Issue 3: Loosening the Grip of Abusive Behaviors
Patient Care in a Punitive Culture
Introduction by Dr. Maureen Boshier
The Dangerous Culture of Science: Ethical Implications of Bullying in the Health Care Workplace by Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP
Violent Patients, Abusive Staff: A Summary of Unpublished Study Findings by Dr. James Blando
Overview of Early Career Nurses Experiences of Verbal Abuse from Other Nurses by Dr. Christine Kovner, Dr. Carol Brewer, and Dr. Wendy Budin
An Interview with Suzanne Godon on Toxic Hierarchies, with Dr. Maureen Boshier
Acknowledgements, Commenting Policies, and other Fine Print
Dr. Maureen Boshier
I have been told by readers of this Journal, by the authors in this issue, by colleagues, and even by patients, that the level of tolerance for abusive, threatening, humiliating, demoralizing and all other types of dysfunctional behavior in health care is frightening, repugnant and dangerous to patients and practitioners alike. Yet it is allowed, and occurs largely without censure.
Bad behavior that is given tacit approval becomes embedded, then continues as the norm. This behavior creates disharmony, isolationism, and self-doubt, impeding healing and interfering with a sustained environment of care and peace. In these circumstances, the road less travelled is the one that would change attitudes and force the intolerable to become impermissible.
So you ask, are these episodes of bad behavior clandestine, unwitnessed by colleagues and consumers? Is that why there is no expectation of confrontation and consequences? Is that why disrespectful and downright mean behavior exists?
In health care, work is often accomplished in teams whose work can be observed. All practitioners and health care workers focus first on the patient and are believed to be there to speak up and prevent situations that could harm patients or community members who count on the team. Remember the TV show ER? The first time I saw an episode, I was struck by the inordinate courtesy and respect the actors demonstrated toward one another as they worked through life-threatening as well as everyday situations. I was thinking about how the ER in the university hospital where I worked functioned, and there was little resemblance.
Many reports in the literature, and anecdotally, about medical disrespect confirm a disconnect between the virtues and the realities of teamwork. In fact, many care providers are socialized by example from the first day of training to be disdainful, competitive, and even rude to fellow workers and sometimes to patients and families. Who among us has not witnessed episodes of uncivil and abusive behavior? Who among us has done anything about it? Who among is responsible for turning the situation around?
And why pick on this issue now?
For one thing, there is much discussion in popular media and literature about the phenomena of bullying. In the professional literature, the label of bullying has now been applied to the abusive behavior of care providers against their fellows and their patients. You will read in the articles of this issue about the ethics, the safety, the harmful effects, and the continuum of actions that comprise unacceptable professional behavior, which for some represent bullying behavior (someone not able to defend themselves from another) and for some, represent aggression that is intolerable and abusive, but could fall short of bullying.
The reader should keep in mind the differences noted by the authors and also be thinking of gradients of activity to prohibit the offensive behavior recognized as ubiquitous in the profession.
Since it is likely that we all have stories that illustrate the toxic culture of health care we have to ask why that is.
Here’s what Dr. Kate Fenner, an advisory board member to this Journal and a nursing professional par excellence has to say on the subject: “The culture of tolerance for verbal abuse and incivility jeopardizes patient safety unacceptably. The initial analysis of sentinel events conducted by The Joint Commission when the SE process was first imposed demonstrated that a significant portion of errors in care were attributable to staff fear of being castigated if seen as questioning the authority of a physician or even a more seasoned practitioner. Even the much heralded advances represented by Universal Protocol in the OR are uneven and still hobbled by fear of speaking out. Culture trumps policy, common sense, and logic any day.”
So I ask you, what can be done?
Within this issue of Nursing in the 21st Century, you will read Ellen Fink-Samnick’s article, "The Dangerous Culture of Silence," which discusses ethics and safety as components of patient care that are damaged right along with empowerment of the workforce when abusive behavior is permitted and allowed to continue.
Dr. James Blando showcases findings of his original research on violence in the workplace in which abusive behavior from the patient targets the homecare aide assigned to provide ambulatory care. A good example of the hierarchical nature of abusive behavior in health care, which is not only between professionals assumed to be one up or one down on the provider continuum, but also between patients and patient care aides, often perceived to be on the bottom of the power hierarchy. Physical violence is admittedly a notch up in the abusive behavior realm, but all forms of violence are equally unacceptable, and a mindset that eschews all abusive behavior has to be the new normal.
Dr. Christine Kovner shares points from a recent paper regarding the experiences of early career nurses with verbally abusive behavior by mentors and employers.
Suzanne Gordon, a well-known journalist, author, and nurse advocate, uses the term "toxic hierarchy" in her writings, and shares her thoughts and observations on aspects of dysfunctional behavior that are alive and well in the culture of care. She also shares some important comments on the responsibilities of managers, educators, and individuals for eliminating tolerance of abusive behavior.
Much more can be said about all components of abusive behavior, and it is hoped that readers will add their comments by tapping or clicking the comment bubble.
We know about the issues these authors bring to our attention with the evidence of their research and their scholarly and thoughtful review of the topic based on their experiences in the field.
Now is the time for all segments of the health care community to courageously take a stand of intolerance for behavior and communication that is abusive on any level. We realize that what is at stake is the safety and well-being of ourselves, as well as those in our care. We must be the ones to demonstrate and teach new models of interaction, interprofessional education, and cooperation that is supportive, non-punitive, and intolerant of abusive behavior.
Every one of us can do something that will change these phenomena and repurpose the culture of health care into a culture that is reliably and unarguably one of cooperation, civility, healing care intolerant of abuse on any level. Let's look around ourselves: What will we continue to do, or what will we contribute to making a permanent positive change in the culture?
Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Introduction: A Reflection
My father was a physician; one of the rare breed of practitioners who valued communication as the means to achieve quality patient care. This premise shaped my foundation of the health care workforce I entered over thirty years ago.
The evening prior to my first professional role as a hospital social worker, my father provided his usual counsel to the youngest of his children. In preparation for this sharing of expertise, my father inquired what thoughts I had about starting the job. I remember my reply and our interaction like they were yesterday:
“Dad, I’m confident I’ll learn the job, but something came up during my interview that I can’t shake. The panel gave me a case scenario and the focus was surprising. They didn’t ask how I would manage a particular patient or family situation, but instead how I would handle when a physician yells at me. The Director was clear with me that one of the toughest parts of the role involves managing communications with physicians. She expects that the candidate who is hired will be assertive and confident, someone not afraid of his or her own shadow. I want to fulfill those expectations."
He looked at me with his ever-patient blue eyes and replied:
“You have grown up with physicians your whole life. You know they are people just like everyone else. Just remember that you both care about the same thing: the patient. Yet, be prepared for them to show that caring differently from you. The physicians you work with will posture and their bark will be worse than their bite. Remember, that bite is not really directed at you. It will only seem like it is.”
Truer words were never said. Though what presented early in my career as a need to manage simply a few posturing and intimidating colleagues has evolved into a virulent epidemic of bullying across the health care industry. This behavior obstructs the care process, puts patients at grave risk, and grossly hinders the ethical practice by professionals.
Bullying: The Problem Framed
Bullying manifests as acts perpetrated by an individual in a higher level of authority toward others. They could be covert and/or overt acts of verbal or non-verbal aggression. (Dellasega, 2009 on ANA, 2014a). Note the following examples:
- A physician screams obscenities at the nurse who approaches him to clarify a patient’s code status. The physician threatens to have the nurse fired if she ever seeks to second guess him again.
- The case manager throws a tantrum during the weekly unit care conference, cursing out team members and stomping out of the room yelling, “You are all incompetent! These meetings are a waste of time since I know better than the lot of you.” A patient and family in attendance are shocked by the interchange.
- A new physician regularly slaps the buttocks of sedated patients upon finishing their surgical procedures. While the staff is appalled, they have been told by administration, “Let it go. This physician is a revenue generating machine for the hospital. Besides, the patients are asleep and won’t know what happened unless someone tells them.”
While each of these scenarios could make for entertaining television or movie storylines, they are based on events that play out daily across the transitions of care. Each are forms of workplace bullying which affects a significant proportion of health care professionals. All involve a real or perceived imbalance of power and repetition of negative behavior (Larson, 2014). The domino effect of the negative consequences of this behavior on the mental health and well-being of employees is a growing focus in the literature, as it directly impacts organizational performance (Ariza-Montes, et. al, 2013).
Bullying behavior has both intensified and escalated over the past decade with the current figures staggering. In a survey of more than 4,500 health care workers, 77 percent reported disruptive behavior by doctors and 65 percent reported the same presentation among nurses. 99 percent indicated that these behaviors led to impaired nurse-physician relationships (Rosenstein, A and O’Daniel, M, 2008).
Studies by the Robert Wood Johnson Foundation’s (RWJF) RN Work Project found that nurses who experience verbal abuse by both physicians and nurse colleagues report a greater intent to leave their jobs. They are also more likely to develop negative perceptions of their work environments (RWJF, 2013). This factor yields further potential to compromise staffing and subsequent care quality, adding another layer to the staffing challenges faced. Recruitment and retention of highly-quality staff is viewed as a top priority for many health care organizations (Pizzi, 2011).
Bullying is now regarded in the context of workplace violence. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as any physical assault, threatening behavior or verbal abuse occurring in the workplace. Violence includes overt and covert behaviors ranging in aggressiveness from verbal harassment to murder (NIOSH in ANA, 2014b). The concept of lateral violence specially addresses bullying, as it refers to incidents that occur between colleagues; the act is perpetrated by one who is in a higher level of authority (ANA, 2014b). This can refer to situations involving one nurse against another nurse as readily as across professional disciplines and teams.
A study by the Workplace Bullying Institute found 35 percent of workers have been bullied in the workplace. The actions described included verbal abuse, job sabotage, misuse of authority, intimidation and humiliation, and deliberate destroying of relationships. Other pivotal outcomes note that bullying is four times more common than either sexual harassment or racial discrimination on the job, though not yet illegal (Drexler, 2013).
While these numbers alone are glaring, other outcomes evoke paramount concern. The Joint Commission identified that intimidating and disruptive behaviors fuel medical errors and lead to preventable adverse outcomes (TJC, 2008). Another study yielded that more than 75 percent of those surveyed identified how disruptive behaviors led to medical errors with nearly 30 percent contributing to patient deaths (Painter, 2013). Other reports cite the number at potentially as high as 200,000 deaths a year (Brown, 2011).
Cultural Change Mandates Interprofessional Practice
The health care industry is amid vast cultural change. Interprofessional practice is on the rise courtesy of the global efforts of the Canadian Interprofessional Health Collaborative (CIHC), the Institute of Medicine (IOM) and the Interprofessional Education Collaborative (IPEC) to name a few entities. This evolving mindset speaks to the newer models of interprofessional teamwork appearing across the transitions of care. These models are marked by high levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient-centered care (IPEC, 2011).
The concept of Interprofessional Team-Based care is marked by intentionally created, usually relatively small work groups in health care. These are strategically formed entities who are recognized by themselves and others to have a collective identity and shared responsibility for a patient or group of patients. e.g., rapid response teams, palliative care team, primary care team, operating room team (IPEC, 2011).
The three influential entities mentioned above have each advanced competencies to promote the integration of individual professional expertise toward patient-centered and quality care delivery. CIHC went to the point of including a competency specific to Interprofessional Conflict Resolution. (CIHC, 2010, IOM, 2003 & IPEC, 2011). Table 1 provides a listing of the competencies defined by these three influential entities.
Interprofessional practice sets a new tone for the health care workplace, one where practitioner cohesion rather than continued fragmentation and competition between disciplines is allowed to flourish. IPEC not only leveraged the work of the IOM and other academic and professional accreditation entities to this end, but also reinforced a powerful message. Health care quality is a comprehensive and consolidated team effort which is interprofessional and thus transdisciplinary in scope (Fink-Samnick and Treiger, 2013).
Most experts would agree the newest models of care coordination, including those found in Accountable Care Organizations (ACOs) and integrated behavioral health initiatives, mandate efficient team collaboration and communication. They also require a mindset that embraces interprofessional practice. The appearance of bullying within the treatment team has gross potential to hamper the quality of patient care processes. I’m reminded of a colleague who developed and used flow charts to map all health care quality processes, plus the requisite decision-making to resolve any variances. The simple question beckons: How effective and efficient can the outcomes of any process be when the process itself is laden with impediments to quality care?
Bullying as an Impediment to Communication and Collaboration
Effective health care team communication and collaboration have long been identified as integral components of the health care process. The IOM identified the direct connection of these two concepts specifically to quality and patient safety. It was found that the largest number of medical errors stemmed from interactions within the health care team (IOM, 1999). By 2001 research identified that tens of thousands of Americans were dying from these errors in their care, with additional numbers suffering or barely escaping from non-fatal injuries that a truly high quality care system should not present with (IOM 2001). The IOM’s Five Competency Model included the distinct domain, Work in Inter-Professional Teams. This competency frames that professionals must cooperate, collaborate, communicate and integrate care (IOM, 2003).
Communication and collaboration are included as core competencies across the industry’s diverse professional stakeholder groups such as those for nursing, social work and medicine (AONE, 2005; CSWE, 2008; & AACM, 2014). In fact, the IPEC Model includes distinct foci on Communication plus Teams and Teamwork as two of their four identified Competency Domains; the others being Value/Ethics and Roles/Responsibilities (IPEC, 2011).
Bullying interferes with all that health care strives to be; quality-driven, patient centered, and an interprofessional team effort marked by respectful communication. Creating a culture of respect in today’s health care environment is not just about feeling good for its own sake. It’s better for patient care (Yukiewicz, 2014). When professionals feel disempowered to address the dynamics of bullying, whether manifesting as insults and/or threats toward them and/or patients and families, the outcomes can and will be deadly. This theme of organizational silence requires deep levels of change to address cultural practices, social norms and personal skills (Maxwell et. al, 2010).
With respect to the impact of bullying in the health care workplace there is one universal theme which transcends professional disciplines, team models, and practice settings. While clearly obstructing interprofessional teamwork, bullying equally impedes the ability of health care professionals to practice ethically and for that matter in the best interests of the patient and family, according to established codes of professional conduct.
The Ethical Effect
When circumstances prevent professionals from appropriately intervening on behalf of their patients the question must be asked; how can their practice be ethical? With the basic objective of ethical standards and codes of professional conduct to protect the public interest (CCMC, 2009) there should be no question of the interplay between the disruptive behaviors that reflect bullying and patient safety.
Independent of a practitioner’s professional discipline of origin, most if not all are beholden to the regulations and ethical codes that underlie their primary credential, whether that credential is a license and/or certification. To that end the potential of legal and/or ethical sanction for an individual’s failure to adhere to those established principles is worth noting. It has equally been noted in the literature that health care professionals have an ethical, as well as moral obligation to improve care for patients (Pronovost and Vohr, 2010).
While the ethical tenets of practice have remained relatively constant across the health care industry, the societal constructs that have influenced them have changed dramatically (Fink-Samnick, 2013). One only has to review the recent decade’s onslaught of health information technology to see a glimmer of the impact on the ethical fundamentals of privacy, confidentiality, and fraud. In addition, social media’s popularity has pushed managing professional boundaries to the edge with evolving standards to reflect the new generation of ethical dilemmas specific to dual relationships. Bullying is the latest element to be added growing list of ethical challenges faced by the health care workforce.
In the current interprofessional practice climate, all who are involved in rendering care are ethically accountable for their actions. Ethics is an integral part of the foundation for all professional disciplines, especially those in nursing (ANA, 2014c). In the context of ethical tenets and principles, an individual’s inability to communicate in the interests of patient safety presents simply stated, as unethical practice.
Consider the following ethical tenets for nursing. Provision 1 of the Code of Ethics for Nurses frames the prominence of this document.
“The nurse, in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by social or economic status, personal attributes or nature of health problems.”
The ethical responsibility of all nurses is clear. This provision, plus those identified in Provisions 2-6 which follow, have particular relevance to dealing with bullying behaviors.
- Provision 2: The nurses’ primary commitment is to the patient, whether individual, family, group or community
- Provision 3: The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.
- Provision 4: The nurse is responsible for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
- Provision 5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
- Provision 6: The nurse participates in establishing, maintaining, and improving the conditions of employment conducive to the quality health care and consistent with the values of the profession through individual and collective action.
The case scenario in Box 1 provides a means to apply each of the aforementioned provisions. Provisions 2-5 are highlighted especially, though the reader may opt to include 1 and 6 in their own analysis. Healthy debate accompanies the assessment of ethical analysis with all welcome to discuss alternative perspectives to those presented.
Case management continues to be viewed as an advanced practice and not a unique profession. As a result, the ethical tenets defined compliment those for each of the professional disciplines that actively comprise this realm (e.g. nursing, social work). Case management’s tenets do not supersede the scope of an individual’s primary license, yet they are viewed in the context of those professional standards and/or functions which are endemic to this specialty practice; those to assess, plan, collaborate, implement, monitor, evaluate (CMSA, 2010). As a result the application of tenets for case management may be viewed as transdisciplinary, extending across those boundaries that define the parameters of professional intervention.
1. Beneficence: To do good.
2. Nonmalfeasance: To do no harm.
3. Autonomy: To respect individuals’ rights to make their own decisions.
4. Justice: To treat others fairly.
5. Fidelity: To follow-through and to keep promises.
Case managers are required to act with integrity in dealing with other professionals to facilitate their clients’ achieving maximum benefits (CCMC, 2009). Maintaining the integrity of the code is equally paramount. Bullying is antithetical to established principles.
The case example provided in Box 2 relates to each tenet and principle. It is for example only though assess your thoughts for this situation. All are reminded that the final determination of sanction for an individual’s case management credential is up to the respective certification body.
Examining the dynamic of bullying from an interprofessional lens transitions the focus from individual accountability for disruptive behavior to that of team. The consequences for care that reflect poor quality, and/or disrespect of patients is of paramount attention. Table 2 details the Values/Ethics Competency for Interprofessional Practice developed by IPEC (2011). It is an important reminder that despite this expanded scope of ethical responsibility to the group rendering collaborative patient centered care, individual team members are still beholden to their distinct professional ethical codes.
IPEC’s Values/Ethics Competency is clear to that level of professional responsibility, one that should transcend across the entire team, amid its distinct members and to stakeholders. It speaks to a sense of shared purpose in supporting the common good in health care, and reflects a shared commitment to creating safer, more efficient, and more effective systems of care (IPEC, 2011). The case scenario portrayed in Box 3, demonstrates how bullying’s impact can potentially present from an interprofessional perspective.
Moving Forward: Advocacy, Accountability and Awareness
Bullying in any form is an unwelcome visitor to health care organizations. Its presence has a domino effect across every aspect of care. The professional who hesitates to jointly confront and address the incidences of intimidation and oppression in the workplace negates ethical practice. Terminating the dangerous culture of silence that can swiftly take root in an organization’s foundation mandates a strategic approach to assure resolution; one marked by advocacy, accountability and awareness.
Although, there is no federal standard that requires workplace violence protections, other efforts are in place to support minimizing bullying. Effective January 1, 2009 The Joint Commission (TJC) created a new standard in the Leadership chapter, LD.03.01.01. This standard calls for organizational leaders to create and maintain a culture of safety and quality throughout the (organization):
- A4: Leaders develop a code of conduct that defines acceptable and disruptive and inappropriate behaviors, and
- A5: Leaders create and implement a process for managing disruptive and inappropriate behaviors that undermine a culture of safety.
(TJC in ANA, 2014b)
A number of states have in place, or are amid passage of legislation to address workplace violence. A current map appears on American Nurses Association website. (ANA, 2014b).
At the organizational level leaders must take a strong stance to promote a culture where advocacy to address bullying becomes the norm. Hospitals and other organizations that render care have a primary responsibility to protect all stakeholders from the impact of this issue, employees and patients alike. Standards of professional behavior should be developed and implemented. Uniform application must occur across all departments, with consistent monitoring to assure adherence to the standards. All employees need to know they can report incidents confidentially (Brown, 2011). An atmosphere of support is essential to minimizing the stigma and re-traumatization often associated with those who are victims of bullying.
For years I’ve been known for my own mantras, more of my father’s influence now seasoned by my tenure in this industry. I have been known to say how at the end of the day one is only accountable for his or her own practice. However, this mantra finds an additional dimension in the context of bullying.
It can actually feel as if each individual must be accountable for managing the behaviors of others in addition to their own, which can be overwhelming as well as unrealistic. However when bullying is identified as unethical practice it can lead to a continuum of actions. The starting point should be direct discussion between the involved parties to confront the actual behavior, plus seek available resolution routes through the employer. Ultimately the action could mean filing a complaint against a colleague with the requisite credentialing body. By engaging in a gradient action plan professionals are empowered to be accountable for their own practice through directly addressing and reporting of bullying as necessary.
Threats, insults, and degrading behavior aimed toward colleagues are a hindrance to the smooth and effective communication patterns on which all patient-centered care relies. Toward establishing a culture that is accountable for quality communication and team collaboration, Rosenstein and O’Daniel put forth recommendations that appear in Figure 1. Their concepts advance from the premise that health care teams which lack the ability to trust, respect and collaborate with one another are more likely to make a mistake that could negatively impact the safety of patients (2008).
When the workplace culture becomes subsumed by fear of challenging those professionals who abuse their authority, employees become marginalized and patients are put at grave risk. The manifesting silence created by this marginalization is a paradox since the repercussions so loudly interfere with the ability of professionals to render care that is safe and ethical. Accountability for one’s behavior equals recognition for necessary action toward change.
Awareness is paramount on all levels to eliminate the implications of bullying for health care’ stakeholders. Awareness fosters the advocacy directed toward facilitating legislation at the federal, state and local levels will not progress. The vast array of regulatory and organizational initiatives that reframe the delivery of care become meaningless in the absence of awareness.
The tangible efforts of those with vested interest in the overall quality and safety of the health care industry will fall short without industry awareness. This extends to the work of the IOM, IPEC, TJC, plus the diligence of professional associations as the ANA and AONE. Awareness by professionals and their employers of the vital role served by ethical standards and codes further supports their prime objective, to protect the public interest (CCMC, 2009).
Awareness of the expanding industry resources developed in response to the continued evolution of bullying play a role in empowering populations of providers. While space does not allow for all of those resources to be provided, readers are invited to explore the reference list for additional information to guide their own continued journey in addressing problem in their workplace.
At the end of the day several dynamics will interplay to overturn the dangerous culture of silence allowed to invade the health care workplace; environments tasked with assuring the highest attention to quality and safe delivery of health care for so very many consumers.
The blend of advocacy, accountability and awareness by the overall institution of health care will empower those professionals who highly value their commitment to render care and interventions without compromise. This care must be provided in accordance with the ethical practice standards and codes defined by each unique professional discipline plus the newest interprofessional teamwork perspectives. Professionals should feel empowered by their employers to address behaviors utilizing the organizational processes available. Though when internal modes of resolution cease to appropriately address the issue(s) at hand, external intervention may be required. Complaints should then be made to the respective credentialing entities for the necessary action and/or sanction; the importance of this action can not be overstated.
There must be a concerted effort by the entire industry to convey the message that bullying in all forms will be escorted out of the building at every opportunity. The presence of this oppressive and disruptive behavior can no longer be permitted in whatever setting health care is rendered. Far too much is at stake for professionals and patients to stand for anything less.
American Organization of Nurse Executives (2005) The AONE Nurse Executives Competencies, Retrieved May 12, 2014 http://www.aone.org/resources/leadership%20tools/nursecomp.shtml
American Nursing Association (ANA) (2014a) Bullying and Workplace Violence http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence
American Nursing Association (ANA) (2014b) Workplace Violence.
American Nursing Association (ANA) (2014c) Code of Ethics for Nurses, Retrieved May 13, 2014, http://www.nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses/code-of-ethics.pdf
Association of American Medical Colleges (2014) Competencies for Entering Medical Students, Retrieved May 12, 2014 https://www.aamc.org/initiatives/admissionsinitiative/competencies/
Ariza-Montes, A., Muniz N., Montero-Simo M. and Araque-Padilla R, (2013) Workplace Bullying Among Healthcare Workers, International Journal of Environmental Research and Public Health , 10, 3121-3139, doi:10.3390/ijerph10083121
Brown, Theresa (2011) Physician Heel Thyself, NY Times The Opinion Pages, Retrieved
Canadian Interprofessional Health Collaborative (2010) A national interprofessional competency framework. Retrieved May 13, 2014, from http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf
Case Management Society of America (2010). CMSA Standards of Practice for case management Revised 2010.
Retrieved April 10, 2014 from http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf
Council on Social Work Education (CSWE), (2008) Education Policy and Accreditation Standards (EPAS) Implementation, Retrieved from http://www.cswe.org/Accreditation/EPASImplementation.aspx
Drexler, P (2013) Are Workplace Bullies Rewarded for Their Behavior? Forbes, Retrieved April 25, 2014 http://www.forbes.com/sites/peggydrexler/2013/07/10/are-workplace-bullies-rewarded-for-their-behavior/
Fink-Samnick, E (2013) Case Management’s Ethical Eight: Preparing for the Next Wave, Case In Point, November 2013, Dorland Health/AccessInteilligence.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
Institutes of Medicine (1999) To Err is Human: Building a Safer Healthcare System, The National Academies Press
Institutes of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academies Press
Institutes of Medicine (2003). Health Professions’ Education: A Bridge to Quality; The Quality Chasm Series; The National Academies Press.
Jennifer Larson, (2014) Bullying a persistent problem in nursing Retrieved April 25, 2014, http://w3.rn.com/news/news_features_details.aspx?Id=41619
Maxfield, D., Grenny, J., Lavandero, R., and Groah, L. (2010) 2005: The Silent Treatment: When Tools and Checklists aren’t enough to Save lives: Retrieved from CMS.VitalSmarts, April 30, 2014.
Painter K (2013) When Doctors are Bullies, Patient Safety May Suffer, USA Today, Retrieved April 25, 2014,http://www.usatoday.com/story/news/nation/2013/04/20/doctor-bullies-patients/2090995/
Pizzi, R (2011) Facing Down the Challenges of Healthcare HR, Healthcare Finance News, Retrieved May 21, 2014, http://www.healthcarefinancenews.com/news/facing-down-challenges-healthcare-hr
Pronovost, P. & Vohr, E. (2010). Safe patients, smart hospitals. New York: Hudson Street Press.
Robert Wood Johnson Foundation, (2013) Bullying: When Words Get in the Way, Retrieved April 25, 2014, http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/09/bullying--when-words-get-in-the-way.html
Rosenstein, A and O’Daniel, M in Hughes, RG (Ed.)(2008) Patient Safety and Quality: An Evidenced-Based Handbook for Nurses, Chapter 33 Professional Communication and Team Collaboration, Agency for Healthcare Research and Quality, US
The Commission for Case Manager Certification (2009), The Code of Ethics and Professional Conduct for Case Managers, Retrieved May 21 2014 from http://ccmcertification.org/sites/default/files/downloads/2012/Code%20of%20Professional%20Conduct%20for%20Case%20Managers.pdf
The Joint Commission [TJC], (2008). Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety, Retrieved May 17, 2014 from http://www.jointcommission.org/assets/1/18/SEA_40.PDF
Treiger, T and Fink-Samnick, E (2013) COLLABORATE©: A Universal Competency-Based Paradigm for Professional Case Management, Part 1: Introduction, Historical Validation and Competency Presentation, Professional Case Management, 18(3), Wolters Kluwer Health/Lippincott Williams and Wilkins
Yurkiewicz, I (2014) Why Rude Doctors Make Bad Doctors, AEON Magazine, Retrieved April 10, 2014 from
Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP
Principal of EFS Supervision Strategies, LLC
Ellen Fink-Samnick, Principal of EFS Supervision Strategies, LLC, is an industry expert who empowers health care’s transdisciplinary workforce through professional speaking, mentoring & consultation. She is a popular presenter and respected author with publications in diverse journals around the globe.
Ellen is adjunct faculty for George Mason University’s College of Health & Human Services, trainer for the National Association of Social Workers, Director of Social Work Education for Athena Forum, LinkedIn Moderator for Ellen’s Ethical Lens© and Editorial Board Member for Lippincott's Professional Case Management. With Teresa Treiger, Ellen is the co-author of the book COLLABORATE© for Professional Case Management: A Universal Competency-Based Paradigm, First Edition, to be published by Wolters Kluwer in Spring 2015.
Ellen has received awards and accolades across the health care industry. She has served as a Commissioner for CCMC and Chair of their Ethics & Professional Conduct Committee, plus in a variety of leadership roles amid the industry's professional associations. Queries can be directed to Ellen at firstname.lastname@example.org
Workplace Violence in Health Care
Workplace violence is all too common, and sadly many stories among health care providers exist that highlight the seriousness of the problem. Stories such as:
A doctor refuses to give a patient in the emergency department pain medicine believing that the patient is an abuser. He tells his nurses, “I don’t want to deal with him, you do it. Tell him to leave." The nurse gets in an argument with the family, but they leave the ED. It is only later that the nurse finds them in the employee parking lot waiting to harass her and follow her home. Thankfully, her husband is a police officer and she received a police escort.
A patient arrives for an intake physical exam prior to admission to the behavioral health unit. Unfortunately, the fact that this patient is homicidal was not communicated to the intake physician who performs her exam in an isolated room. The patient attacks the physician and strangles her with a scarf she is wearing. The physician is found several hours later by a cleaning crew.
An operating room nurse hesitates when asked by a surgeon for a device, the surgeon responds to her perceived slow reaction by throwing a bloody scalpel at the nurse. To complicate matters, the patient had AIDS. The surgeon’s privileges were revoked but he simply brought his patients and revenue with him to another nearby town.
A gang member who was shot walks into an emergency department and is quickly admitted. The rival gang finds out where the patient went for medical care and shows up in force at the emergency department. While the patient is receiving medical care, rival gang members tell the medical staff to step back and then proceed to shoot the patient multiple times while he is lying on a bed in the trauma room.
These stories demonstrate the gravity of the workplace violence problem in health care. This article summarizes some of the research that has been published and some research that hasn’t been published as it relates to violence in the workplace.
The National Institutes of Occupational Safety and Health defines workplace violence as “violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty” (NIOSH, 1996). Many researchers have broadened this definition to include verbal violence beyond threats and also include harassment, stalking, and more subtle forms of hostility. Health care workers are nearly four times more likely to be injured and require time away from work as a result of workplace violence (WPV) than all workers in the private sector combined (Bureau of Labor Statistics (BLS), 2013). Seven states have enacted laws to reduce WPV against health care workers by requiring workplace violence prevention programs (American Nurses Association, 2014).
The potential for violence affects nurse performance, job satisfaction, employee turnover and retention, and patient satisfaction (Jackson et al. 2002, Roche et al. 2010, Hegney et al. 2010, Gates et al. 2011). Nurses who experience aggression tend to become more apathetic toward patients and less caring, which can lead to poor care and less patient satisfaction (Astrom et al. 2004, Josefsson et al. 2007, Gates et al. 2011). Nurses have reported much higher personal stress levels as a result of perceived risk of violence (Gates et al. 2011). Therefore, workplace violence among health care workers is both an employee health issue and also a patient and quality of care issue.
Over the last several years workplace violence has received significant attention from researchers with NIOSH leading the effort on workplace violence. A summary of work performed and funded by NIOSH can be found at their website for occupational violence. We have participated in this effort over the last 10 years, and have found that WPV is a significant challenge in the health care setting for a variety of reasons:
- The very nature of health care requires a great deal of contact with the public at large.
- It involves many stressful situations for both the patient and employee.
- It incorporates family and societal dynamics.
- It confronts the consequences of many of society’s ills such as drug abuse.
- It involves very close and often intimate contact to provide care or necessary services.
As one emergency department nurse said during a focus group we held to support some of our research, “We see people in the most vulnerable time of their life, there’s going to be stress.” In addition, health care facilities are very permeable to the public, meaning that access control is very difficult in the health care setting. Hospitals must treat and allow entry to all those seeking services and the patients and family members in the hospital are constantly changing. The result is that one of the primary control mechanisms used to prevent violence, access control, is often difficult to implement. It is therefore no surprise that workplace violence is an important issue that requires a great deal of effort to address and prevent.
Many researchers studying violence utilize the categorizations provided by the Federal Bureau of Investigation, whereby workplace violence is categorized into four broad categories or types (Romano et al., 2011). Type I violence is considered acts of aggression where the offender has no relationship to the victim, as in the case of simple robbery. Type II violence involves aggression where the offender is receiving services from the victim, as in the case of a nurse providing care to a patient. Type III violence involves aggression where the offender is either a current or former employee acting out against other coworkers. Type IV violence involves aggression where the offender has a personal relationship with an employee and acts out at the employees workplace, as in the case of domestic abuse. All four types of violence have been observed in the health care setting, however, Type II violence appears to be the most prevalent source of OSHA-reportable injuries among hospital workers (New Jersey Department of Health and Senior Services, 2007). Subtle forms of Type III violence (bullying) has also been recently recognized as highly prevalent and underreported among health care workers (Thomas & Burke, 2009).
The relative frequency of each type of violence may also vary by the specific healthcare workplace. For example, Type I violence may be a much higher risk for home health care workers than for hospital staff. The severity of violence and injuries resulting from violence also spans the entire range of possibilities from verbal aggression and resulting negative mental health outcomes to physical injury including death. Several high profile cases of health care workers being murdered at their workplace have been highly publicized over the last several years (e.g. Friedman, 2010). Other extreme events, such as a nurse who had been raped in an outpatient clinic by a hospital visitor, have also been documented (New Jersey Department of Health and Senior Services, 2007).
Violence Prevention Research
Research efforts over the last 10 years have found that effective interventions to prevent violence do exist and if implemented can reduce the injury rate among health care professionals (Casteel et al. 2009). In particular, it has been found that effective WPV prevention programs are multifaceted and include elements of training, reporting and data tracking, environmental and workplace design controls, and official policies that provide management backing of their staff in preventing and responding to violence. This has been within the larger context of effective WPV programs characteristics summarized by Lipscomb and El Ghaziri (2013).
In an assessment of both Emergency Department (ED) and Psychiatric units, it was found that implementation of recognized WPV prevention program elements was variable (Peek-Asa et al, 2009; Peek-Asa et al, 2007). These assessments indicated that states with regulations requiring WPV programs in healthcare facilities tended to have more complete programs in terms of training and policies, but other elements of a complete program were still lacking. Additional analyses also found that the incident rate of violence within the emergency department of hospitals is not necessarily related to the community crime rate associated with the hospital’s location but is more closely associated with the size of the hospital and the comprehensiveness of the security program within the hospital (Blando et al., 2012).
It was concluded that because emergency care is inherently stressful there is potential for violence in any community setting and therefore the only mitigating factor is an effective and comprehensive workplace violence prevention program (Blando et al., 2012). In this study, two particular hospitals provided a notable contrast, where one hospital in an urban setting with gang problems had a very comprehensive security program and hence a relatively low assault rate whereas a small rural hospital with a weak security program had a very high assault rate. Two days before the small rural hospital was assessed for the study by Blando et al. (2012), a fight between two brothers arguing over their father’s care in the ED resulted in a security guard getting his neck broken. The security guard in the small rural hospital did not have the proper training nor was physically capable of providing a physical intervention in this altercation.
These studies highlighted the need to investigate how employees perceive violence and the need to assess differences in employee perceptions based on their work environment and training. Violence is very contextual and for many health care professionals personal judgments are made during their “labeling” of the incident. Some quotes from a recent focus group study (Blando et al., 2014) demonstrate this point, where one nurse stated the following, “I think, again, what we're all saying is we all have different perceptions. Yes, it is violence, yes, it is…but we're looking at the patient or the family member and we're taking that into consideration.”
A study of nurse perceptions of violence (Blando et al., 2013) demonstrated a stark difference in the perceptions of ED nurses and Psychiatric nurses. ED nurses were much less tolerant of aggressive behavior, whereas psychiatric nurses were much more tolerant and tended to attribute and interpret aggression as a disease rather than as violence, per se. In a separate unpublished pilot study of nursing homes, it was also found that employees tended to perceive aggression by elderly patients as a disease rather than as violence because of the assumption that the patient is too old to be a physical threat. A notable belief among nursing home staff appeared to be that because patients with dementia do not intend to hurt staff then it can not be violence. In fact, in this pilot work on nursing homes, a nurse who was stabbed in the back with a fork did not report it as violence because the patient had dementia. Metal forks were not replaced immediately with plastic forks because the incident wasn’t reported and management was not aware of the potential risk. In this way, perception has a high impact on reporting and hence interventions. For this reason, many workplace violence researchers do not utilize intent as a required characteristic before they classify an incident as violence.
Research on Violence Prevention in Home Health Care
Inpatient acute care hospital settings have received the most attention with regard to workplace violence. However, other settings such as home health, developmental centers, and hospice care are equally important and have been found to have important deficiencies (West et al., 2014; Nakaishi et al, 2013; Gross et al. 2013). Recently, an unpublished focus group pilot study with unskilled home health aides found that these workers frequently experience violence from their coworkers, supervisors, patients, and families (Blando, J.D., 2013, unpublished data). This data was collected through a structured focus group held with four unskilled home health aides recruited through a local union and two of their union representatives. This focus group utilized a prompt sheet that guided the discussion through workplace characteristics, risk of violence during home visits, perceptions of violence, recommendations for improved safety, and discussion of regulatory approaches to address violence. One of the unique characteristics among these workers is that they work in patients’ homes and therefore are put at a high risk of violence.
Many of the home health workers reported that they often face accusations that they stole something from a residence when in fact it is a veiled attempt to bully the home health aid (Blando, J. D., 2013, unpublished data). In fact, most home health workers reported that their employer almost always takes the side of the patient with little interest in the workers (Blando, J. D., 2013, unpublished data). Supervisors often “discipline” home health aides for speaking up by changing the aide’s schedule such that they get less work (and less pay), accusing them of a criminal act (e.g. theft), and separating their home visits by great distances so that it limits the number of patients they can provide care to and yet requires more gas for traveling to patient residents that are far apart (Blando, J. D., 2013, unpublished data). Home health aides believe that management feels that the aides can be easily replaced because of the unskilled nature of their job (Blando, J. D., 2013, unpublished data). This is also a very poorly paid population of workers and, as such, we also uncovered criminal behavior among some home health aides, in particular, prostitution was reported among aides as a way to make more money (Blando, J. D., 2013, unpublished data). However, it is unclear if these accusations were simply motivated by a desire for some aides to bully others by accusing them of criminal behavior. Aides reported instances of drugs, guns, and gang activity in the homes they visited and also reported that untreated mental health conditions seemed to be common during their home visits (Blando, J.D., 2013, unpublished data). There are several instances where home health care workers have been murdered or severely injured while attending to patients at their home (e.g. Lacy, D.).
Workplace violence is a critical issue in health care as it directly impacts staff satisfaction, employee turnover, staff mental and physical health, patient satisfaction, and quality of care. Violence is very common in health care, with Type II (patient – staff) and Type III (bullying) violence being the most common. Health care facilities are particularly prone to violence because of the stress associated with sickness, diseases that pre-dispose individuals to aggression, and the open public access needed to provide care to a community. For these reasons, violence in hospitals is not simply a reflection of the community they serve but an expression of many complex factors. In addition, violence is very contextual and employee perceptions are an important factor in determining what is reported as violent and this perception varies among the different medical professions. NIOSH has invested a significant amount of resources into training employees about workplace violence and training. Training is one of the key elements to prevention and a free NIOSH course is available that can be used to earn continuing education units (CEUs) for health care professionals.
American Nurses Association (2014). Nursing World Online Fact Sheet for State Legislative Agenda, Workplace Violence. Retrieved May 14, 2014 from: http://nursingworld.org/workplaceviolence
Astrom S., Karlsson S., Sandvide A., Bucht G., Eisemann M., Norberg A. & Saveman B.-I. (2004) Staff’s experience of and the management of violent incidents in elderly care. Scand J Caring Sci 18, 410-416.
Blando, J.; McGreevy, K; O’Hagan, E; Worthington, K; Valiante, D.; Nocera, M.; Casteel, C.; Peek-Asa, C. (2012). Emergency department security programs, community crime, and employee assaults. J Emergency Medicine, 42( 3): 329–338
Blando, J. D.; O’Hagan, E.; Casteel, C.; Nocera, M.; Peek-Asa, C. (2013) Impact of Hospital Security Programs and Workplace Aggression on Nurse Perceptions of Safety. Journal of Nursing Management, 21: 491-498.
Blando, J.D.; Ridenour, M.; Hartley, D.; Casteel, C. (2014). Barriers to effective implementation of programs for workplace violence prevention in hospitals, submitted to Online Journal of Issues in Nursing.
Bureau of Labor Statistics (BLS) (2013). Nonfatal Occupational Injuries And Illnesses Requiring Days Away Fromwork, 2012, publication # USDL-13-2257 Retrieved May 14, 2013 from: http://www.bls.gov/news.release/pdf/osh2.pdf.
Casteel C, Peek-Asa C, Nocera M, Smith JB, Blando J, Goldmacher S, O'Hagan E, Valiante D, Harrison R. (2009). Hospital employee assault rates before and after enactment of the California Hospital Safety and Security Act. Ann Epidemiol., 19(2); 125-133.
Friedman, E. (2010). Johns Hopkins Hospital: Gunman Shoots Doctor, Then Kills Self and Mother. Available at: http://abcnews.go.com/US/shooting-inside-baltimores-johns-hopkins-hospital/story?id=11654462, accessed May 20, 2014.
Gates D., Gillespie G. & Succop P. (2011) Violence Against Nurses and its Impact on Stress and Productivity. NURSING ECONOMICS 29(2), 59-67.
Gross, N.; Peek-Asa, C.; Nocera, M. (2013). Workplace violence prevention policies in home health and hospice care agencies. Online Journal of Issues in Nursing 18(1), 1.
Hegney D., Tuckett A., Parker D. & Eley R.M. (2010) Workplace violence: Differences in perceptions of nursing work between those exposed and those not exposed: A cross-sector analysis. International Journal of Nursing Practice 16(2), 188-202.
Jackson D., Clare J. & Mannix J. (2002) Who would want to be a nurse? Violence in the workplace - a factor in recruitment and retention. Journal of Nursing Management 10, 13-20.
Josefsson K., Sonde L. & Wahlin T.-B.R. (2007) Violence in municipal care of older people in Sweden as perceived by registered nurses. Journal of Clinical Nursing 16(5), 900-910.
Lacy, D. Psychiatric Center nurse attacked and killed on the job. available at : http://www.thecommunicator.org/021999/down.htm, accessed May 20, 2014.
Lipscomb, J.; El Ghaziri, M. (2013). Workplace violence prevention: improving front-line health-care worker and patient safety. New solutions : a journal of environmental and occupational health policy, 23(2): 297-313
Nakaishi, L.; Moss, H.; Weinstein, M. (2013). Exploring workplace violence among home care workers in a consumer-driven home health care program. Workplace Health & Safety 61(10), 441-450.
NIOSH . Current Intelligence Bulletin 57: Violence in the workplace; risk factors and prevention strategies. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 96–100.
New Jersey Department of Health and Senior Services. (2007). Workplace Violence and Prevention in New Jersey Hospital Emergency Departments. Trenton, NJ. Available at: http://www.nj.gov/health/surv/documents/njhospsec_rpt.pdf
Peek-Asa C, Casteel C, Allareddy V, Nocera M, Goldmacher S, Ohagan E, Blando J, Valiante D, Gillen M, Harrison R. (2009). Workplace violence prevention programs in psychiatric units and facilities. Arch Psychiatr Nurs., 23(2): 166-176.
Peek-Asa C, Casteel C, Allareddy V, Nocera M, Goldmacher S, OHagan E, Blando J, Valiante D, Gillen M, Harrison R. (2007). Workplace violence prevention programs in hospital emergency departments. J Occup Environ Med; 49(7); 756-763.
Roche M., Diers D., Duffield C. & Catling-Paull C. (2010) Violence Toward Nurses, the Work Environment, and Patient Outcomes. Journal of Nursing Scholarship 42(1), 13-22.
Romano, S.; Levi-minzi, M.; Rugala, E.; Van Hasselt, V. (2011). FBI Law Enforcement Bulletin, Workplace Violence Prevention Readiness and Response. http://www.fbi.gov/stats-services/publications/law-enforcement-bulletin/january2011/workplace_violence_prevention, accessed May 20, 2014.
Thomas, S.; Burk, R. (2009). Junior nursing students’ experiences of vertical violence during clinical rotations. Nursing Outlook, 57(4). doi: 10.1016/j.outlook.2008.08.004
West, C. ; Galloway, E.; Niemeier, M. (2014). Resident aggression toward staff at a center for the developmentally disabled. Workplace Health & Safety 62(1), 19-26.
James Blando, Ph.D., is currently an Assistant Professor at Old Dominion University in the School of Community and Environmental Health. Prior to his faculty appointment, Dr. Blando was a researcher for 11 years at the New Jersey Department of Health and Senior Services where he designed and conducted several diverse projects in environmental and occupational health funded by NIOSH, EPA, and CDC. Dr. Blando has evaluated occupational exposure histories in support of cancer cluster studies, participated in the design and validation of occupational exposure assessment tools, and has served as the principal investigator for studies evaluating protective measures for emergency responders during nuclear power facility accidents, violent assaults in hospital settings, and exposure to lead paint dust among general remodeling home renovation contractors. Dr. Blando has also conducted inhalation toxicology studies for DuPont that evaluated respiratory hazards in polymer processing facilities. In addition, Dr. Blando also has several years of practical field experience in Industrial Hygiene and has been an industrial hygienist with Exxon-Mobil, Schering-Plough Pharmaceuticals, and AT&T Bell Labs (now called Lucent).
Dr. Maureen Boshier
It is inferred by the data reported in this article that early career nurses report verbal abuse that is directed at them from more experienced nurses, but that is not to say that verbal abuse between the early career nurses themselves doesn’t occur. A topic for further research, perhaps, especially since the pervasiveness of many types of abusive behavior perpetuated by health professionals is getting attention and discussion. A call to action for nursing education programs to teach and model empowering behavior that is intolerant of verbal or any type of abuse is in order. The perfect opportunity to change culture: Interprofessional Education! See issue 2 of Nursing in the 21st Century.
To read the complete article on the research highlighted in this article go to the following Journal of Nursing Scholarship article.
Early Career Nurses’ Experiences of Verbal Abuse from Other Nurses
Highlights from an ongoing panel survey of early career nurses are presented. Data were collected in 2011 from 1,407 nurses who were a nationally representative sample of nurses who were licensed for the first time in 2004 and 2005. The purpose of the survey was to obtain information about nurses’ work decisions and their experiences of verbal abuse. The nurses’ names and contact information were obtained from licensing boards from 34 states and the District of Columbia.
- Almost 50% of the nurses said they experienced verbal abuse from other nurses during the previous three months.
- Early career RNs who reported no verbal abuse (24%) from other nurses were less likely to say that they would leave their position within the following three years than those who reported verbal abuse.
- Early career RNs who reported low (11%) to moderate (18.6%) verbal abuse from other nurses were more likely to plan to leave their jobs within the following year than those who reported no verbal abuse.
- 88% of early career RNs who experienced high levels of verbal abuse from other nurses planned to have an RN job a year later, although not necessarily with their current employer.
- Early career nurses who worked in hospitals were the most likely to report moderate or high levels of verbal abuse from other nurses compared to those who worked in other settings.
- Compared to those working the evening or night shift, those early career RNs who worked the day shift reported more verbal abuse from other nurses.
- Higher levels of abuse from other nurses were related to lower levels of perceived collegial nurse-physician relationships.
- Early career RNs who reported no abuse from other nurses had higher job satisfaction scores than those who experienced verbal abuse.
Experienced nurses’ verbal abuse of early career nurses continues to be a problem. In their first year of work 62% reported experiencing verbal abuse (Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Kim, H., & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58-70. doi:10.1097/01.NAJ.0000287512.31006.66). In the survey reported on here, we asked the nurses to identify who was doing the verbal abuse and found that nurses continue to abuse other nurses. It is unclear if verbal abuse creates an unfavorable work environment or if poor working conditions create an environment where verbal abuse is acceptable. But whatever the causal pathways, nurse managers must intervene to stop the abuse.
Dr. Maureen Boshier
Suzanne Gordon, journalist and author of the recently published book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, participated in the following interview with N21 editor, Maureen Boshier. The subject is Ms. Gordon’s work regarding dysfunctional communication among health professionals and its toxic effect on the caring environment. To paraphrase Ms. Gordon: “In health care, a toxic hierarchy and the silence it generates is a gift that keeps on giving. The punitive, unsupportive and toxically hierarchical medical system has developed and survived over centuries.” She describes in her blog, of September 27, 2013, the following story told by a nursing student: “No one in the teaching hospital where the student was doing a clinical rotation ever acknowledged her presence, much less said hello. Physicians looked through her, most nurses regarded her as a nuisance and she was made to feel unwelcome, as if she were a problem.”
Ms. Gordon believes that people in health care workplaces have been socialized to work as individuals, to compete, and to put one profession, person, or discipline above another, functioning in a command-and-control workplace in which collective input into decision making is discouraged, disrespected and even belittled. She contends that this type of dysfunctional behavior, especially in the team setting that is supposed to be the culture of patient care, is damaging and leads to stress, poor quality care, and a culture of silence. She paraphrases author Lucian Leape, MD, on this topic saying: “We have to put respect into the system and reprogram our brains to never humiliate anyone no matter how angry or frustrated people are.”
Retired former CEO of CGFNS International, an organization recognized globally for its expertise in credentials assessment of foreign-educated health professionals and currently President and CEO of Barbara Nichols Consulting.
PhD, RN, FAAN, a Professor and Senior Faculty Associate, Hartford Institute for Geriatric Nursing both at the College of
Nursing, New York University. She is a Nurse Attending at New York University Langone Medical Center. Her work focuses on the organization and delivery of nursing care.
DIANE L. HUBER
PhD, RN, NE-BC, FAAN, and a nationally recognized nursing administration expert, researcher, academic, speaker, and consultant. She specializes in leadership and nursing care management, emphasizing case and population health management.
Compass Clinical Consulting Managing Director, RN, and PhD, with more than 30 years of experience in senior health care leadership roles in university, regional, state and national organizations. She is a regular keynote speaker throughout the country and has authored a leading college text on law and ethics in healthcare.
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