Physician, Heel Thyself

New York Times
By Teresa Brown, Op-Ed Contributor
Published May 7, 2011

It was morning rounds in the hospital and the entire medical team stood in the patient’s room. A test result was late, and the patient, a friendly, middle-aged man, jokingly asked his doctor whom he should yell at.

Turning and pointing at the patient’s nurse, the doctor replied, “If you want to scream at anyone, scream at her.”

This vignette is not a scene from the medical drama “House,” nor did it take place 30 years ago, when nurses were considered subservient to doctors. Rather, it happened just a few months ago, at my hospital, to me.

As we walked out of the patient’s room I asked the doctor if I could quote him in an article. “Sure,” he answered. “It’s a time-honored tradition — blame the nurse whenever anything goes wrong.”

I felt stunned and insulted. But my own feelings are one thing; more important is the problem such attitudes pose to patient health. They reinforce the stereotype of nurses as little more than candy stripers, creating a hostile and even dangerous environment in a setting where close cooperation can make the difference between life and death. And while many hospitals have anti-bullying policies on the books, too few see it as a serious issue.

Today nurses are highly trained professionals, and in the best situations we form a team with the hospital’s doctors. If doctors are generals, nurses are a combination of infantry and aides-de-camp.

After all, patients are admitted to hospitals because they need round-the-clock nursing care. We administer medications, prep patients for tests, interpret medical jargon for family members and double-check treatment decisions with the patient’s primary team. Nurses are also the hospital’s front line: we sound the alert if a patient takes a serious turn for the worse.

But while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

When a doctor thoughtlessly dresses down a nurse in front of patients or their families, it’s not just a personal affront, it’s an incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are.

That said, the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

And because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

Such an uncomfortable workplace can have a chilling effect on communication among staff. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about the role of bullying in medical errors, the Joint Commission, the primary accrediting body for American health care organizations, has warned of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.

What can be done to counter hospital bullying? For one thing, hospitals should adopt standards of professional behavior and apply them uniformly, from the housekeepers to nurses to the president of the hospital. And nurses and other employees need to know they can report incidents confidentially.

Offending parties, whether doctors or nurses, would be required to undergo civility training, and particularly intransigent doctors might even have their hospital privileges — that is, their right to admit patients — revoked.
But to be truly effective, such change can’t be simply imposed bureaucratically. It has to start at the top. Because hospitals tend to be extremely hierarchical, even well-meaning doctors tend to respond much better to suggestions and criticisms from people they consider their equals or superiors. I’ve noticed that doctors otherwise prone to bullying will tend to become models of civility when other doctors are around.

In other words, alongside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.

This shouldn’t be hard: most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them. But unless we can change the overall tone of the workplace, doctors like the one who insulted me in front of my patient will continue to act with impunity.

I wish I could say otherwise, but after being publicly slapped down, I will think twice before speaking up around him again. Whether that was his intention, or whether he was just being thoughtlessly callous, it’s definitely not in my patients’ best interest.

Theresa Brown, an oncology nurse, is a contributor to The Times’s Well blog and the author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.”

Bullying and Adult EMS Education Podcast

Listen as I discuss workplace bullying in the context of EMS education with the hosts of EMS EdUCast, Greg Friese, Rob Theriault, and Bill Toon.

Click here.

 

Corporate Integrity = Organizational Performance

Companies that encourage employees to speak up about misbehavior and to communicate openly average shareholder returns 5% higher than competitors who do not encourage these behaviors, according to a Corporate Executive Board (CEB) survey cited in the January issue of T+D Magazine. The survey included 500,000 employees from 150 global companies in 85 countries.

The survey also showed that high integrity cultures are 67% less likely to see major incidences of violations of law or company policy, including harassment, finance fraud, and regulatory violations. On the other hand, in companies with a culture not focused on integrity these (mis)behaviors are 10 times more prevalent.

Further, and even more interesting, the survey indicated that when managers exhibit integrity their employees actually perform better - there was a 12% difference in employee performance between employees with integrity-driven managers and those without.

According CEB, seven specific characteristics drive corporate integrity:

1. comfort in speaking up
2. trust in colleagues
3. strong relationship with direct manager
4. tone from the top
5. clarity of expectations around compliance
6. openness of communication
7. organizational justice

In other words, organizations that focus on these seven values will see better performance, less misbehavior, better internal communication, increased shareholder returns, and a better bottom line.

Simply put, when employees trust their managers and each other they are more engaged. It's no secret that engagement means performance.

Ethics Resource Center Study: Whistleblowing and Workplace Bullying

Last month the Ethics Resource Center released a survey report regarding whistleblowing and retaliation (aka workplace bullying).

The survey found that 15% of employees who reported misconduct perceived that they were retaliated against. According to the report:

60% reported another employees gave them a cold shoulder
62% reported management excluded them from decisions and work activity
55% were verbally abused by a manager
48% almost lost their job
42% were verbally abused by other employees
43% were not given a promotion or raise
27% were relocated or reassigned
18% were demoted

In other words 15% of the survey respondents reported that they were bullied as a result of their actions.

The report also discusses the value organizational culture plays in an employee's decision to report. Not surprisingly, if ethics and the value of ethical behavior comes across as a strong message from the top, employees are more likely to report misconduct. In these strong ethical cultures employees felt comfortable reporting misconduct directly to their immediate supervisor because they felt confident the report would be handled immediately and with professionalism. In climates with weak ethical cultures employees felt they could not report the behavior to their immediate supervisor and often went "up the chain" to someone believed to be more reliable in handling the issue.

Retaliation against whistleblowers is certainly nothing new. If it were, Congress would not have enacted laws against it and businesses would not have corporate policies forbidding it. As with anything, circumstances can prevail and although retaliation is illegal in many instances, it doesn't prevent it from happening.

Unfortunately, as with bullying, psychological repercussions of being retaliated against are pervasive. According to an article published in Current Sociology in 2008 by Rothschild, whistleblowers say they have suffered severe depression, decline in physical health, severe financial decline, and harmed family relationships at home. Many also begin to lose trust in the people around them - distrust becomes a way of life.

The bottom line: Retaliation for whistleblowing IS bullying. As we know, bullying is difficult to prove, especially when managers and human resources professionals everywhere disagree that bullying even exists in the first place. Sigh.

Workplace bullying, stress, and fibromyalgia

From: Minding the Workplace, The New Workplace Institute Blog hosted by David Yamada

Over the past few weeks I’ve had conversations, in person and online, with three women who have been diagnosed with fibromyalgia, and each has experienced severe bullying and heavy-duty stress at work. If you’re unfamiliar with fibromyalgia, here’s a chance to learn something about it.

Fibromyalgia is a chronic, disabling medical condition marked by widespread pain and fatigue that afflicts women far more often than men. Compared to many other serious maladies, research on fibromyalgia is an early work in progress, but we’re learning a lot about it. According to the Mayo Clinic:

Fibromyalgia is a chronic condition characterized by widespread pain in your muscles, ligaments and tendons, as well as fatigue and multiple tender points — places on your body where slight pressure causes pain.

Fibromyalgia occurs in about 2 percent of the population in the United States. Women are much more likely to develop the disorder than are men, and the risk of fibromyalgia increases with age. Fibromyalgia symptoms often begin after a physical or emotional trauma, but in many cases there appears to be no triggering event.

In other words, we’re talking about severe, ongoing pain and the power of a knockout punch.

Gender implications

The gender implications of fibromyalgia are significant. Let’s juxtapose some numbers: If the Mayo Clinic is correct in stating that fibromyalgia will occur in 2 percent of the population, and if studies such as this one suggesting that 9 in 10 sufferers are female are even close to hitting the mark, then we have a hidden epidemic among women.

Bullying connection

The Workplace Bullying Institute recognizes that fibromyalgia can be a consequence of workplace bullying (link here). Research is making the link: For example, a 2008 study led by Canadian researcher Sandy Hershcovis (news coverage, here) found that workplace bullying targets were more likely to develop fibromyalgia. A 2004 study led by Finnish researcher Mika Kivimaki (abstract, here), found that stress at work “seems to be a contributing factor in the development of fibromyalgia.”

Read the rest of this article by David Yamada at his blog by clicking here.