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Patient Safety Tip
of the Week
March
22, 2022
Not
Just Politicians That Behave Badly
It
seems these days that disrespect and rude behavior have become “normalized” in
many facets of our society. One need only look at behavior of politicians or
interchanges on social media. Healthcare is not immune to this phenomenon.
ISMP
(Institute for Safe Medication Practices) was one of the first organizations to
describe such behavior in healthcare and point out how it serves as a barrier
to a culture of safety. In 2004 (ISMP 2004) reported on responses to a 2003 survey. Respondents
noted that intimidating behaviors were not attributable to
physicians/prescribers alone. They encountered a surprising degree of
intimidation among other healthcare providers as well and repeated occurrences
of intimidating behavior did not arise from a single menacing individual.
Subtle forms of intimidation were more frequent than more explicit forms. 88%
of respondents encountered condescending language or voice intonation (21%
often); 87% encountered impatience with questions (19% often); and 79%
encountered a reluctance or refusal to answer questions or phone calls (14%
often). Almost half of the respondents reported more explicit forms of
intimidation, such as strong verbal abuse (48%) or threatening body language
(43%). Incredibly, 4% of respondents even reported physical abuse.
Another
ISMP survey in 2013 (ISMP 2013) largely echoed the 2003 survey. ISMP
concluded “The results of our 2003 and 2013 surveys expose healthcare’s
continued tolerance and indifference to disrespectful behavior. These behaviors
are clearly learned, tolerated, and reinforced in the healthcare culture, and
little improvement has been made during the last decade.”
In 2005 a very valuable contribution to patient safety came
from AACN (American Association of Critical-Care Nurses): “Silence Kills. The
Seven Crucial Conversations for Healthcare” (AACN
2005), results of a survey of
nurses, physicians, administrators and a variety of healthcare workers. The survey highlighted 7 issues of concern
that have largely flown under the radar. One of those 7 issues was “Disrespect”.
The survey revealed that 77 percent of nurses and other clinical-care providers
work with some who are condescending, insulting, or rude. 33 percent work with
a few who are verbally abusive—yell, shout, swear, or name call. Many of the
issues were considered “undiscussable”. Even the nursing supervisors
participating in the study admitted that they often did not confront the
offending party or take appropriate action.
So, why
don’t people speak up and share their full concerns? 59% of nurses and other clinical-care
providers said that it was difficult or impossible to confront the person
showing disrespect or abuse. Lack of ability, belief that it is “not their
job,” and low confidence that it will do any good to have the conversation were
the three primary obstacles to direct communication. Other obstacles include
time and fear of retaliation. Some don’t want to make others angry or undercut
their working relationships, so they leave difficult discussions to others or
to another time, and never get back to the person.
But a
quarter to half of the respondents did discuss the problem with coworkers or
with the person’s manager. But they often noted that the purpose for discussing
these problems with coworkers was not to solve problems. Rather, it was to “work
around them, warn others about them, and blow off steam”.
The Joint Commission issued its Sentinel Event Alert #40 “Behaviors
that undermine a culture of safety” in 2008 (TJC
2008). It cited the 2004 ISMP
report and indicated that both overt activities and more passive examples of
disruptive behavior can foster medical errors, contribute to poor patient
satisfaction and to preventable adverse outcomes, increase the cost of care,
and cause qualified clinicians, administrators, and managers to seek new
positions in more professional environments. It issues suggested actions for
hospitals, including “zero tolerance” for intimidating and/or disruptive
behaviors.
But it was Lucian Leape and colleagues (Leape
2012a, Leape
2012b) who really got the
attention of the medical community with their series on the “Culture of Disrespect”
(see our July 2012 What's New in the Patient Safety World column “A
Culture of Disrespect”).
He and his colleagues described disrespectful behavior in 6 categories. While
we all easily recognize the first category – the disruptive physician – such
account for a relatively small proportion of the problem. Moreover, the
disruptive physician is easiest to recognize and probably easiest to take
action on. But Leape’s main point is that the behaviors in the other categories
are the more subtle parts of the continuum of disrespect and collectively the
far bigger problem. Most of the culture of disrespect is rooted more deeply in
the highly hierarchical environment in medicine where the physician has been
traditionally accorded a stature at a different level than everyone else. Leape
notes that remains a huge barrier in a time when we have to rely on growing
multidisciplinary teams to manage increasingly complex medical conditions.
Importantly,
while some aspects of disrespect are due to characteristics of individuals,
Leape emphasizes that disrespectful behavior is also learned, tolerated and
reinforced by the hierarchical hospital culture.
Most
recently, ISMP reported on yet another survey done in 2021 (ISMP 2022) and it showed that disrespectful behaviors
in healthcare continue to occur at an alarming rate, demonstrating little or no
improvement, and in some cases, worsening. In 2021, respondents reported that
“disrespectful behaviors persist unchecked, they are not isolated events, they
are not limited to only one or two offenders of a single gender, and they occur
in both lateral (peer-to-peer) and hierarchical working relationships.”
The
prevalence and frequency of the disrespectful behaviors was largely similar
among the 3 ISMP surveys, though between 2013 and 2021 there was an increase in
making negative comments about colleagues and leaders.
The
COVID-19 pandemic may have exacerbated the problem, with a more stressful healthcare
environment, poor staffing levels, excessive workloads, power imbalances, and
the ever-changing science and data associated with COVID-19 treatments.
And
the issues clearly have a potential impact on patient safety. 47% of
respondents admitted to feeling pressured to accept an order, dispense a
product, or administer a drug despite concerns about its safety, and 35% had
concerns about a medication order but assumed it was correct rather than interact
with a particular prescriber.
Guo et al. just published a systematic review on the impact
of unacceptable behavior between healthcare workers on clinical performance and
patient outcomes (Guo
2022). After winnowing down a
huge list of articles dealing with unacceptable behavior, they were left with 36
studies for inclusion in the review. They found considerable variability in the
quality and methodology of the included studies. In general, the studies
reporting on perception of respondents demonstrated a negative impact on
quality of care, patient outcomes, patient safety, and workplace productivity. This
was substantiated by a smaller number of higher quality studies with more
rigorous methodology and more objective outcome measures. We also discussed some of the consequences of
rude and disrespectful behavior in our September 22, 2015 Patient Safety Tip of
the Week “The Cost of Being Rude” and our August 2019 What's New in
the Patient Safety World column “More
on the Cost of Rudeness”.
The
term “microaggressions” has been used to refer to ‘commonplace behavioral
indignities whether intentional or unintentional communicating hostile,
derogatory or negative attitudes toward marginalized groups.’ Implicit bias,
microaggression, prejudice, and stereotyping may play a role in the persistent
healthcare disparities seen among marginalized groups (Ehie 2021).
Even academic
medicine is not immune to disrespectful behavior, as evidenced by a recent exchange
at an oncology conference in which several participants were rude or condescending
(Nelson
2022).
It’s clearly not just physicians that are
exhibiting intimidating, rude, or disrespectful behavior. Over the past decade
there has been much written about so-called “lateral violence” and bullying
among nurses. And responses from administrators have often been less than
satisfying. An article in Becker’s Hospital Review (Becker
2016) described the acronym L.I.S.T.E.N.
used by Phyllis Quinlan, PhD, RN, an authority on bullying in multiple venues, to
guide nurse leaders in investigating nurse bullying:
L:
Lean into the situation.
I:
Insight is the goal.
S:
Solving the reason for the behavior is not your job.
T:
Take notes.
E:
Engage human resources early.
N:
Never share an opinion.
The
really bad behavior in our minds is that clinical leaders and hospital
administrators often tolerate the disrespectful behavior, thereby sanctioning
it and inadvertently leading to its adoption by others. Medical students,
resident physicians, nursing students, etc. all see examples of disrespectful
behavior that go unchallenged and then begin to adopt such behavior themselves
as the “norm”.
A recent article on patient safety “culture” (French
2022) in InSight+, a
newsletter of the Medical Journal of Australia, described 4 characteristics
of organizational culture as described in an article from the Harvard
Business Review (Groysberg
2018). Culture is:
- Shared – culture is not an individual phenomenon, nor is it simply the
average of individual characteristics. It exists as shared behaviors,
values, beliefs and assumptions that manifest as unwritten rules of
behavior (how we do things around here).
- Pervasive – culture permeates every level of a group, although it is not
monolithic and can vary widely within an organization. It manifests in
collective behaviors, physical environments, group rituals, stories, and
legends. Other aspects of culture are less overt, such as unspoken
assumptions, mindsets, and motivations. Culture is a way of seeing and
also not seeing and can lead to collective blind spots to important
issues.
- Enduring – culture continuously evolves through shared experience and
problem solving. Its endurance is partly explained by the
attraction-selection-attrition model. People are drawn to organizations
with characteristics similar to their own; organizations are more likely
to select individuals who seem to “fit in”; and over time those who don’t
fit in tend to leave. Culture becomes a self-reinforcing pattern that
grows increasingly resistant to change and external influences. It can
reduce organizational flexibility and adaptability – deeply held values
and beliefs are slow to change.
- Implicit – the effect of culture is
subliminal. People are instinctively hardwired to recognize and respond to
it. Unconscious assumptions about behavioral norms are taken for granted.
Culture acts as a kind of silent language, a shared understanding that
facilitates cooperative action.
Stay
tuned! The upcoming Part II of ISMP’s 2022 report will explore how to address
disrespectful behaviors in healthcare.
Some of our prior columns on the impact of
“bad behavior” of healthcare workers:
January 2011 “No
Improvement in Patient Safety: Why Not?”
March 29, 2011 “The
Silent Treatment: A Dose of Reality”
July
2012 “A Culture of Disrespect”
July 2013 “"Bad
Apples" Back In?”
July 7, 2015 “Medical
Staff Risk Issues”
September 22, 2015 “The
Cost of Being Rude”
April 2017 “Relation of Complaints about Physicians to
Outcomes”
October 2, 2018 “Speaking Up About Disruptive Behavior”
August
2019 “More on the Cost of Rudeness”
January
21, 2020 “Disruptive
Behavior and Patient Safety: Cause or Effect?”
April
6, 2021 “ISMP
on Just Culture”
Some of our prior columns related to the
“culture of safety”:
April
2009 “New Patient Safety Culture Assessments”
June
2, 2009 “Why Hospitals Should Fly...John Nance Nails
It!”
January 2011 “No
Improvement in Patient Safety: Why Not?”
March
2011 “Michigan ICU Collaborative Wins Big”).
March 29, 2011 “The
Silent Treatment: A Dose of Reality”
May
24, 2011 “Hand Hygiene Resources”
March
2012 “Human Factors and Operating Room Safety”
July
2012 “A Culture of Disrespect”
July 2013 “"Bad
Apples" Back In?”
July
22, 2014 “More on Operating Room Briefings and
Debriefings”
October
7, 2014 “Our Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical
Staff Risk Issues”
September 22, 2015 “The Cost
of Being Rude”
May
2016 “ECRI Institute’s Top Ten Patient Safety
Concerns for 2016”
June 28, 2016 “Culture of Safety and Catheter-Associated
Infections”
April 2017 “Relation of Complaints about Physicians to
Outcomes”
April 2017 “Joint Commission Sentinel Event Alert on
Safety Culture”
October 2, 2018 “Speaking Up About Disruptive Behavior”
August
2019 “More on the Cost of Rudeness”
January
21, 2020 “Disruptive
Behavior and Patient Safety: Cause or Effect?”
April
6, 2021 “ISMP
on Just Culture”
July
27, 2021 “Sustainability”
September
2021 “Ambiguous
Language in the OR”
https://www.ismp.org/resources/intimidation-practitioners-speak-about-unresolved-problem-part-i
American
Association of Critical-Care Nurses (AACN) and VitalSmarts. Silence Kills. The
Seven Crucial Conversations for Healthcare. AACN 2005
ISMP
(Institute for Safe Medication Practices). Unresolved Disrespectful Behavior in
Healthcare - Practitioners Speak Up Again (Part I). ISMP Medication Safety
Alert! Acute Care Edition 2013; October 3, 2013
ISMP
(Institute for Safe Medication Practices). Survey Suggests Disrespectful
Behaviors Persist in Healthcare: Practitioners Speak Up (Yet Again) – Part I. ISMP
Medication Safety Alert! Acute Care Edition 2022; February 24, 2022
Guo
L, Ryan B, Leditschke IA, et al. Impact of unacceptable behaviour between
healthcare workers on clinical performance and patient outcomes: a systematic
review. BMJ Quality & Safety 2022; Published Online First: 19 January 2022
https://qualitysafety.bmj.com/content/early/2022/01/18/bmjqs-2021-013955
The
Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event
Alert #40. TJC 2008; July 9, 2008, updated June 18, 2021
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 2012; 87(7): 845-852
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med 2012; 87(7): 853-858
Ehie
O, Muse I, Hill L, Bastien A. Professionalism: microaggression in the
healthcare setting, Current Opinion in Anaesthesiology 2021; 34(2); 131-136
Nelson R. Twitter
storm over ‘reprehensible behavior’ at conference podium. MDedge 2022; Publish
date: February 22, 2022
Becker’s Hospital Review. Use this acronym to
guide investigations into nurse bullying
Becker’s Hospital Review 2016; August 16,
2016
French
J, Sutcliffe K. Patient safety: what’s culture got to do with it? InSight+
2022; 28 February 2022
https://insightplus.mja.com.au/2022/7/patient-safety-whats-culture-got-to-do-with-it/
Groysberg
B, Lee J, Price J, Cheng J. The Leader’s Guide to Corporate Culture. How to
manage the eight critical elements of organizational life. Harvard Business Revieww
2018; January–February 2018)
https://hbr.org/2018/01/the-leaders-guide-to-corporate-culture
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