A Disruptive Force Linked to Compromised Patient Safety

REVIEWS & ANALYSES

Bullying in Healthcare: A Disruptive Force Linked to Compromised Patient Safety

Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Patient safety officers (PSOs) from Pennsylvania facilities contacted the Pennsylvania Kelly Gipson, BSN, RN, CPPS Patient Safety Liaison Patient Safety Authority for information about workplace bullying to help healthcare workers address such behaviors. Bullying, a type of disrespect, is a threat to patient Pennsylvania Patient Safety Authority safety because it inhibits teamwork, obstructs communication, and impedes implementation of new practices.1 A bullied healthcare worker may not speak up with pertinent ABSTRACT clinical information or point out a safety problem to the team.2 Bullying or aggressive behaviors Workplace bullying has increasingly become part of the national dialogue since the between healthcare providers, such Joint Commission recommended adoption of a zero-tolerance policy toward bullying as verbal abuse and intimidation, behaviors in 2008.3 The Workplace Bullying Institute defines bullying* as repeated mis- can be a threat to safe patient care. treatment of an intended target in one or more combinations of the following forms: Bullying behaviors can inhibit team- verbal abuse; threatening, humiliating, or intimidating behaviors (including nonver- work, obstruct communication, and bal); or work interference (e.g., sabotage).4 The Joint Commission does not consider delay implementation of new practices; the following behaviors to be bullying: illegal harassment, discrimination, setting high it can interfere with patient care. This workplace standards, having a different opinion, or giving constructive feedback.5 type of behavior may contribute to low worker morale, absenteeism, and high State legislators in 29 states, including Pennsylvania, and 2 territories have introduced rates of staff turnover. A query of the bills to address workplace bullying.6 In addition, the American Nurses Association,7 the Pennsylvania Patient Safety Reporting American College of Obstetricians and Gynecologists,8 and the Lucian Leape Institute System (PA-PSRS) database revealed at the National Patient Safety Foundation9 are among the institutions that have pub- 44 events associated with bullying lished position papers on this subject. The Institute for Safe Medication Practices behaviors over a two-year period. (ISMP) conducted national surveys of healthcare workers about disrespectful behavior; Strategies to reduce bullying behaviors results indicate that continued negative behaviors encountered by healthcare workers include scripting methods to speak up are influencing communication and suggest that healthcare facilities need to take fur- to bullying in an assertive manner, such ther actions to address this issue.10 as D.E.S.C. (i.e., describe, express, A 2010 Pennsylvania Patient Safety Advisory article on disruptive behavior reported delays suggest, consequences); role playing in communication between clinicians could potentially compromise patient safety.11 through simulation to practice confront- The recent PSO inquiries prompted an updated analysis of events reported through the ing a bully; instituting zero tolerance Pennsylvania Patient Safety Reporting System (PA-PSRS), examination of the literature, anti-bullying policies with leadership and interviews of healthcare professionals who have explored this issue and taken steps enforcement; and enhancing staff towards decreasing bullying events. awareness of human resources and management support. (Pa Pat Saf Advis METHODS 2017 Jun; 14(2): 64-70.) Analysts queried the PA-PSRS database for reports of events that occurred over a two- Corresponding Author year period from July 1, 2014, through June 30, 2016, using the following keywords Susan C. Wallace and derivations: bellig*, bully, coerc*, cried, cry, disrupt*, holler, in charge, intimidat*, profan*, refuse, repeated, rude, scream, threat, throw, upset, yell. The wildcard char- acter (*) ensured that the search also yielded events containing other word forms (e.g., disrupt* returns both disruptive and disruption). Events identified by relevant monitor codes to classify events were also included in the dataset. Analysts manually reviewed the resulting set of 5,807 event report narratives to identify reports describing behaviors synonymous with bullying using the Workplace Bullying Institute definition. Event reports were then grouped into related categories by harm score, event type categories, event reporting taxonomy, and care area. Excluded were event reports addressing bullying by or toward patients.

* The term bullying may overlap with terms such as incivility; horizontal, lateral, or workplace violence; and unprofessional, disruptive, or disrespectful behavior.

Page 64 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority Analysts conducted a review of the litera- Bullying Events Examples of bullying events reported to ture to identify prevalence and strategies Analysts interviewed a healthcare pro- the Authority in PA-PSRS are presented to reduce bullying in healthcare facilities. vider who spoke to the Authority on the by category, as follows:* Interviews were conducted with executive condition of anonymity and described a Verbal abuse leaders, clinical practitioners, and nurse bullying situation over the course of 15 Night nurse yelled at other nurses educators to identify best practices and years involving a nursing supervisor.12 She with a negative and aggressive atti- resources to reduce bullying and patient described the supervisor as harsh and tude after she was questioned about harm. abrupt with others, who used condescend- her documentation of assessments ing tones, eye rolling, and deep sighing done during her shift. She stated, RESULTS when new workers did not understand “How dare I question her” after ask- Analysts identified 44 events describing instructions. ing for the information. bullying between healthcare providers At least two nurses left their positions The radiology technician yelled at including physicians, nurses, and techni- in a month’s time after working with the nursing staff for not entering the cians. Although analysts recognize that the supervisor, while other workers were procedure correctly [into the electronic bullying represents repetitive behaviors afraid and avoided working with the health record]. This took place in over time, the examples in PA-PSRS dem- individual, she said. Some repeat patients front of the patient. onstrate individual situations in isolation would request another nurse and indi- that, if repeated, could confirm bullying. cated on questionnaires that the nurse was “mean,” she said.12 When the supervi- The identified events were reported in five sor’s behavior was brought to leadership’s * The details of the PA-PSRS event narratives event type categories with 56.8% (n = 25 in this article have been modified to preserve attention, the nurse said, it was not of 44) reported in “other/miscellaneous,” confidentiality. None of these specific event addressed. “We were told that this is just narratives came from facilities interviewed for followed by 27.3% (n = 12) reported in the way she is,” she said. this article. “error related to procedure/treatment/ test” (Table 1). Most of the events described overt bully- Table 1. Bullying Events by Event Type* (N = 44) ing with no direct patient harm. Analysts found 77.3% (n = 34) of the PA-PSRS EVENT TYPE NO. (%) OF EVENTS events involved a physician engaging in Error related to procedure/treatment/test 12 (27.3) verbally abusive behavior. The remaining Complication of procedure/treatment/test 5 (11.4) events (n = 10) involved a nurse or technician. Twenty-seven percent (n = 12) of the Medication error 1 (2.3) events were witnessed by a patient. Transfusion 1 (2.3) Examination of event descriptions Other/miscellaneous 25 (56.8) revealed five categories of bullying behav- Note: As reported to the Pennsylvania Patient Safety Authority, July 1, 2014, through June 30, 2016. iors based on the Workplace Bullying * Event types are defined by Pennsylvania Patient Safety Reporting System taxonomy and are assigned to Institute definition. Analysts assigned events by healthcare facilities at the time of report submission. some events to more than one category, resulting in 92 entries. The top two event Table 2. Bullying Events by Description of Event* (N = 44) categories in order of frequency were CATEGORIES NUMBER OF EVENTS PERCENTAGE verbal abuse and intimidating behaviors (Table 2). Verbal abuse (e.g., rude behavior) 34 77.3 Analysis of care areas where bullying Intimidating behaviors (e.g., badgering) 32 72.7 events were identified revealed three top Work interference (e.g., sabotage) 13 29.5 areas where the events occurred: periop- Humiliating behaviors (e.g., mimicking) 7 15.9 erative care areas 29.5% (n = 13 of 44); Threatening behaviors (e.g., frightening) 6 13.6 medical/surgical units 25.0% (n = 11); and the emergency department 15.9% Note: As reported to the Pennsylvania Patient Safety Authority, July 1, 2014, through June 30, 2016. (n = 7; Figure). * These events total more than 100% because some reports described more than one event category.

Figure. Bullying Events By Care Area (N = 44) interrupt the nurse and stated every- thing was fine. A AA 13 Threatening behaviors Perioperative care areas (2.%) Surgeon insisted on modifying equipment 11 in a manner that was against hospital edicalsurgical units (2.0%) policy. After lengthy arguments between the healthcare workers, the surgeon Emergency departments (1.%) refused to perform the procedure unless the modifications were made. The nurse Cardiac 4 (invasive and noninvasive) (.1%) stated she was being forced to practice contrary to hospital policy. 3 Nonnursing clinical areas (6.%) Humiliating behaviors 2 Nurse asked physician to re-sign a abor and delivery units (4.%) consent form since there was no wit- 2 ness for the original consent. Instead Transitionalstepdon units (4.%) of signing the form where it was indi- 1 cated, the physician signed it on the Cardiac intensive care unit (2.3%) witness line and stated to the nurse, 1 “There, you have a witness.” Radiology (2.3%) MS17354 DISCUSSION 0 2 4 6 10 12 14 Impact of Bullying on Patient N PS Safety Note: As reported to the Pennsylvania Patient Safety Authority, July 1, 2014, through Of the 44 bullying events reported to June 30, 2016. PA-PSRS from July 1, 2014, through June 30, 2016, most occurred in the periop- again and tell him what to do. No erative area, involved physicians as the Intimidating behaviors new orders were given. perpetrators, and included verbal abuse and intimidating behaviors. The small Patient admitted with bleeding and Work interference needed an order and consent for a number of events reports over the two-year Physician was notified of a patient blood transfusion. Physician refused period may reflect a lack of recognition injury by the charge nurse. Due to to speak to the patient to obtain of bullying behaviors, particularly if they a miscommunication about which the consent and told the nurse that are covert; a reluctance to report for fear patient was involved with the event, it would be the nurse’s fault if the of retribution; and absence of a PA-PSRS the physician thought the patient patient dies. He repeated his order category for bullying as it relates to was a new admission. Physician fired and hung up the phone. patient safety. off multiple questions and would Patient had been transferred from the not allow the nurse to answer her Leape and colleagues propose that disre- cardiac care unit with stable vital inquiries. The nurse tried again to spectful behavior causes the dysfunctional signs. The patient’s pulse became give appropriate information about culture found in healthcare and inhibits irregular and blood pressure dropped. the injury [using the facility-approved progress in patient safety.1 He attributes Patient was otherwise without symp- format] and the physician again inter- this to the high stress environment found toms. [The nurse] called the physician rupted the nurse. in healthcare, the hierarchical structure and informed him of change in vital Nurse asked physician to perform of the workforce, and the autonomous signs, and asked him if he wanted a medication reconciliation together behavior of professionals who resist cardiology consult. [The physician] 1 [to prepare a patient for discharge] following safe practices. Disruptive told nurse several times [the nurse] and physician refused. The nurse behaviors can affect one’s ability to think was incompetent, never to call him attempted to go through the list; clearly, making unsafe acts and errors however, the physician continued to more likely. Caregivers may even divert

Page 66 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority their attention from the patient to that of such as training new staff, which is esti- included shouting and insulting language self-protection, as evidenced by avoidance mated at $100,000 per new hire.17 directed towards others in supporting of the instigator.1 Bullying may inhibit positions (e.g., nurses, technicians). Evaluating the culture. In an interview cross-monitoring by team members who with the Authority, Grena Porto, RN, Nurses can be compassionate to patients, 13 are reluctant to speak up. ARM, CPHRM, vice president, risk man- but may also be “horrific” to each other, Understanding prevalence and con- agement, ESIS ProClaim, and a member according to Renee Thompson, DNP, sequences. The Workplace Bullying of the Joint Commission’s Patient Safety RN, CMSRN, CEO and president Institute estimates that 27% of adult Advisory Group, stated that as recently as of RTConnections, LLC, based in Americans have experienced workplace 10 years ago, few people thought of bully- Pittsburgh.18 Thompson, an author and bullying and another 21% have witnessed ing as a patient safety issue.13 Porto, who expert about nurse bullying, said, “Every it.14 A Joint Commission survey found was instrumental in developing the Joint single day of my life, a nurse reaches out 50% of nurses were victims of disruptive Commission’s Sentinel Event Alert on to me about being a target of bullying.” behaviors and 90% witnessed these behav- this topic, also stated that today, no one Nurses work in extremely stressful situa- 3 iors. Other researchers state the true questions that bullying and other disrup- tions in which they are dealing with life number of bullying events is unknown, tive behaviors have a profound impact on and death in unpredictable circumstances, 13 because it is often unrecognized and patient safety. Thompson said.18 “We haven’t taught 15 underreported. Hospitals can take the first step to deter- nurses good coping mechanisms,” she In ISMP’s 2013 survey, 4,884 healthcare mine how bullying impacts patient safety said. “So they lash out at each other and workers (i.e., physicians, nurses, pharma- in their facility, by administering the then that becomes their pattern.” cists, quality/risk managers) responded AHRQ (Agency for Healthcare Research Working with a bully can be a huge that disrespectful behaviors most often and Quality) survey on the patient safety distractor that impacts patient safety, 16 encountered were as follows: culture, which can be accessed at http:// Thompson said.18 “How can you really —— Negative comments about colleagues www.ahrq.gov/professionals/quality- focus on your patient if you are worried (73%) patient-safety/patientsafetyculture/index. about keeping out of harm’s way of the html. Porto also recommends conducting —— Reluctance or refusal to answer ques- bully,” she said. “If you are uncomfort- focus groups of healthcare workers from tions or return calls (77%) able about being open and honest with various shifts and departments to gain a someone, how can you share information —— Condescending language or demean- clearer understanding of the culture.13 ing comments or insults (68%) about your patients? It stops the flow of Bullying on the Frontline. Bullying can information.” —— Impatience with questions or hang- occur in all areas of healthcare. It takes ing up the phone (69%) Thompson advocates for training manag- strong medical-staff leadership to tackle ers about bullying behaviors.18 Frontline —— Reluctance to follow safety practices disruptive physician behavior, Porto said. or work collaboratively (66%) managers determine the culture in the “Depending on the situation, it may just nursing unit, but no one is teaching the Compared with survey results from 10 mean sitting down with the physician over frontline managers how to set expecta- years earlier, ISMP found disrespectful coffee,” she said. More serious episodes of tions with the staff, how to hold people behaviors continue to be prevalent, with bullying or repeated patterns of bullying accountable, and how to create a culture little improvement.10 behavior may require a stronger approach, of professionalism, she said. Bullied workers may experience humili- including discipline and termination as 13 ation and powerlessness in response appropriate. It is important to intervene The Role of Leadership early, tailor actions to the situation, and to behaviors that range from the overt Leadership support is crucial in intro- such as verbal outbursts and physical ensure that medical leaders are actively involved in the process, she said.13 ducing, setting policy, and maintaining threats, to the subtle or covert such as a successful anti-bullying program.3,13,18 eye rolling or purposefully holding back Studies show yelling, insulting other Kendra Aucker, president and CEO, 3,14 patient information. Bullying behaviors healthcare workers usually of lesser status Evangelical Community Hospital, may contribute to low worker morale, (i.e., medical students), and refusing to Lewisburg, PA, discovered that 30% of absenteeism, and high rates of turnover follow established policies are the most the employees who completed a sur- 3,5 of highly qualified staff. There is also common types of behaviors reported vey in 2015 measuring the “culture of 9 a financial cost associated with bullying for physicians. Behaviors of physicians respect” answered that abusive behavior found by analysis of the PA-PSRS events

was tolerated at the hospital, 25% were “I am very proud of the work force,” she workers, managers, and senior leaders frequently bullied, and 40% found it said. “Behavior isn’t always black and seeking to reduce bullying and other dis- unpleasant to work with other depart- white, but you have to feel free to speak ruptive behaviors. ments.19 “I read this and couldn’t believe up and stand up for yourself if you feel it,” she said. “I thought this was unaccept- you are a victim of bullying or bad behav- All Healthcare Workers able and we have to start now to address ior. You have to take responsibility for —— Report and document bullying this.” yourself and other people. While there is behaviors through established Aucker introduced policies on anti- still lots of work to be done, patients are protocols.20 bullying and respectful workplaces talking to us about how kind and helpful —— Review personal behaviors (e.g., do 19 (http://patientsafety.pa.gov/pst/Pages/ staff are to them.” you sometimes ridicule or joke about PSAPatientSafetyTopicList.aspx) for every It is imperative that hospitals develop a a new or inexperienced co-worker?) level of the organization to help establish leadership team, including middle manag- and take steps to modify these a safety system and culture.19 In addition, ers and unit managers who can lead by behaviors (e.g., seek out an Employee she met with about 1,100 employees over example and model the desired behaviors, Assistance Program.)18 several months in informal meetings Porto said. “It is critical to understand —— Learn scripting techniques to help entitled “Coffee with Kendra” to get that even managers and senior leaders are stop a bullying situation such as firsthand insight into the culture. “I was capable of bullying behavior, and organi- D.E.S.C. (i.e., describe, express, sug- told about outbursts, shouting, passive- zations who fail to identify and address gest, consequences).21 aggressive behaviors, and other ways we such behaviors in leaders cannot succeed —— Think about strategies to handle a treated one another,” she said. “We would in establishing a culture of safety,” Porto bullying situation (e.g., staff members never achieve a higher level of patient care said.13 feeling tensions rising, can call out, unless we changed our attitudes and our “Tempo!” as a reminder for everyone behaviors. There is an expectation in the Limitations to calm down, or when a bullying way you treat the people you work with, Limitations of this study include scant situation occurs, have workers notify and that translates to how you treat the detail in some PA-PSRS reports, the others so they can stand beside and 22 people you care for.” potential to misinterpret information in support the bullied worker). She worked in committees to alleviate the narrative descriptions in the reports, —— Know your healthcare facility’s some of the system problems causing frus- and the possibility that reporters used policy and procedure on bullying, so trations that lead to bullying behaviors, terms not included in the search strat- you can refer to it and seek help, as 20 focused on the departments with the egy. Although analysts recognize that needed. lowest survey scores, instituted training bullying represents repetitive behaviors, programs for staff and managers, wrote PA-PSRS events demonstrate individual Managers about the improvements in e-mail blasts, situations in isolation that, if repeated, —— Observe staff at work and dur- and talked about the issues in a “state of could confirm bullying. Events may not ing key interactions such as the union” address.19 be recognized as reportable by frontline change-of-shift reports to identify staff if bullying is viewed as “normalized” patterns of unacceptable behavior or With someone willing to listen and deter- 13 behavior, because of the lack of a struc- communication. mined to make changes, Aucker said, tured data field for reporting bullying —— Appoint preceptors who will uphold staff began speaking out about situations or employee events or because of fear of a zero-tolerance policy for bullying that could jeopardize patient safety. “The retribution. Bullying events, especially behaviors and can serve as a resource patient is the center of all that we do, and those in which there is physical harm for those on the receiving end of bul- that includes our behavior,” she said.19 If between providers, may be reported as lying behavior.13,23 employees could not change their behav- an Infrastructure Failure, which is not —— Ask senior leaders for educational iors, then this was not the organization for reported to the Authority. classes on bullying for staff and them anymore, she said. A year after the managers.20 survey, Aucker said improvement was mea- sured with an employee engagement survey, RISK REDUCTION STRATEGIES —— Engage organizational staff mem- which found a 38% decrease in the per- The following strategies suggested in the bers with expertise in this area (e.g., human resources experts) to be avail- centage of employees who felt disengaged. literature, and by anti-bullying groups and 23 professionals, may be useful to healthcare able to staff, as needed.

Page 68 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority —— Know your facility’s policy and state and federal standards and CONCLUSION 3,20 procedure addressing bullying, and professional behavior standards. Analysts identified 44 bullying events 20 enforce it in your department. Recommended elements include reported through PA-PSRS over a —— Place posters and fact sheets about zero tolerance, non-retaliation two-year period; most occurred in the bullying in your break and locker towards those who report/cooper- peri-operative area and were overt actions rooms.13,18 ate in investigations, responding to such as verbal abuse and intimidating —— Ensure each bullying incident is witness (e.g., patients), and defining behaviors. Limitations of reporting bully- 3 resolved in a manner that protects disciplinary actions. ing behaviors are discussed and include the person being targeted and —— Ask for input from staff to ensure lack of recognition of bullying behaviors, enhances the overall unit or depart- staff co-owns the process and particularly if they are covert, and a reluc- mental culture.24 expectations.23 tance to report for fear of retribution. —— Establish a multi-disciplinary com- Bullying behaviors may threaten the safe Senior Leaders mittee of senior leaders, managers, care of patients by inhibiting teamwork, —— “Declare a new day” by not letting and healthcare workers to review obstructing communication, and delaying past events disrupt new efforts, and bullying events.3,10 implementation of new practices. Studies move forward regardless of past —— Encourage employees to report show that bullying decreases morale and 25 events. incidents of bullying, and provide increases absenteeism and turnover of —— Survey the staff to establish a base- feedback on these behaviors to all highly qualified staff. Studies suggest that line about bullying behaviors in employees.19 hospitals take a focused look at these behaviors and institute effective policies your facility and conduct ongoing —— Offer educational programs on 13,19 with leadership support, educate staff and monitoring. strategies for conflict resolution and managers to recognize and handle bully- —— Develop or review existing poli- encourage employees to participate.3 cies and procedures on bullying, ing situations, and involve medical staff —— Lead by example and model non- leadership. and make sure they follow current bullying behaviors.13

NOTES

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