A Culture of Respect, Part 1: the Nature and Causes of Disrespectful Behavior by Physicians Lucian L

Culture of Medicine Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians Lucian L. Leape, MD, Miles F. Shore, MD, Jules L. Dienstag, MD, Robert J. Mayer, MD, Susan Edgman-Levitan, PA, Gregg S. Meyer, MD, MSc, and Gerald B. Healy, MD Abstract A substantial barrier to progress in common are everyday humiliations of is also devastating for patients. patient safety is a dysfunctional culture nurses and physicians in training, as well Disrespect underlies the tensions and rooted in widespread disrespect. The as passive resistance to collaboration and dissatisfactions that diminish joy and authors identify a broad range of change. Even more common are lesser fulfillment in work for all health disrespectful conduct, suggesting six degrees of disrespectful conduct toward care workers and contributes to categories for classifying disrespectful patients that are taken for granted and turnover of highly qualified staff. behavior in the health care setting: not recognized by health workers as Disrespectful behavior is rooted, in part, disruptive behavior; humiliating, disrespectful. in characteristics of the individual, such demeaning treatment of nurses, as insecurity or aggressiveness, but it residents, and students; passive- Disrespect is a threat to patient safety is also learned, tolerated, and reinforced aggressive behavior; passive disrespect; because it inhibits collegiality and in the hierarchical hospital culture. dismissive treatment of patients; and cooperation essential to teamwork, A major contributor to disrespectful systemic disrespect. cuts off communication, undermines behavior is the stressful health care morale, and inhibits compliance with environment, particularly the presence At one end of the spectrum, a single and implementation of new practices. of “production pressure,” such as the disruptive physician can poison the Nurses and students are particularly requirement to see a high volume of atmosphere of an entire unit. More at risk, but disrespectful treatment patients. The slow pace of improvement in every year.6 Other reasons include our undermines the teamwork needed to patient safety has been a source of lack of knowledge of how to prevent most improve practice. Dismissive treatment widespread dissatisfaction for policy complications of treatment, inadequate of patients impairs communication and makers and the public, but even more government investment in patient safety their engagement as partners in safe care. to the health professions. Despite initiatives, and insufficient preventive and extensive efforts by many institutions remedial measures.7 In addition to its toxic impact on patient and individuals, recent studies show little safety, disrespectful behavior affects many improvement in the rate of preventable We believe, however, that the funda- other aspects of health care. Quality suffers patient harm since the Institute of mental cause of our slow progress is not when caregivers do not work in teams. Medicine’s (IOM’s) “To Err Is Human”1 lack of know-how or resources but a Disrespect saps meaning and satisfaction sounded the alarm and issued its call for dysfunctional culture that resists change. from daily work and is one reason nurses a nationwide safety improvement effort Central to this culture is a physician experience burnout, resign from hospitals, 1–4 12 years ago. ethos that favors individual privilege or leave nursing altogether.8 Lack of and autonomy—values that can lead respect poisons the well of collegiality and One explanation for this poor record is to disrespectful behavior. We propose cooperation, undermines morale, and that the problem is so large and its causes that disrespectful behavior is the “root inhibits transparency and feedback. It is a are so varied. For example, the Centers cause” of the dysfunctional culture major barrier to health care organizations for Disease Control and Prevention that permeates health care and stymies becoming collaborative, integrated, estimates that 5,000 people acquire an 5 progress in safety and that it is also a supportive centers of patient-centered infection in our hospitals every day, product of that culture. care. and the IOM estimates that 1.5 million patients are injured by medication errors Disrespectful behavior threatens Students and residents suffer from organizational culture and patient safety disrespectful treatment. “Education by Please see the end of this article for information in multiple ways. A sense of privilege and humiliation” has long been a tradition about the authors. status can lead physicians to treat nurses in medical education and still persists. Correspondence should be addressed to Dr. Leape, with disrespect, creating a barrier to Patients suffer when physicians do not Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115; telephone: (617) the open communication and feedback listen, show disdain for their questions, or 432-2008; e-mail: [email protected]. that are essential for safe care. A sense fail to explain alternative approaches and of autonomy can underlie resistance fully involve them in the decision-making Acad Med. 2012;87:845–852. 9,10 First published online May 22, 2012 to following safe practices, resulting process. Failure to provide full and doi: 10.1097/ACM.0b013e318258338d in patient harm. Absence of respect honest disclosure when things go wrong Academic Medicine, Vol. 87, No. 7 / July 2012 845 Culture of Medicine is the epitome of disrespect and is a major collective personal experience, we suggest Humiliating, demeaning treatment of reason patients file malpractice suits.11 the following as a useful classification of nurses, residents, and students disrespectful behaviors in the health care Much more common than egregious Respectful behavior is a moral value setting. forms of disruptive behavior are patterns esteemed in its own right. Respect of demeaning or humiliating treatment Disruptive behavior is also a foundational element of of subordinates, particularly nurses, professionalism that forms the core At one end of the spectrum of disrespect residents, and medical students. of the self-image of most physicians. are physicians whose behavior has been Professionalism is a critical element characterized as disruptive, defined by Abuse of nurses by physicians has a of the six competencies that form the the Ontario College of Physicians and long history. Twenty years ago, Cox17,18 foundation of medical education and Surgeons as “inappropriate conduct, reported on the high rate of verbal practice espoused by the Accreditation whether in words or action, that abuse of nurses and its negative effects. Council on Graduate Medical Education, interferes with, or has the potential A recent review of the literature yielded the standard-setter for graduate medical to interfere with, quality health care 10 U.S. studies since 2000 of abusive education, and by the American delivery.”14 Hickson and Pichert15 define treatment of nurses.19 A large percentage Board of Medical Specialties (ABMS), disruptive behavior as “any behavior of nurses reported being subjected to the standard-setter for all medical that impairs the medical team’s ability to abuse or disruptive behavior, and in four 12 specialties. Although professionalism achieve intended outcomes.” Disruptive of the studies, more than 90% of nurses embraces a number of other behaviors physicians are found in almost all reported that they had experienced such and attitudes, showing respect for hospitals. Although most observers agree abuse. In one large study, 31% of nurses others is central to all aspects of that only 5% or 6% of physicians fall into reported knowing a nurse who had professionalism. this category,16 the detrimental influence left the hospital because of disruptive 19 of this small minority far outweighs their physician behavior. The vast majority of physicians treat numbers. others respectfully most of the time; Medical students, at the bottom of the however, some do not. In a recent Disruptive actions include angry patient care team hierarchy, are very national survey, two out of three outbursts, verbal threats, shouting, vulnerable to disrespect from faculty, physicians reported witnessing other swearing, and the threat or actual house staff, nurses, and others through physicians disrupting patient care or infliction of unwarranted physical force verbal or physical abuse, belittlement, collegial relationships at least once a that legally would be considered battery. humiliation, harassment, intimidation month. One in nine physicians reported Having a temper tantrum, throwing and exploitation, or simply by being seeing disruptive behavior every day.13 ignored. Nurses and residents may make objects, and breaking things are other them feel insignificant or “in the way.” forms of disruptive behavior, as is any A culture of disrespect is harmful for Annual surveys by the Association of unwanted physical contact of a sexual many reasons, but it is its effect on the American Medical Colleges show that nature. Disruptive conduct may be safety and well-being of our patients 14% to 17% of graduating students directed at anyone—nurses, colleagues, that makes it a matter of urgency. In report having been subjected to or residents, medical students, ward staff, simple terms, we believe that a health witnessing some form of mistreatment.20 hospital administrators, and even patients care organization that supports and However, other studies and informal tolerates disrespectful

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