Intimidation: Practitioners Speak Up About This Unresolved Problem (Part I)

All too often, seasoned healthcare providers feel compelled to warn new staff members about a particularly difficult physician, and perhaps even shield them from this person for as long as possible. It's a telling sign of a culture that tolerates, even fosters, intimidation. More than 2,000 (N=2,095) healthcare providers from hospitals (1,565 nurses, 354 pharmacists, 176 others) responded to our November 13, 2003, survey on this subject. Sadly, they clearly confirmed that intimidating behaviors continue to be far from isolated events in healthcare. What's more, these behaviors are not necessarily limited to a few difficult physicians, or for that matter, to physicians alone. In Part I of our report, learn what respondents had to say about workplace intimidation. Recommendations to address this longstanding problem will be presented in Part II of our report, in the March 25, 2004, edition of the newsletter.

Healthcare providers feel the sting of intimidating behaviors. Regardless of the source of intimidation (physicians or others), respondents reported that subtle yet effective forms of intimidation occurred with greater frequency than more explicit forms. For example, during the past year, 88% of respondents encountered condescending language or voice intonation (21% often); 87% encountered impatience with questions (19% often); and 79% encountered a reluctance or refusal to answer questions or phone calls (14% often). Almost half of the respondents reported more explicit forms of intimidation during the past year, such as being subjected to strong verbal abuse (48%) or threatening body language (43%). Incredibly, 4% of respondents even reported physical abuse.

Physicians clearly intimidate, but it's not just physicians. According to respondents, physicians and other prescribers engaged in intimidating behaviors more frequently than other healthcare providers (e.g., pharmacists, nurses, supervisors). For example, respondents reported that physicians/prescribers often used condescending language, were reluctant to answer questions or return phone calls, and were impatient with questions at least twice as often as other healthcare providers. Sixty-nine percent of respondents told us that physicians/prescribers had often (12%), or at some time during the past year (57%), stated: "Just give what I ordered;" whereas 34% of respondents encountered similar pressure from other healthcare providers to give what the prescriber had ordered. Likewise, physicians and prescribers more frequently exhibited strong verbal abuse and threatening body language than other healthcare providers.

On the other hand, about 40% of respondents reported that both physicians/ prescribers and other healthcare providers had reported (or threatened to report) them to their manager during the past year. In fact, respondents made it abundantly clear that intimidating behaviors were not attributable to physicians/prescribers alone; they encountered a surprising degree of intimidation among other healthcare providers as well. Furthermore, repeated occurrences of intimidating behavior did not arise from a single menacing individual. Thirty-eight percent reported that 3-5 individuals were involved, and 19% reported repeat occurrences with more than 5 individuals during the past year. These disturbing findings suggest that healthcare providers at large, not just 1-2 difficult physicians, have adopted this unhealthy and unsafe practice habit.

Intimidation clearly impacts patient safety. Almost half (49%) of all respondents told us that their past experiences with intimidation had altered the way they handle order clarifications or questions about medication orders. At least once during the past year, about 40% of respondents who had concerns about a medication order assumed that it was correct, or asked another professional to talk to the prescriber, rather than interact with the particularly intimidating prescriber. Three quarters (75%) had asked colleagues to help them interpret an order or validate its safety so that they did not have to interact with an intimidating prescriber. Similarly, 34% reported that they found the prescriber's stellar reputation intimidating and had not questioned an order for which they had concerns. Even when the prescriber had been questioned about the safety of an order, 31% of respondents had suggested or allowed the physician to give the medication himself, and almost half (49%) 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 past year in which intimidation clearly played a role.

Respondents not satisfied with efforts to reduce intimidation. Only 60% of respondents felt their organization had clearly defined an effective process for handling disagreements with the safety of an order. Even less, just 33%, felt that the process allowed them to bypass a particularly intimidating prescriber, or their own supervisor if necessary. While 70% of respondents reported that their organization/manager would support them if they reported intimidating behavior, in the end, only 39% felt that their organization dealt effectively with intimidating behavior.

Gender makes little difference. Female respondents (86%) to the survey outnumbered male respondents (14%), but only minor differences were reported in the frequency with which each group encountered intimidating behaviors. Overall, male respondents reported a higher degree of effects from intimidation, but again, the differences were not large. For example, more 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 (48% male, 37% female); assumed that a medication order was correct and safe because of the stellar reputation of the prescriber (42% male, 32% female); and felt pressure to accept an order, dispense a product, or administer a drug despite concerns about its safety (53% male, 49% female). On the other hand, female respondents had asked another professional to talk to a particularly intimidating person more often than male respondents (41% female, 35% male).

The least experienced practitioners may not be the most affected. Surprisingly, nurses with less than 2 years experience encountered intimidating behaviors from both physicians/prescribers and others less frequently than more experienced nurses. Nurses with less than 2 years experience also reported fewer individuals involved in repeated encounters, but the number steadily rose as nurses gained more experience. Furthermore, nurses with less than 2 years experience reported less frequent effects from workplace intimidation than nurses with more experience, with one notable exception: newer nurses had asked another professional to talk to a particularly intimidating person more often than experienced nurses. These findings suggest that perhaps less experienced nurses are initially shielded from intimidating staff, or they are not confident enough to speak up about drug safety issues, thus encountering less frequent situations where intimidation may be a factor. It's also possible that less experienced nurses were not as comfortable as more experienced nurses in disclosing intimidation and its effects on their practice. To this point, there was a significantly lower response rate to the survey from nurses with less than 2 years experience (n= 63, 4% of nurse respondents).

Nurses with 2-5 years experience reported a marked increase in the frequency with which they encountered intimidating behaviors, and were more negatively affected by these behaviors when compared to nurses with less than 2 years experience. For example, 40% of nurses with less than 2 years practice reported that their past experiences with intimidation had altered the way they handle order clarifications; the same was true for 54% of nurses with 2-5 years experience. Similar effects of intimidation continued for nurses with more than 5, even 10, years experience. However, as years of experience increased, nurses reported less satisfaction with the organization's ability to handle intimidation effectively (48% satisfied during the first 2 years, 33% satisfied by years 5-10), with some improvement after 10 years (39% satisfied).

Pharmacists reported a remarkably similar pattern of experiences associated with the number of years in practice, although it was less pronounced. Overall, pharmacists with less than 2 years experience reported fewer intimidating behaviors than pharmacists with more experience. They also reported fewer individuals involved in repeated encounters involving intimidation, but the number steadily rose as pharmacists gained more experience, and then decreased after 10 years of practice. Likewise, the negative effects from intimidating behaviors were fewer for pharmacists with less than 2 years experience than for those with more experience. In this survey, 50% of pharmacists with less than 2 years of practice reported that their past experiences with intimidation had altered the way they handle order clarifications; the same was true for 60% of pharmacists with 2-5 years experience. But as with inexperienced nurses, pharmacists with less than 2 years practice comprised a small percent (7%, n=24) of all pharmacists who responded to the survey. Also like nurses, pharmacists' satisfaction with the organization's ability to handle intimidation effectively decreased along with their years of service (46% satisfied during the first 2 years, 22% satisfied by years 5-10), with some improvement after 10 years (38% satisfied).

Intimidation may affect pharmacists more than nurses. Overall, pharmacists and nurses encountered about the same frequency of intimidating behaviors by physicians/prescribers. However, pharmacists encountered less frequent use of condescending language or threatening body language. On the other hand, pharmacists reported more frequent intimidating behaviors perpetuated by other healthcare providers, especially strong verbal abuse (encountered by 50% of pharmacists, 38% of nurses), and a reluctance or refusal to answer questions or return calls (encountered by 83% of pharmacists, 69% of nurses). Because a pharmacist may interact with a larger scope of prescribers and other providers than a nurse, it's not surprising that 30% of pharmacists reported that more than 5 individuals were involved in repeated occurrences of intimidating behavior; only 17% of nurses reported this.

Pharmacists also reported more frequent effects from intimidation than nurses. For example, 64% of pharmacists and 34% 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 (56%) reported more often than nurses (29%) that they had assumed a medication order was correct because of the stellar reputation of the prescriber. Pharmacists (49%) had also asked another professional to talk to an intimidating prescriber about an order more frequently than nurses (38%). While more nurses (62%) than pharmacists (50%) felt that their organizations had defined an effective process for handling disagreements with the safety of an order, both reported equal dissatisfaction with their organizations' ability to deal effectively with intimidation (61% dissatisfied).

Look for Part II of our report covering suggestions to reduce workplace intimidation in our next issue.