In our June 27, 2013 newsletter, we discussed the topic of bullying, incivility, intimidation, and other forms of disrespectful behavior that have run rampant in healthcare while many remain silent or make excuses in an attempt to minimize the profound devastation that disrespectful behavior has caused. Ten years ago, ISMP conducted a national survey regarding intimidation in the workplace (www.ismp.org/sc?id=248). Results showed that disrespectful behaviors were not isolated events, they were not limited to just a few practitioners, they involved both lateral (peer-to-peer) and inter-disciplinary staff (and not just physicians), and they involved both genders equally. During July and August 2013, ISMP conducted a similar survey to measure progress (or lack thereof) during the past decade. Sadly, the results paint a grim picture of a hostile work environment in which disrespectful behaviors continue to erode professional communication, which is essential to patient safety.
In Part I of our report, we present what respondents had to say about disrespectful behaviors in the workplace and compare the results to the 2003 survey.
Our 2013 survey included 4,884 respondents—more than double the respondents in our 2003 survey. With the exception of more physicians in the 2013 survey, the respondent profiles were quite similar. Most respondents were nurses (68%) or pharmacists (14%), but more than 200 physicians and almost 100 quality/risk management staff also participated in the survey. Most (66%) respondents were staff-level practitioners, but leaders at the manager/director/administrator-level were also represented (25%). Most respondents had more than 10 years of experience (70%) and were female (87%).
Practitioners feel the sting
Regardless of the source of disrespectful behavior (physicians or others), respondents in 2013 reported a wide variety of behaviors (Table 1 on page 2 of the PDF version) encountered during the past year. When ranked by frequency of occurrence, the behaviors most often encountered during the past year included:
The least frequent disrespectful behaviors encountered at least once during the past year included:
- Negative comments about colleagues or leaders (encountered by 73% at least once, by 20% often)
- Reluctance or refusal to answer questions or return calls (77% at least once, 13% often)
- Condescending language or demeaning comments or insults (68% at least once, 15% often)
- Impatience with questions or hanging up the phone (69% at least once, 10% often)
- Reluctance to follow safety practices or work collaboratively (66% at least once, 13% often)
- Shaming, humiliation, or spreading malicious rumors (46%)
- Reporting staff to a manager (actual or threat) (42%)
- Insulting or slighting an individual due to race, religion, or appearance (24%)
- Thrown objects (18%)
- Physical abuse (7%)
Although these were the least frequent behaviors encountered in aggregate by respondents, it is truly a sad state of affairs when nearly a quarter (24%) of respondents—that’s 1,148 practitioners—reported that at least one of these behaviors were among the most frequent they had encountered during the past year. Furthermore, one of these behaviors—physical abuse—increased between 2003 and 2013 from 4% to 7% respectively, regardless of the source, and from 5% to 8% when the source was a physician. While respondents suggested that some forms of disrespectful behavior have lessened in the last decade, particularly impatience with questions or the use of condescending language and insults, many disrespectful behaviors continue to occur at an alarming frequency, demonstrating little improvement.
Not just physicians
In both 2003 and 2013, respondents reported that physicians and other prescribers engaged in disrespectful behavior more often than other healthcare professionals. However, respondents in 2003 and 2013 also made it clear that it’s not just physicians who behave in a disrespectful manner—in many cases, encounters have been nearly as frequent, or sometimes more frequent, with other healthcare professionals. For example, in both 2003 and 2013, a little more than 40% of respondents reported that both physicians and other healthcare professionals had reported (or threatened to report) them to their manager during the past year. To cite another example, between 63% and 69% of the 2013 respondents reported resistance on the part of physicians, as well as other healthcare professionals, to following safety practices or working collaboratively with others.
Furthermore, repeated occurrences of disrespectful behavior did not arise from a single menacing individual. Thirty-eight percent of respondents in 2003 and 36% in 2013 reported that 3 to 5 individuals were involved in disrespectful behaviors, and 19% and 21% respectively reported that more than 5 individuals were involved in occurrences during the past year. Respondents in 2013 also reported that more non-physicians than physicians were involved in disrespectful behavior.
Impact on safety
Almost half of the 2003 (49%) and 2013 (44%) respondents told us that their past experiences with intimidation had altered the way they handle order clarifications or questions about medication orders (see Table 2 online at: www.ismp.org/sc?id=252). At least once during the year, 39% of respondents in 2003 and 33% in 2013 had concerns about a medication order but assumed it was correct rather than interact with an intimidating prescriber. Similar results were reported when the prescriber’s stellar reputation led to reluctance to question or clarify orders despite concerns. More than one-third of respondents in both 2003 (39%) and 2013 (38%) asked another professional to talk to a particularly disrespectful prescriber about the safety of an order. Small improvements were seen between 2003 and 2013 in regards to asking a colleague to help validate the safety of an order, asking a colleague to talk to a disrespectful prescriber on their behalf, or feeling pressured to accept an order despite safety concerns. However, there was no reduction between 2003 and 2013 in the percent of respondents who were aware of a medication error during the year in which disrespectful behavior played a role. Eleven percent of the 2013 respondents reported such errors; see Table 3 (page 4 of the PDF version) for a few examples.
Not satisfied with organizational efforts
It appears that the 2013 respondents were less satisfied than the 2003 respondents with organizational efforts to address disrespectful behavior. Only 60% of respondents in 2003 and 50% of respondents in 2013 felt their organization had clearly defined an effective process for handling disagreements with the safety of an order. Even less (33% in 2003, 14% in 2013) felt that the process allowed them to bypass a particularly disrespectful prescriber or their supervisor if necessary. While 70% of respondents in 2003 reported that their organization/manager would support them if they reported disrespectful behavior, just 52% of the 2013 respondents felt this way. In the end, only 39% in 2003 and 25% in 2013 felt that their organization dealt effectively with disrespectful behavior.
Gender makes little difference
Female respondents to the survey outnumbered male respondents in both the 2003 and 2013 survey, but only minor differences were reported in the frequency with which each group encountered disrespectful behaviors. For example, a higher percentage of male respondents reported that they had, during the past year, assumed that a medication order was correct and safe rather than interact with a particular prescriber (2003: 48% male, 37% female; 2013: 40% male, 32% female). A higher percentage of male respondents also felt pressured to accept an order, dispense a product, or administer a drug despite concerns about its safety (2003: 53% male, 49% female; 2013: 43% male, 38% female). In 2013, male respondents also reported more frequently being reported to a manager (49% male, 42% female) and being physically abused by non-physicians (8% male, 5% female). On the other hand, female respondents in 2013 reported that more individuals were engaged in disrespectful behavior than reported by male respondents.
Practitioner type differences
In the 2013 survey, nurses and physicians encountered about the same frequency of disrespectful behavior by physicians, although physicians reported more nit-picking/fault-finding and inappropriate joking, and less impatience with questions than nurses. However, physicians reported significantly less frequent disrespectful behavior by other healthcare professionals (non-physicians) than nurses and pharmacists. Nevertheless, the frequency of disrespectful behaviors toward physicians by non-physicians was unexpected. More than half of the physicians reported encountering these behaviors by non-physicians one or more times during the prior year:
- Negative comments about colleagues (71%)
- Refusal to answer questions or return calls (68%)
- Constant nit-picking/fault-finding (56%)
- Reluctance to follow safety practices or work collaboratively (55%)
- Impatience with questions (55%)
- Condescending language, demeaning comments, and insults (54%)
Overall, nurses and pharmacists also encountered about the same frequency of disrespectful behavior by physicians. However, pharmacists reported more frequent physician reluctance to follow safety practices or work collaboratively than nurses, and less nit-picking/fault-finding, shaming, thrown objects, and insults due to race, religion, gender, and appearance than nurses. In contrast, pharmacists experienced more frequent disrespectful behavior by non-physicians than nurses, particularly a refusal to answer questions or return calls, impatience with questions, yelling and cursing, and being reported to their manager.
Pharmacists also reported more frequent effects from disrespectful behavior than nurses in both the 2003 and 2013 survey. For example, in 2013, 63% of pharmacists and 30% of nurses reported that, during the past year, they had assumed a medication order was correct and safe rather than interact with a particular prescriber. Pharmacists (57%) asked another professional to talk to a particular prescriber about an order more frequently than nurses (36%). Pharmacists (29%) also asked, suggested, or allowed a physician to give a medication himself despite concerns about the safety of an order more often than nurses (17%). Very similar findings were reported in 2003. While more nurses (54%) than pharmacists (41%) felt that their organizations had defined an effective process for handling disagreements with the safety of an order, pharmacists (83%) reported greater dissatisfaction than nurses (74%) with their organizations’ ability to deal effectively with disrespectful behavior.
The results of our 2003 and 2013 surveys expose healthcare’s continued tolerance and indifference to disrespectful behavior. These behaviors are clearly learned, tolerated, and reinforced in the healthcare culture, and little improvement has been made during the last decade. The stressful healthcare environment, particularly in the presence of productivity demands, cost containment, and hierarchies that nurture a sense of status and autonomy, have likely been the most influential factors. This creates an environment in which victims may feel they have no choice but to become perpetrators and join in the practice.
Organizations have largely failed to address disrespectful behavior for a variety of reasons. First, some individuals who engage in disrespectful behaviors may be powerful in the organization, which may discourage reporting of the behavior due to fear of retaliation and a general reluctance to confront the individual. Organizations may also be wary of offending high-revenue producers and therefore fail to take action. But, the deep sense of frustration threaded through many of the comments from survey respondents suggest that now is the time for action. In Part II of our report in a future newsletter, we will provide recommendations to help address this longstanding problem. In preparation, we would love to hear from organizations that have been working towards a culture of respect to learn more about the barriers to action and what has worked. Please send a message to firstname.lastname@example.org if you would like to contribute to the dialogue on this important issue.