Disrespectful Behaviors and Their Negative Effects in Healthcare
For years, disrespectful behavior has flourished in healthcare and has been silently endured or rationalized by staff who make excuses—“That’s just the way they are”—in an attempt to minimize the profound devastation that it can cause. In fact, disrespectful behavior occurs more frequently in healthcare than in other industries, largely because of the demands and pace of the dynamic, complex, and often stressful work environment along with dysfunctional hierarchies that nurture a sense of status and autonomy.1-3 Sadly, in healthcare, all forms of disrespectful behavior are commonly believed to be part of the job and an accepted occupational hazard.1
Defining Disrespectful Behavior in Healthcare
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 (Table 1).1-7 Some organizations label all forms of disrespectful behavior in the workplace as “bullying.” For example, the Workplace Bullying Institute (WBI) defines bullying as “repeated, health-harming mistreatment of one or more persons by one or more perpetrators.”8,9 The American Medical Association (AMA) defines bullying as “repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target.”10 According to WBI, workplace bullying is status-blind harassment, but unlike its discriminatory cousin, it is not yet illegal in the US.9
Sadly, disrespectful behavior occurs in all healthcare settings. It can arise from all genders, from people who are higher in position or rank, and from people who are equal or subordinate in position. This behavior may also arise from patients and customers.11
Table 1. Categories of Disrespectful Behavior in Healthcare1-7,19,20
Effects of Disrespectful Behavior
The adverse effects of disrespectful behavior are widespread. On a personal level, disrespectful behavior can jeopardize an individual’s psychological safety, emotional health, and overall wellbeing through the involuntary onset of many harmful stress-related diseases.1-10,12 It causes the recipient to experience fear, vulnerability, anger, anxiety, humiliation, confusion, loss of job satisfaction, professional burnout, uncertainty, isolation, self-doubt, depression, suicidal ideation, and a whole host of physical ailments such as insomnia, fatigue, gastrointestinal discomfort, hypertension, palpitations, and chest pain. These adverse effects place individuals at greater risk of making human errors or not following procedures.1,3
Everyday negative encounters can impair an individual’s cognitive function, lead to an inability to focus, reduce effective teamwork, and decrease the performance of technical skills. Just witnessing disrespectful behavior can impact an individual’s ability to think and make them less likely to want to help others.7 Disrespectful behavior also damages the individual’s professional identity, potentially limiting career opportunities and job promotions.1 Furthermore, individuals take these feelings home with them, affecting their home life and social relationships.1,3
On an organizational level, disrespectful behavior can significantly impact expenses and often creates an unhealthy or even hostile work environment.1 Lower staff morale, productivity, and attendance may lead to increases in employee attrition, exacerbating the current healthcare provider shortages and leading to increased operating costs and reduced financial performance.1-10,12 Unresolved incidents may lead to costly lawsuits. Disrespectful behavior also erodes professional communication, teamwork, and collaboration, which is essential to patient safety and quality.
Patients also have paid a high price—sometimes with their lives—for our inability to be respectful to each other. There is a clear link between adverse patient outcomes and disrespectful behavior.1,9,13-16 The victims of disrespectful behavior are often nervous and may underperform because of their anxiety, posing a threat to patient safety.9 Disrespectful behavior may also be directed towards patients and their families, thus undermining the patient-provider trust and, in itself, leading to adverse outcomes. Further, if disrespectful behavior has led to an unhealthy team dynamic, individuals may be hesitant to raise patient safety issues.17 As a result, many practitioners have reported knowing about medical errors, malpractice cases, and procedural violations that resulted from disrespectful behavior.14
Prior Estimates and Surveys
Have disrespectful behaviors in the workplace lessened today? The World Health Organization (WHO) identified disrespectful behavior as a silent epidemic in healthcare; it is estimated that 50% of employees globally experience disrespectful behavior in the workplace.1,18 However, the true incidence of disrespectful behavior is likely higher due to underreporting.1 In 2021, according to a WBI nationwide survey about the most serious forms of workplace bullying in all sectors, not just healthcare, 39% of employed Americans suffer abusive conduct at work, another 22% witness it, and 73% are aware that it happens.8 Also in 2021, an American Pharmacists Association and National Alliance of State Pharmacy Associations national pharmacy workplace survey found that respondents, most of whom worked in community or ambulatory care settings, thought it was likely that both harassment and bullying from patients (69%) and harassment from managers or co-workers (36%) contributed to medication errors.11
Factors that Perpetuate Disrespectful Behavior
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.5 Poor staffing levels, excessive workloads, power imbalances, subpar management skills, role conflict and ambiguity, ignorance of social inequalities, and bystander apathy are some of the factors that contribute to disrespectful behaviors.1,9,10,12,17 The 2021 WBI survey uncovered other factors associated with disrespectful behaviors, including the personality (personal problems) of the perpetrator, human resources/management response to complaints, and organizational retaliation for filing a complaint.8 Nevertheless, the stressful healthcare environment, particularly in the presence of productivity demands, cost containment, the hierarchal nature of healthcare, and a culture that nurtures autonomy, have likely been the most influential factors,1,10,17 along with an unfortunate progression of victims who, in turn, become perpetrators, feeling that they have no choice but to join in the practice. Sadly, disrespectful behavior has become a survival strategy for some victims—they feel they need to be aggressive to discourage anyone from coming after them.
We will present recommendations to prevent and correct disrespectful behavior in a future newsletter. In preparation, we are seeking your input about your experiences with disrespectful behavior in community and ambulatory care work settings. We also would love to hear from pharmacies and organizations that have been working towards a culture of respect and learn more about what strategies have worked. We strongly encourage pharmacists, pharmacy technicians, clerks, physicians, nurses, and other community and ambulatory care healthcare professionals to participate in a short survey. We estimate that it will take less than 10 minutes to complete the survey. Responses must be submitted by May 27, 2022. Also, please share any medication errors, including close calls, related to disrespectful behavior by going to the ISMP National Medication Errors Reporting Program.
- LaGuardia M, Oelke ND. The impacts of organizational culture and neoliberal ideology on the continued existence of incivility and bullying in healthcare institutions: a discussion paper. Int J Nurs Sci. 2021;8(3):361-6.
- Ariza-Montes A, Muniz NM, Montero-Simó MJ, Araque-Padilla RA. Workplace bullying among healthcare workers. Int J Environ Res Public Health. 2013;10(8):3121–39.
- Nielsen MB, Notelaers G, Einarsen S. Measuring exposure to workplace bullying. In: Einarsen SV, Hoel H, Zapf D, Cooper CL, eds. Bullying and harassment in the workplace: developments in theory, research, and practice. 2nd ed. Boca Raton, FL: CRC Press; 2011:140–76.
- Fink-Samnick E. The new age of bullying and violence in health care: part 2: advancing professional education, practice culture, and advocacy. Prof Case Manag. 2016;21(3):114-26.
- 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.
- 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.
- Elena Power Simulation Centre. Make or break: incivility in the workplace [Video]. Epsom and St. Helier University Hospitals. YouTube. Published September 17, 2019. Accessed September 6, 2021.
- Workplace Bullying Institute. 2021 WBI U.S. workplace bullying survey: the fifth national scientific WBI study: Zogby Analytics, pollster: the complete report. Published 2021. Accessed September 6, 2021.
- Pellegrini CA. Workplace bullying is a real problem in health care. Bull Am Coll Surg. 2016;101(10):65-6.
- Schommer JC, Gaither CA, Lee S, Alvarez NA, Shaughnessy AM. APhA/NASPA national state-based pharmacy workplace survey: report of initial findings. American Pharmacists Association and National Alliance of State Pharmacy Associations. Published December 2021. Accessed March 27, 2022.
- American Medical Association. Bullying in the health care workplace. A guide to prevention and mitigation. Published 2021. Accessed September 6, 2021.
- NHS Employers. Bullying in healthcare: resources and guidance to help build a positive culture and a supportive environment. Guidance from the NHS Council’s Health Safety and Wellbeing Partnership Group (HSWPG). Published January 1, 2019. Accessed September 6, 2021.
- Garth K, Todd D, Byers D, Kuiper B. Incivility in the emergency department: implications for nurse leaders. J Nurs Adm. 2018;48(1):8-10.
- Edmonson C, Bolick B, Lee J. A moral imperative for nurse leaders: addressing incivility and bullying in health care. Nurse Lead. 2017;15(1):40-4.
- 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.
- Johnson C. Bad blood: doctor-nurse behavior problems impact patient care. Physician Exec. 2009; 35(6):6-11.
- Murphy B. Why bullying happens in health care and how to stop it. AMA Web site. Published April 2, 2021. Accessed September 6, 2021.
- Cooper CL, Swanson N. Workplace violence in the health sector: state of the art. Geneva, Switzerland: International Council of Nurses; World Health Organization; Published 2002. Accessed September 6, 2021.
- Limbong A. Microaggressions are a big deal: how to talk them out and when to walk away. NPR. Published June 9 2020. Accessed March 27, 2022.
- Smith A. What to know about microaggressions. Medical News Today. Published March 9, 2022. Accessed March 27, 2022.