Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.
In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.
Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.
“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.
“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”
According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.
Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.
“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”
Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”
Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.
Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.
First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”
On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.
Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.
The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.
“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”
It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”
Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.
Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”
Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.
One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)
Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.
It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.
For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.
“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”
While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”