Hospital bullies take a toll on patient safety

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Hospital bullies take a toll on patient safety

Bad behavior by doctors and others undercuts morale, leads to errors

By JoNel Aleccia, Health writer MSNBC

http://www.msnbc.msn.com/id/25594124/

They're the bullies of the operating room, the browbeaters of bedside

manner: doctors, nurses and other clinicians who make a habit of

behaving badly.

They yell, they cuss, they throw things. Or they engage in more

subversive behaviors: ignoring questions, acting impatient, insulting

colleagues or speaking to them in condescending tones.

" It can go from verbal abuse to sexual harassment and physical

assault, " said Dianne Felblinger, an associate professor of nursing

at the University of Cincinnati who studies medical intimidation.

The acts are bad enough when they affect staff morale, leading to

greater turnover and less job satisfaction. But the Joint Commission,

a national hospital accrediting agency, warned Wednesday that there's

mounting evidence that such disruptive behaviors are tied to medical

errors that can cause patient harm — and that hospitals across the

country should no longer tolerate it.

Starting in January, the agency will require hospitals to establish

codes of conduct that define inappropriate behaviors and create plans

for dealing with them. Suggested actions include better systems to

detect and deter unprofessional behavior; more civil responses to

patients and families who witness bad acts; and overall training

in " basic business etiquette, " including phone skills and people

skills for all employees.

The Joint Commission's first-ever alert about the problem is the

latest industry effort to address an issue that has challenged the

medical community for years, said Dr. Gerald Hickson, director of the

Center for Patient and Professional Advocacy at Vanderbilt University

Medical Center in Nashville, Tenn.

" The data is clear that certain members of the team don't play so

well with other members of the medical team, " said Hickson. " We've

dealt more effectively with drugs and alcohol than we have dealt with

the kicking, spitting and cussing. "

Dr. Mark Chassin, president of the Joint Commission, said growing

emphasis on preventing medical errors has made it clear that a

culture of intimidation contributes to the mistakes.

" It's a problem that goes underreported, threatens patient safety and

has become so ingrained in health care that it's rarely talked

about, " Chassin told reporters Wednesday.

Nearly everyone who has worked in hospitals can recount a tale of bad

behavior. Hickson recalled a doctor who hurled a table across a room,

sending shards flying back at co-workers. Felblinger remembered when

a doctor threw a used needle at a nurse, piercing her skin.

Don't ignore bad behavior

Ignoring bad behavior has potentially serious consequences for

patients, said Felblinger, author of an analysis of studies on

medical bullying published this spring in the journal of Obstetric,

Gynecologic & Neonatal Nursing.

About 70 percent of nurses studied believe there's a link between

disruptive behavior and adverse outcomes, and nearly 25 percent said

there was a direct tie between the bad acts and patient mortality,

she said.

A 2004 study of workplace intimidation by the Institute for Safe

Medication Practices (ISMP) in Horsham, Pa., found that nearly 40

percent of clinicians have kept quiet or ignored concerns about

improper medication rather than talk to an intimidating colleague.

Petitt, 54, a clinical nurse specialist in Cincinnati, Ohio,

said she went into private practice several years ago because she

could no longer tolerate the atmosphere that allowed a doctor to

scream and yell in an operating room — with no repercussions.

" He told me: I refuse to talk to you, so now what are you going to do

about it? " said Petitt, who was the charge nurse at the time.

BULLYING BEHAVIORS Acts that interfere with patient care

Medical intimidation can encompass behaviors that range from verbal

insults to physical assault, say researchers who've studied the

problem for years. The broad category includes the following specific

behaviors, outlined in a medical safety journal.

— Profane or disrespectful language

— Demeaning behavior, such as name-calling

— Sexual comments or innuendo

— Inappropriate touching, sexual or otherwise

— Racial or ethnic jokes

— Outbursts of anger

— Throwing instruments, charts or other objects

— Criticizing other caregivers in front of patients or other staff

— Comments that undermine a patient's trust in other caregivers or

the hospital

— Comments that undermine a caregiver's self-confidence in caring for

patients

— Failure to adequately address safety concerns or patient care needs

expressed by another caregiver

— Intimidating behavior that suppresses input by other members of the

healthcare team

— Deliberate failure to adhere to organizational policies without

evidence to support an alternative

— Retaliation against any member of the health care team who has

reported a violation to the code of conduct or who has participated

in an investigation of an incident

Only a small percent are bad actors

Estimates based on malpractice claims suggest that between 4 percent

and 6 percent of doctors and other health workers actually engage in

intimidation, Hickson said. That's probably about the same percentage

of bad actors in any profession, he added.

But that small proportion has a big impact, said Felblinger.

" I think it is endemic, " she said. " We've been so used to having

these behaviors occur for so long. "

In the ISMP study of about 2,000 clinicians, more than 90 percent

said they'd experienced condescending language or voice intonation;

nearly 60 percent had experienced strong verbal abuse and nearly half

had encountered negative or threatening body language.

" Some people are intimidated because they think the doctor has the

higher authority, " said Setteducato, 55, a nurse at Lutheran

Medical Center in Brooklyn, N.Y.

It's important to note that bad behavior is not limited to doctors,

said Dr. ph Heyman, chair of the board of directors for the

American Medical Association. The Joint Commission warning also

covers nurses, pharmacists and other clinicians, he noted.

It's not just doctors

Setteducato observed her share of tantrums and slammed phones in 37

years of nursing. But it's not just doctors bullying nurses, she

said. Nurses do their share of intimidation, too.

" The experienced nurses are not patient with the new doctors, " she

observed.

The AMA has had a policy calling for zero tolerance for disruptive

behavior for all workers for years. Heyman said he believes the

climate is much better now than when he was a resident in the 1970s.

" I don't see it as a huge problem, " he said, adding: " Having

standards encourages hospitals to look for this kind of behavior and

head it off at the pass. "