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Intimidation: Mapping a Plan for Cultural Change in Healthcare (Part II)

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 healthcare providers.

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 appraisals.

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 process.

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 change.

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 relationships.

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 our colleagues.


  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 Medicine Feb(82).
  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 Pract 7(2):35.