From the March 25, 2004 issue
More than 2,000 hospital nurses, pharmacists, and others
who responded to our November 13, 2003 survey on workplace
intimidation, offered a daunting glimpse of an apparent culture
of disrespect among healthcare providers. Our survey results,
covered in our March 11, 2004 issue, clearly showed that healthcare
providers frequently employ intimidating behaviors when interacting
with each other. These behaviors stem from a longstanding
hierarchical culture obsessed with who is doing the talking,
and also the listening.1 What once may have been regarded
as firm leadership is now relegated to everyday behavior punctuated
with implicit and explicit forms of intimidation - tactics
reserved not just for impressionable new recruits, but a damaging
style of personal interaction that spans entire careers.
Survey respondents also made it abundantly clear that they
are not satisfied with their organizations' efforts to handle
intimidation. Healthcare providers who endure ongoing intimidation
may, in turn, subconsciously employ these tactics themselves
when interacting with others, thus perpetuating this damaging
culture. This may explain survey respondents' widespread
experiences with intimidating behaviors from various different
Certainly, pushing back - treating intimidation with more
intimidation - is not the solution. In fact, there are no
easy or standard remedies for this longstanding problem.
However, as with error prevention in healthcare, the solution
will reveal itself only when we admit there's a problem,
begin to talk openly about the issue, analyze its causes,
and lay the groundwork for significant change in our culture.
To begin this long journey, consider the following:
Establish a steering committee of trustees and senior
leaders, middle managers, physicians, pharmacists, nurses,
and other staff from diverse areas of the workplace.2 Define
workplace intimidation and list examples of the many forms
it can take. This is no easy task, since people have varying
tolerances to certain behaviors, but consider this simple
definition: not being treated with respect, or any behavior,
no matter how small, that causes another to doubt their
self-worth. Develop a mission statement that defines the
organization's effort to reduce intimidation. The committee
should establish an action plan and share it with the workforce,
gain full administrative support, and educate providers
about the damaging effects of intimidation on patient safety
and staff morale.
Create a code of conduct that flows logically from
your organization's mission statement.3 While no code can
list every possible violation, specify both blatantly unacceptable
behaviors as well as behaviors that can subtly undermine
team cohesion, staff morale, self-worth, and safety. Convene
a group of diverse staff to list positive and negative behaviors
related to interpersonal interactions between staff. Use
this list as the basis for the code of conduct, and also
to develop values statements about staff interaction. Have
all existing and new staff sign a copy of the code of conduct
and values statements upon hire/appointment and annually.
Also include the code of conduct and values statements in
all job descriptions, medical staff bylaws, and performance
Survey staff attitudes about intimidation, the kinds
of behaviors they find intimidating, and the levels of intimidation
occurring in your organization from all healthcare providers.2
The survey can also be used for self reflection to garner
information about whether staff feel valued in the organization,
how they handle stress and intimidation, how they treat
others at work, and secret rules they share with new staff
about how to interact with (or avoid) certain staff.
Open the dialogue about workplace intimidation.
Hold frank discussions using objective moderators to keep
the conversation productive. The survey results will likely
trigger a process of questioning the way healthcare providers
interact with each other. However uncomfortable, opening
the dialogue on this issue is crucial to the development
of more effective and respectful ways of interacting with
each other in the future.
Establish a standard, assertive communication process
for use among healthcare providers who must convey important
information. For example, consider asking staff to use the
first names of colleagues, even doctors, to get their attention
when important information must be communicated.1 Using
a colleague's first name can help break down artificial
barriers that may impede effective communication. To enhance
awareness of intimidating behaviors, consider establishing
a code, such as "red light," that can be used
to halt the behavior immediately. Stating the problem along
with its rationale and a potential solution can also improve
assertive communication. If the response from a colleague
is not mutually acceptable, follow a conflict resolution
Establish a conflict resolution process to communicate
effectively and protect patients, not to punish, embarrass,
or coerce involved staff. Be sure the process provides an
avenue for resolution outside the typical chain of command
if the conflict involves a subordinate and his supervisor.
Following a "two challenge rule" is one option.
Used in highly reliable industries with excellent safety
records, the rule requires communication of critical information
twice to the same person. If there's no resolution, the
matter is automatically referred to at least one other person
before a final decision is made.
Encourage confidential reporting of behavior that
intimidates. Provide periodic updates to complainants on
how the issue is being addressed.
Enforce zero tolerance for intimidating behaviors,
regardless of the offender's standing in the organization.
Expect intimidating behaviors to reemerge and establish
a process for dealing with each reported event.4 Confront
offenders with data, authority, and compassion; punitive
responses will not foster interpersonal skills or the desired
culture changes.3 Solicit the offender's side of the story
while stressing that, regardless of why it happened, the
behavior is unacceptable. Offer concrete advice for positive
Provide ongoing education that reinforces your organization's
commitment to a caring and respectful culture. Use role-playing
and vignettes to strengthen skills associated with assertive
communication, conflict resolution, and interpersonal interactions.
Provide managers with customer service and conflict resolution
training, as well as other non-clinical skills necessary
to facilitate the desired culture.
Lead by example and surround staff with positive
workplace experiences and ever-growing circles of positive
Reward outstanding examples of collaborative teamwork,
respectful communication, and positive interpersonal skills.
For example, several times a year, allow staff to select
and recognize colleagues, including physicians, who demonstrate
superior interpersonal skills, thus establishing role models
for the organization.
Conclusion. It will likely take years to deal effectively
with this deeply human matter. And because we develop our
interpersonal skills early in life, the results may not
be all that we desire.3 However, we can certainly begin
to moderate the problem today and break the cycle of disrespect
through steadfast commitment from the entire workforce and
administration, and personal reflection on how we treat
(1) Adubato S. Talk is not cheap when it saves lives. The
Star-Ledger (Newark, NJ). Feb 15, 2004; Business section:7.
(2) Kaeter M. Medicine confronts workplace abuse. 1999 Minn
(3) Sotile WM, Sotile MO. How to shape positive relationships
in medical practice and hospitals. The Phys Exec 1999 Sept/Oct:51-55.
(4) Aiyegbuis A. Anne's angle [editorial]. 2003 Mental Health