). It is frequently manifested in overt and covert nonphysical hostility (Duffy, 2004). Lateral violence, horizontal violence, bullying, hostility, incivility, and verbal abuse are synonyms for disruptive behavior. Disruptive behavior has been related to increased RN turnover, increased medical errors, and greater patient mortality. The problem of disruptive behavior has been recognized by the Joint Commission (2008), which now requires hospitals to develop policies and training on management of this behavior.

Disruptive Behavior

After reviewing the international nursing literature, Griffin (2004) identified 10 common forms of disruptive behavior: non-verbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, back-stabbing, failure to respect privacy, and broken confidences. These behaviors have been shown to significantly increase workplace stress, burnout, job dissatisfaction, and decisions to leave the profession (Rosenstein & O’Daniel, 2005) (Table).

The 10 Most Frequent Forms of Lateral Violence in Nursing Practicea

Table: The 10 Most Frequent Forms of Lateral Violence in Nursing Practice

Many nurses do not consider these behaviors disruptive. Instead, they accept these behaviors as typical of women who work together (Duffy, 1994). Stanley et al. (2007) reported that the measurement of disruptive behavior is challenging because of nurses’ uncertainty about whether this phenomenon even exists. In a study of a senior-level nursing transition course, the authors found the initial student reaction to this content to be disbelief that such behaviors existed in any profession. The literature recommends that interventions that address disruptive behavior be developed for both the workplace and nursing schools (Bartholomew, 2006; Griffin, 2004; Stanley et al., 2007).

Nursing Education

Educating nursing students to recognize and appropriately respond to disruptive behavior is a challenge because students may have an idealized view of nursing. In our teaching experiences, students have argued that disruptive behavior is not as bad as the literature portrays it. They have suggested that it is simply gossip and is common in any work group where people work closely together. Students who have experienced disruptive behavior in a clinical setting recognize that it is a problem but are uncertain how to handle the behavior. Their response to disruptive behavior entails no more than discussing it with fellow students. Teaching strategies are needed that engage students in education and self-reflection about the various forms of disruptive behavior. Reader’s theater is such an innovative teaching strategy.

Reader’s Theater

Reader’s theater is a teaching modality used by educators to improve reading skills and comprehension. Pardue (2004) integrated reader’s theater in associate degree and baccalaureate classes as a strategy to expose students to caring and person-centered understanding of health and illness. Reader’s theater is a scripted, formalized storytelling experience. It involves the oral presentation of a script by two or more readers about a particular topic. The goal of reader’s theater is to stimulate thinking about the stories so the cast and audience can engage in a meaningful discussion. It also provides opportunity for reflection and group discussion.

Reader’s theater does not use scenery, props, or costumes. It relies on the vocal ability of readers to portray the characters; body movements or gestures are rarely used during a performance. Cast members do not make eye contact with the audience or engage with other members. Instead, each role is read directly from the printed script. Garrison Keillor’s radio show “Prairie Home Companion” is a contemporary example of this strategy. As scenes unfold, there is a weaving and connecting of voices, emotions, and associated messages on behalf of the various characters (Pardue, 2004).

As nursing faculty, the authors developed reader’s theater scripts addressing each of Griffin’s (2004) 10 disruptive behaviors. The scripts were written from actual experiences of the authors, staff nurses, and students. Some of the scripts focus on one particular disruptive behavior, whereas others incorporate multiple behaviors. Student volunteers from a senior role transition class were solicited to perform the stories. Each volunteer student was assigned a role, given a script, and participated in a short rehearsal before presentation to the class. After reading the scripts, all of the students were asked to identify the disruptive behavior, assess whether the person experiencing the disruptive behavior had responded appropriately and whether others in the scripts had responded appropriately, and how they would handle the scenario. The scripts helped the students experience situations involving disruptive behavior in a safe environment. The purpose of the reader’s theater scripts is three-fold: help future nurses identify and respond appropriately to disruptive behavior, maintain healthy working relationships, and improve patient safety and outcomes.

Reader’s Theater Scripts to Address Disruptive Behavior

“Only the Strong Will Survive” addresses verbal affront, with some instances of nonverbal innuendo. This script was chosen for the article because it identifies the disruptive behavior occurring in the situation.

Title: Only the Strong Will Survive

Scene: Surgical unit of a large public hospital

Script characters:

  • Joyce: Nurse manager.
  • Katie: New baccalaureate nursing (BSN) degree graduate who is starting orientation.
  • Mona: RN with a BSN who has worked on the unit for 5 years.
  • Tom: RN with an associate’s degree who has worked on the unit for 7 years and is completing his BSN degree.
  • Joni: RN with a diploma who has worked on the unit for over 20 years.

Narrator: It is the first day of orientation for Katie. She loved her surgical rotations in school and is very excited that she was able to “land” this job on a busy surgical unit. She has heard that the nurses on this unit are very cliquish, but she is sure she will be able to handle this situation. Katie starts her day with Joyce, the nurse manager.

Joyce: Good morning. Are you ready to start your orientation? Do you think you have what it takes to fit in here? It takes a special nurse to work with my nurses. (Joyce laughs)

Narrator: Katie is thinking to herself. “That is one scary laugh!”

Katie: (with enthusiasm) Not only am I ready to start my orientation, but I am very excited to learn and I know I will fit in here.

Narrator: “Well, let’s see how Pollyanna performs,” Joyce thinks.

Joyce: I am going to have you shadow Joni today. She has been working on the unit for over 20 years. I am going to warn you that she doesn’t really like BSN students and she may make comments that you don’t like, but the best way to handle the comments are to ignore them and work hard! (Laughs again) Yes, Joni is a firm believer in the good-ole work ethic.

Narrator: Joyce gives Katie a quick tour of the surgical unit and then introduces her to Joni.

Joyce: Hey Joni, this is Katie the new grad that will be shadowing you today. Don’t be too hard on her. (Laughs loudly)

Narrator: Katie seeing Joni for the first time feels her heart rate increase. Joni is a large imposing woman with a very stern look on her face. Katie had heard about nurses like Joni from other students, but she had always thought they were exaggerating.

Katie: (timidly) Hi Joni, it is nice to meet you.

Joni: (loudly) Well, we’ll see if you feel the same way at the end of the day. Now let’s get busy. There is a lot of work to do and having you tag around like a dog only makes more work for me. I hope you are smarter than most BSN students. The last one only lasted 6 months!

Narrator: Katie doesn’t know how to respond to Joni’s remarks so she just stands in the middle of the report room looking at Joni. She has a sinking feeling in the pit of her stomach and wishes she could complete her orientation with one of the other nurses. Joni rolls her eyes thinking, “Another stupid BSN grad. What do they teach at those worthless universities?” Mona, feeling sorry for Katie, says…

Mona: (pleasantly) Come on Joni, don’t you remember what it was like to be a new grad?

Joni: (defiantly and with emphasis on the I) When I was a new grad I had already worked so many hours in the hospital, and surgery, that I was ready to go. I hardly needed an orientation.

Narrator: Joni and Katie head out of the report room. Tom turns to Mona and says…

Tom: (with a sly look on his face) It should be an interesting day for Katie (laughs and then thoughtfully) I don’t know, maybe it isn’t a good idea for Joyce to put the new employees with Joni. She is demeaning and verbally abusive with them. What do you think?

Mona: We had to go through it. It’s the way of the world. If Katie can’t make it through the hazing, I mean orientation, with Joni then she doesn’t have what it takes to be a nurse. Joni isn’t that bad once you know how to take her verbal abuse. Just yesterday she needed help and yelled, ‘Hey, worthless BSN nurse, get me more sutures stat!”

Tom: (with emphasize) That’s a perfect example of verbal affront.

Mona: Oh baloney! It’s just Joni.

Tom: You are wrong. In the nursing class I’m taking this semester we are reading a book on disruptive behavior. I am pretty sure the author of the book would label Joni’s comments as verbal affront, and her eye rolling as nonverbal innuendo.

Mona: (hurriedly) Listen Tom, I don’t have time for this now. Maybe we can talk about this later.

Narrator: Mona hurries out of the report room to get ready for her first surgery of the day. Tom has a few minutes before his first surgery and spends those minutes thinking about how nurses “eat their young.” He has been very intrigued by the discussions his class has had on disruptive behavior. Before these discussions he would not have questioned Joni’s approach to new RNs on the unit. Tom decides he will talk to Joyce about his thoughts soon. Meanwhile, Joni and Katie are busy setting up a surgical table.

Joni: (loudly) No, that isn’t the way you do it. I can see you are going to be one of the slow ones. You have to be sharp as a tack to work in surgery.

Narrator: Katie turns bright red at this comment. She is a smart person, but does not perform well when criticized and is not used to being treated like she is stupid. Maybe she will ask Joyce if she can do her orientation with Tom or Mona. It was a long day for Katie. The only way she knew to endure the verbal abuse of Joni was by trying harder and turning red. Neither of these approaches seemed to work very well. At the end of the day, Katie met again with Joyce.

Joyce: (cheerfully) How did your first day go?

Katie: (almost in tears) Not well. I don’t think Joni likes me and it makes it hard for me to learn. I always did well in my clinical rotations, but I am not used to being told I am slow and stupid! Joni is so intimidating that I am afraid to reply to her.

Joyce: (reassuringly) Oh that is just Joni. Her bark is worse than her bite. She’s really a nice person.

Katie: (hesitantly) That was not my impression of her. It seems like she takes delight in terrifying new nurses. I am very concerned and don’t feel like Joni is the best nurse to do my orientation. Do you think I could be with Tom or Mona instead of Joni?

Joyce: (with concern) Joni always does the new nurse orientation and she won’t be happy if I put you with the other nurses. I did that once before and she was really hard on the nurse. That nurse made it for about 6 months and then asked for a transfer.

Narrator: Katie did not know what to do. She had started her first day on the unit with enthusiasm and now found herself wondering if she would be able to make it through Joni’s orientation methods. If Joyce, the nurse manager, didn’t see that there was a problem, what could she do? As Katie was leaving Joyce’s office she ran into Tom. Seeing Katie’s look of distress Tom said…

Tom: (with concern) Tough day?

Katie: A really tough day! The more I tried to please Joni, the worse she treated me. I have never had anyone say such mean things to me in my life, and I don’t know how to respond to her. I asked Joyce if I could do my orientation with Mona or you and she said I couldn’t because that would make Joni mad and meaner.

Tom: I am not surprised to hear that you had a hard day. I am going to talk to Joyce about Joni. I don’t know if it will do any good, but I will try.

Narrator: Tom knocks on Joyce’s office door.

Joyce: Come in! (pause) Hey Tom! How’s it going? Have a seat.

Tom: (speaking carefully) I ran into Katie as she was leaving your office. She looked pretty distraught.

Joyce: (casually) Oh, she’ll be OK. All the new nurses feel like that after their first day with Joni. (cackles)

Tom: (with emphasis) I know! I used to think it was OK to go through the “orientation from hell” with Joni, but I am not so sure anymore. Remember that recent meeting we attended on the Joint Commission’s new policy on disruptive behavior?

Joyce: Yea, yea! I believe the Commission has blown the situation out of proportion. You know nursing is mostly women and this is the way women work together.

Tom: I am going to respectfully disagree with you. I am reading a book in my issues class this semester about disruptive behavior. Verbal affront is one of the ten disruptive behaviors considered inappropriate. Joni’s treatment of new nurses is a perfect example of verbal affront, one of the ten behaviors. I know that the Joint Commission and the author of the book believe that there should be zero tolerance for this type of behavior. Once the hospital develops the policy and form for reporting an incidence of disruptive behavior, nurses like Katie could file a complaint against nurses like Joni.

Joyce: (in a tired voice) Tom, I don’t have the energy to take on Joni. She has been here longer than I have and it is easier to let her have her way. Katie will just have to develop thicker skin.

Tom: That reminds me, we have lost several very good nurses in the seven years I have been here. I think it’s time to make some changes on this unit, especially with the Joint Commission backing us.

Joyce: What do you suggest?

Tom: I think we should have some education in-services on this topic. I also think you should talk to Joni about her verbal abuse of new employees, and I’ll be glad to take over Katie’s orientation.

Joyce: (sarcastically) Maybe you should take over as manager too!

Narrator: Tom laughs. For once, Joyce does not laugh!

Tom: (smiling) No, I’m not ready for that yet. But, I am ready to try to change the communication patterns on this unit. Come on Joyce, let’s do it!

Discussion

Once the script reading is complete, discussion is facilitated by the faculty. All students, including those reading the script, participate in the discussion. The faculty may make a few neutral comments to help students transition from listener to active participant (Savitt, 2002). Faculty should be prepared for a few moments of awkward silence at the beginning and resist the temptation to fill in those silences. Students are encouraged to share their thoughts and insights before the faculty uses the prepared questions. The following are examples of questions used with this reader’s theater script:

  • How would you respond if you were Katie?
  • Was it appropriate for Katie to ask to be assigned to another preceptor?
  • Was the nurse manager’s response to Katie appropriate? If not, how should she have responded?
  • Should Katie discuss her concerns with Joni? If so, should she do it one-on-one or with the nurse manager present?

Student’s Response to Reader’s Theater

Students (N = 28) were open with their concerns about confronting disruptive behavior and how it might affect their clinical situation with both preceptor and faculty member. Students also shared examples of disruptive behavior that they had experienced and voiced concern about what they felt was non-support from faculty. An evaluation form was given to students 2 weeks after the disruptive behavior lectures and scripts were completed. Evaluation results show that 93% (n = 26) of the students strongly agreed or agreed that they would be able to recognize disruptive behavior and apply what they had learned to their nursing practice. Eighty-nine percent (n = 25) said they would be less likely to engage in disruptive behavior as a result of their training. Written evaluation comments also indicated that the students would be less likely to participate in disruptive behavior.

Conclusion

Nursing research indicates that exposure to disruptive behavior causes nurses to leave positions and, sometimes, the profession. It also undermines the effective delivery of health care. Arming students with knowledge about disruptive behavior and appropriate actions for handling it would add an important component to their transition to the real world. Reader’s theater scripts allowed students to experience realistic disruptive behavior scenarios in a safe learning environment. Our experience using reader’s theater with senior nursing students in a transition course was positive and rewarding.

References

  • Duffy, E. (1995). Horizontal violence: A conundrum for nursing. Collegian: Journal of the Royal College of Nursing, Australia, 2(2), 5–17. doi:10.1016/S1322-7696(08)60093-1 [CrossRef]
  • Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 1–7.
  • The Joint Commission. (2008). Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert
  • Keillor, G. (Writer). (2011). Series [Radio broadcast]. In Hanssen, T. (Producer), A Prairie Home Companion with Garrison Keillor. St. Paul, MN: American Public Media.
  • Maxfield, D., Grenny, J., McMillan, R., Patterson, K. & Switzler, A. (2005). Silence kills. Provo, UT: Vitalsmarts, L.C.
  • Pardue, K. (2004). Introducing reader’s theatre! A strategy to foster aesthetic knowing in nursing. Nurse Educator, 29, 58–62. doi:10.1097/00006223-200403000-00006 [CrossRef]
  • Rosenstein, A. & O’Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety, 34, 464–470.
  • Savitt, T. (Ed.). (2002). Medical readers’ theater: A guide and scripts. Iowa City, IA: University of Iowa Press.
  • Stanley, K., Martine, M., Welton, J. & Nemeth, L. (2007). Examining lateral violence in the nursing workforce. Issues in Mental Health Nursing, 28, 1247–1265. doi:10.1080/01612840701651470 [CrossRef]

The 10 Most Frequent Forms of Lateral Violence in Nursing Practicea

Nonverbal innuendo (raising of eyebrows, face-making)

Verbal affront (covert or overt, snide remarks, lack of openness, abrupt responses)

Undermining activities (turning away, not available)

Withholding information (practice or patient)

Sabotage (deliberately setting up a negative situation)

Infighting (bickering with peers)

Scapegoating (attributing all that goes wrong to one individual)

Backstabbing (complaining to others about an individual and not speaking directly to that individual)

Failure to respect privacy

Broken confidences

Authors

Ms. Hutcheson is Assistant Professor, and Ms. Lux is Associate Professor, Capital University, Department of Nursing, Columbus, Ohio.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Jane Hutcheson, MS, RN, Assistant Professor, Capital University, Department of Nursing, 1 College and Main, Columbus, OH 43209; e-mail: jhutches@capital.edu

10.3928/01484834-20110317-01

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