Bullying, incivility, intimidation, and other forms of disrespectful behavior have run rampant in healthcare, allowed to exist while many remain silent or make excuses—“That’s just the way he/she is”—in an attempt to minimize the profound devastation that disrespectful behavior can cause. The term “disrespectful behavior” encompasses a broad array of conduct, from aggressive outbursts to subtle patterns of disruptive behavior so embedded in our culture that they seem normal (see Table 1 on page 2 in PDF version).1,2 On a personal level, disrespectful behavior causes the recipient to experience fear, vulnerability, anger, anxiety, humiliation, confusion, loss of job satisfaction, professional burnout, uncertainty, isolation, self-doubt, depression, and a whole host of physical ailments such as insomnia, fatigue, nausea, and hypertension.1-8 The presence of disrespectful behaviors erodes professional communication and collaboration, which is essential to patient safety and quality, and creates an unhealthy or even hostile work environment.4
Prevalence and link to safety
Ten years ago, ISMP conducted a national survey of nurses, pharmacists, physicians, and other health professionals regarding intimidation in the workplace. Results showed that disruptive (disrespectful) behaviors were not isolated events, they were not limited to just a few difficult practitioners, they involved both lateral (peer-to-peer) and intradisciplinary staff (and not just physicians), and they involved both genders equally.9 Back then, 88% of respondents reported that, in the year prior to the survey, they had encountered condescending language or voice intonation; 87% encountered impatience with questions; and 79% encountered a reluctance or refusal to answer questions or phone calls. Almost half of the respondents reported more explicit forms of intimidation, such as being subjected to strong verbal abuse (48%) or threatening body language (43%). Incredibly, 4% of respondents even reported physical abuse.
Almost everyone who works in healthcare has a story to tell about disrespectful behavior. Unfortunately, patients have paid a high price–even with their lives–for our inability to be respectful to each other, as there is a clear link to adverse patient outcomes and disrespectful behaviors. Almost half of our 2003 survey respondents told us that their past experiences with disrespectful behavior had altered the way they handled order clarifications or questions about medication orders.9 At least once during the prior year, about 40% of respondents who had concerns about a medication order assumed it was correct or asked another professional to talk to the prescriber, rather than interact with a particularly intimidating prescriber. Almost half felt pressured to accept the order, dispense a product, or administer a medication despite their concerns. As a result, 7% of respondents reported that they had been involved in a medication error during the prior year in which intimidation clearly played a role.
In 2008, Rosenstein and O’Daniel conducted a survey of more than 4,500 nurses, physicians, and other healthcare professionals from 102 hospitals to assess the significance of disrespectful behavior and its impact on patient safety.5 More than two-thirds (70%) of respondents reported a link between these behaviors and medical errors and poor quality patient care; more than 65% linked the behaviors to an adverse event; more than 50% reported that patient safety had been compromised; and more than 25% linked the behavior to patient mortality!
In 2009, the American College of Physician Executives conducted an electronic survey of more than 2,100 physicians and nurses that showed a fundamental lack of respect between the groups.6 Nearly 85% of the participants indicated that degrading comments and insults were the most common form of disrespectful behavior, followed by yelling (73%), cursing (49%), and inappropriate joking (46%). “The worst behavior problem is not the most egregious,” added one participant. “It’s the everyday lack of respect and communication that most adversely affects patient care and staff morale.”6(p.6) In this study, too, respondents reported that disrespectful behavior had led to patient harm. To cite one example, a nurse had called a patient’s physician several times to ask him to come into the intensive care unit (ICU) to see a patient whose condition was declining. Each time, the physician became verbally abusive and refused to come in to the hospital. After two attempts, the nurse hesitated to call the physician again despite the patient’s continued deterioration. By the time she called again, the patient was hemorrhaging internally, was rushed to the operating room, and then died.
In the same year, the Pennsylvania Patient Safety Authority reported receiving 177 error reports that detailed disrespectful behaviors, many of which negatively affected patient care, during a 2-year period.7 In one case, a physician refused to wait 30 minutes (as required for effectiveness) after applying a topical anesthetic to a newborn’s penis before performing a circumcision, despite ongoing protests by staff. In numerous other cases, prescribers had hung up the phone when they were called with a critical laboratory result or when asked to clarify medication orders.
ISMP continues to receive reports of adverse events related to disrespectful behaviors. One recent case involved a cancer patient who sustained serious tissue injury and thrombophlebitis after receiving IV promethazine via a peripheral vein in the hand. Several years before the event, the Pharmacy and Therapeutics Committee at this hospital attempted to remove promethazine from the formulary after adding safer antiemetics. However, given his status and loud insistence, this surgeon “overruled” the otherwise undisputed action to remove the drug. At the time of the event, this surgeon was the only physician still prescribing promethazine.
Why the behaviors persist
Sadly, healthcare has a history of tolerance and indifference to disrespectful behavior. These behaviors are clearly learned, tolerated, and reinforced in both the healthcare culture and the societal culture, where a certain degree of disrespect is considered a normal style of communication, particularly given the increasing opportunity for “aggressive crudity” that has taken hold in the social media.1 Nevertheless, the stressful healthcare environment, particularly in the presence of productivity demands, cost containment, and embedded hierarchies that nurture a sense of status and autonomy, have likely been the most influential factors,1-4 along with an unfortunate progression of victims who, in turn, become perpetrators, feeling that they have no choice but to join in the practice. Thus, disrespectful behavior has become a survival strategy for some—they have to be aggressive enough to discourage anyone from coming after them.3
Organizational leaders may fail to address disrespectful behaviors for many reasons. First, some individuals who engage in disrespectful behaviors may be powerful in the organization,7 which may discourage reporting of the behavior due to fear of retaliation and a general reluctance to confront the individual.4 Organizations may also be wary of offending high-revenue producers and therefore fail to take action.
Where we are today
In our 2004 ISMP Medication Safety Self Assessment for Hospitals, just 34% of participating hospitals felt that hospital leaders dealt effectively with disrespectful behaviors; another 22% suggested that no action had been taken to lessen this behavior. Perhaps spurred by a 2009 leadership standard from The Joint Commission (TJC) that requires hospitals to manage disruptive behaviors,4 improvement was seen in our most recent 2011 Assessment, with 48% of hospitals fully addressing disrespectful behaviors. However, there were still more than half of the hospitals dealing with the behaviors inconsistently (43%) or not at all (9%).
ISMP would like to measure the progress (or lack thereof) during the past decade via a readership survey on managing disrespectful behaviors, which is very similar to the survey we conducted 10 years ago. We strongly encourage nurses, pharmacists, physicians, and other healthcare professionals to participate in the survey that appears on page 4 and at: www.surveymonkey.com/s/disrespect. Responses must be submitted by August 30, 2013. We will present the results of the survey in a future newsletter along with suggestions for managing disrespectful behaviors.
1) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-52.
2) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-8.
3) Johnston J. Those who can, do. Those who can’t, bully. Health and Safety for Beginners. 2004. www.ismp.org/sc?id=200
4) The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Jul 9, 2008;40:1-5.
5) Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008; 34(8):464-71.
6) Johnson C. Bad blood: doctor-nurse behavior problems impact patient care. Physician Exec. 2009; 35(6): 6-11.
7) Pennsylvania Patient Safety Authority. Chain of command: when disruptive behavior affects communication and teamwork. PA Patient Saf Advis. 2010;7(Suppl 2):4-13.
8) O’Daniel M, Rosenstein AH. Professional communication and team collaboration. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality; 2008 Apr. Chapter 33:1-14.
9) ISMP. Intimidation: practitioners speak up about this unresolved problem-part 1. ISMP Medication Safety Alert! 2004;9(5):1-3.