What We Do and Say Matters—How Disrespectful Behaviors Increase Risk
A young pregnant woman called her OB in her last month of pregnancy with twins because she felt a decrease in movement of the babies. As advised, she reported to the hospital labor and delivery (L&D) unit for a non-stress test. An L&D nurse called the OB to report that the test was non-reassuring and requested he come in to see the woman. The OB accused the nurse of not knowing how to read a fetal monitoring strip and yelled at her for bothering him at the end of a busy day. He ordered the woman to be discharged with instructions to call back the next day with an update on fetal movement. The next morning the woman called the OB’s office and reported she felt no fetal movement. She was instructed to return to the hospital where an ultrasound showed fetal demise of both babies. The on-call OB induced labor and the woman gave birth to stillborn twins.
During the resultant malpractice claim against the OB and the hospital, the L&D nurse testified that this physician was well-known for yelling at nurses and for refusing to come in to the hospital when called about a patient concern. Nothing had been done by the organization to stop this behavior which was why the nurse did not invoke the chain of command when he refused to come in. The experts who reviewed the care, opined that the babies would likely have survived if a C-section had been done emergently following the non-reassuring test.
The prevalence of disrespectful, abusive and bullying behavior in health care
Disrespectful, abusive and bullying behaviors, like this case illustrates, are a contributing factor to harm events and have long been recognized as a problem in health care settings. Health care organizations have been identified as having the highest incidence of workplace bullying across American business sectors.1
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.”
In 2003 and 2013, the Institute for Safe Medication Practices (ISMP) launched a survey on disrespectful behavior, which identified that this type of behavior was not an isolated event limited to a few difficult clinicians; it involved lateral and managerial staff (not just physicians).
In 2003, 88% of ISMP’s survey respondents reported that 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. A decade later, little improvement was seen in their 2013 survey results.
In both 2003 and 2013, about half of the survey respondents reported more explicit forms of disrespectful behavior, such as being subjected to strong verbal abuse or threatening body language.
In October of 2021, ISMP invited health care professionals to take their survey again.
Impacts on culture, safety and risk
Recent research reveals what we’ve always known anecdotally: disrespectful behaviors impact culture, safety and risk. In their article, The Effect of Health Care Professional Disruptive Behavior on Patient Care: A Systematic Review, the researchers identified that “disrespectful behavior consistently contributed to a reduction in the quality and safety of patient care manifested through adverse incidents, neglect of care needs, never events and complaints.”
ISMP stated that disrespectful behaviors significantly impaired the safety culture and led to reduced patient safety, evidenced by worse clinical outcomes.
Other research, Associations Between a New Disruptive Behaviors Scale and Teamwork, Patient Safety, Work-Life Balance, Burnout, and Depression, revealed “disrespectful behaviors appear to act as a climate within work settings suggesting that one individual’s unprofessional behavior may induce or license unprofessional behavior by others.” Put more simply, bad behavior breeds more bad behavior. The researchers point out that the resultant loss of psychological safety among the care team is a significant safety threat, setting the stage for a lack of organizational learning and repeated errors.
How to promote collaborative and respectful behavior in your organization
Health care organizations can take steps to address disrespectful behaviors and promote a collaborative, respectful and positive culture including:
- Establishing a written code of conduct policy that includes zero tolerance for disrespectful behaviors, as well as a Chain of Command policy to escalate issues.
- Professional health care associations have taken a firm stance against disrespectful behaviors and have developed standards, ethical codes and guidance such as the AMA’s Bullying in the Practice of Medicine and the American Nurses Association Violence, Incivility, & Bullying.
- Training the entire care team to use communication and conflict management tools like AHRQ’s TeamSTEPPS DESC script or CUS.
- Implementing an easy to use, confidential reporting program that includes “no retribution” for reporting behaviors, fair investigation process and clear consequences for disrespectful behaviors regardless of role or position in the organization.
Find Best Practices and Tools in Constellation’s HEAL Prepare Toolkit. Unit 1: Culture. Sign in to ConstellationMutual.com to access the Toolkit found in Risk Resources.
The HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
Constellation® and HEAL® are trademarks of Constellation, Inc.
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