How your organizational culture could be at risk

The public usually views healthcare workers as compassionate caretakers who offer aid to the sick. However, the work life of nurses, lab technicians, physicians and other healthcare providers may look a little different behind the scenes. Reports show that bullying, as well as other forms of workplace violence, can exist in every area of the hospital. It is a problem in healthcare that can have serious ramifications on productivity and patient care. Consider these examples:

➔ An experienced nurse ignoring a new nurse’s questions, embarrassing her publicly for her lack of knowledge, or refusing to show her how to do a certain task
➔ A physician berating a technician in front of a patient
➔ A patient physically shoving transport staff

Bullying goes by a lot of names and covers a broad range of actions. The Workplace Bullying Institute defines it as “repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators.” This abusive conduct can take the form of verbal abuse; threatening, intimidating or humiliating behaviors; or work interference, which prevents work from getting done. When the bully and the victim are on the same level, as in situations where a nurse bullies another nurse, the act may be called horizontal hostility or lateral violence. There are also situations where superiors bully their subordinates and where patients bully hospital staff. One nurse, who asked to remain anonymous, described a few examples of bullying during her decades-long career. One event, however, stood out as more threatening than the others.

Bullying’s Impact on Employee Productivity and Satisfaction

Hostility in the workplace creates a toxic environment that harms the targeted party, observers and, potentially, patients. Here are a few ways that bullying affects employee productivity and satisfaction:

Health problems. It’s stressful to be the target of bullying—or to simply witness workplace aggression. Many bullying victims and onlookers suffer from stress-related health issues, such as nausea, headaches, depression, anxiety and even substance abuse problems.

Unsafe working conditions. Bullying interferes with team morale and effective employee training, communication and collaboration. If a nurse withholds information or refuses to assist a colleague, major errors can occur that harm patients or otherwise lower the quality of their care, and put clinicians at risk for injury.

Absenteeism and high turnover. Victims of bullying either quit showing up to work or walk off the job at high rates. This leaves hospitals with the financial burden of hiring and training new staff members.

“I once worked with a physician who was clearly breaking a lot of rules and endangering patient safety. It wasn’t just one behavior—it was a variety of behaviors, and I had spoken to him about this previously. Unfortunately, most conversations ended with him screaming at me. “One afternoon, I addressed the fact that he wanted to allow someone to observe a surgery who didn’t have any business being there,” the nurse continues. “This was the incident that broke the camel’s back. The physician was so angry that I was questioning him, he picked up a glass filled with ice water and threw it at my head. My staff observed the incident and ran into the dressing rooms because they were afraid of the physical threat.”

As in the situation this nurse describes, sometimes verbal abuse can escalate, leading to physical violence or the threat of it. According to the National Institute for Occupational Safety and Health, workplace violence is characterized by “violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty.” According to the U.S. Bureau of Labor Statistics, from 2011 to 2013, U.S. healthcare workers suffered 15,000 to 20,000 injuries related to workplace violence every year. Violence can come from frustrated patients, family members and visitors, or from other clinical staff, and it’s a more common source of injury in healthcare than in other industries.

How Common Is Workplace Harassment and Violence?

Almost every year since 1999, nursing has ranked No. 1 in Gallup’s annual poll of Honesty and Ethical Standards in Professions. This makes bullying in nursing and other clinical professions all the more surprising. In 2013, the Institute for Safe Medication Practices surveyed 4,884 healthcare workers, including nurses, pharmacists, physicians and quality management staff, about workplace violence and harassment. The results showed that 77 percent of respondents had encountered other clinical staff who had a “reluctance or refusal to answer questions or return calls.” On top of that, 68 percent experienced “condescending language or demeaning comments,” and 18 percent of respondents had objects thrown at them.

Research shows that not only is bullying common in healthcare, but it also has serious consequences. Forty-five percent of nurses have been verbally harassed or bullied by other nurses, says an RNnetwork study. The survey also found that 41 percent of nurses were verbally harassed or bullied by managers or administrators, and 38 percent reported verbal harassment or bullying by physicians. More than half of the nurses who reported harassment at work were considering leaving the profession altogether.

“Bullying can take all kinds of forms,” explains Angie Mitchell, RN, former director of nursing services at HealthTrust. “It could be nonverbal communication, such as the lack of willingness to help a coworker who needs assistance with a patient. Or it could be more obvious—like mocking or even verbal abuse. What’s key is that the definition of bullying is in the perception of the person who bears this type of behavior. So, what may be perceived by some as an unsafe workplace environment may not be perceived by others that way.”

Regardless of how it is defined, bullying can have major implications for hospitals and other healthcare organizations. In one large healthcare facility, up to 70 percent of nurses left their jobs after being bullied, reports American Nurse Today. On top of that, about 60 percent of new RNs quit their first job within six months of being bullied, and abusive or humiliating encounters caused one in three new graduate nurses to consider quitting nursing entirely. In a study published in the International Journal of Environmental Research & Public Health, 38 percent of 284 U.S. healthcare workers surveyed reported psychological harassment. According to the Journal of Nursing Management, research has found a strong correlation between bullying and the turnover rate of healthcare staff.

Hiring and training new staff is costly. A literature review in the Journal of Nursing Management estimates that the cost of replacing a nurse is $27,000 to $103,000. And research by the Society of Human Resource Management indicates it can take about 42 days to fill a position. Plus, hospital systems lose valuable institutional knowledge when a staff member leaves due to bullying or dissatisfaction with the workplace environment. “If you’re not happy at work, you’re not going to do the best you can do,” Mitchell says. “If you’re refusing to be a collaborative team member, somebody else is going to have to do that work alone. Then you risk injury to the patient as well as to your coworker. It casts a horrible cloud over the entire department.”

A 2017 study published in the International Emergency Nursing Journal suggests that standing by during incidents of bullying, maintaining the status quo and retaliation in a hospital setting can all lead to more bullying and a decline in patient care. “There’s a direct link between bullying and poor patient outcomes,” adds Patrick Beaver, chief nursing officer at 140-bed East Cooper Medical Center, a Tenet Healthcare facility based in Mount Pleasant, South Carolina. “Staff gets distracted by a strong personality or derailed by a bully, and it takes their focus away from providing quality care.”

What Triggers Bullying in Healthcare?

While seasoned clinical professionals may tell you that bullying has always been present at patient care facilities, some experts believe it’s on the rise, likely because of health policy changes putting massive financial pressures on the healthcare system. Reimbursement reductions, in particular, can lead to overworked clinical staff and necessitate pay cuts at hospitals—both of which can create a high-stress atmosphere conducive to verbal abuse and an unpleasant, unsafe working environment. In some cases, nurses or lower-level clinicians or healthcare technicians become victims of bullying by physicians or managers because of the power structure created when assembling care teams.

“Stressful job demands can lead to bullying,” Beaver says. “Healthcare professionals are dealing with life and death, and there may be fewer resources available to help them. Across clinical disciplines, caretakers are spending less face time with patients than they once did.” While certainly not an excuse for bad behavior, he adds, all of this could be making bullying “more prevalent.” Adding to caregivers’ stress are difficult working conditions such as the inability to take breaks during long shifts, limited supplies, pressure to rush patient care, and scant recognition of nurses’ skills and contributions to the clinical team. Nurses can be left feeling overwhelmed and stressed, and pass along those negative emotions to colleagues. Bullying in healthcare has been prevalent for so long that many nurses have come to accept it as part of the job.

If You’re the Target

How do you differentiate between someone having a bad day at work and the actions of a bully? Some types of mistreatment or unkind actions such as eye-rolling, gossip or unfriendliness might be classified as workplace incivility but not necessarily bullying-—which is meant to cause harm and happens over time, according to Renee Thompson, RN, a workplace bullying expert, author and speaker.
While each hospital will have its own specific protocol on dealing with workplace violence, here are some general steps to take if you are being bullied:

  1. Document the situation. Keep a diary and record any incidents, witnesses and how the bully is taking a toll on your productivity and morale. This might help you diffuse your anger—or decide if you need to take the complaint public.
  2. Talk to the person, if you feel confident and safe doing so. In some cases, you might be able to diffuse rude and upsetting behavior just by bringing it to the person’s attention. There could be more going on behind the scenes than you realize.
  3. Follow your facility’s grievance policy. Inform your manager, or, if it’s your manager doing the bullying, see your human resources representative.

If a patient or family member starts to threaten you, remove yourself from the situation immediately and contact facility security who should be experienced in de-escalation methods.

Changing the Culture

For years, healthcare bullying has been widely tolerated because nurses have failed to report harassment, and nurse managers haven’t followed up on bullying accusations. However, bullying has increasingly garnered public attention, prompting more patient care organizations to put protocols and programs in place to improve workplace culture and mitigate the risk of abusive behavior. “The best counterattack is follow-through,” says Shaun McCamant, chief nursing officer at HealthTrust Workforce Solutions. “Facilities need to get at the root cause of bullying, just like they would any other dangerous event, such as someone slipping and falling or a behavioral health crisis. Only then will we be able to prevent it with actions to improve the workplace environment for everyone.”

Some health systems offer crisis prevention training programs for employees who work in high-stress areas such as the emergency or behavioral health departments. “This kind of training helps team members de-escalate potentially dangerous situations, whether with clinicians bullying each other, or patients or other hospital visitors harassing staff members,” McCamant says. She uses the example of Alex Wubbels, a nurse in Salt Lake City, Utah, who was arrested in October 2017 for following hospital policy and refusing to let officers draw blood from an unconscious crash victim. “Facilities are creating behavioral response teams to learn de-escalation tactics and go into those high-stress situations and help alleviate the crisis,” McCamant adds.

In the 2013 Joint Commission publication, “Improving Patient and Worker Safety,” civility was described as a precursor to a safe work culture where all patients and clinical staff are treated with respect. Education, such as annual compliance or ethics training for nurses and clinical staff, is one critical part of creating a healthier work environment. Nurse managers can also play a significant role in changing workplace culture by sharing information about incivility, establishing civility charters, implementing policies and rewarding civility, according to AORN (Association of periOperative Registered Nurses). In addition, other members of the leadership team have a responsibility to enforce a culture of safety by establishing a system that doesn’t tolerate bullying, where bullies are confronted, and bullying targets are supported.

“At East Cooper, we talk about bullying at annual training, but we also hold ourselves and our leaders accountable to address what’s happening with staff,” Beaver says. “The first step is getting staff to acknowledge that violence and bullying exist. Then you have to work to understand the catalysts. To improve workplace culture, you have to work through difficult circumstances and put procedures in place to prevent them from recurring. Then make sure your staff knows that leadership cares and is taking action to address their problems.”

It’s important to give employees the 
opportunity to express their concerns in a safe environment. The Agency for Healthcare Research and Quality offers a culture of safety survey that is widely used in hospitals, giving nurses, clinical staff and other employees the opportunity to anonymously and honestly express any concerns they may have about safety in the workplace. “It’s also about doing things to mitigate the stress,” Beaver says. On rounds, Beaver offers small tokens such as candy bars or healthy snacks to break the monotony, 
celebrate team successes and let individuals know their efforts are appreciated. “You have to assess what the frontline teams feel is a remedy,” he adds. “We want our nurses to understand that it’s OK to step away and take a deep breath when they feel overwhelmed. We believe it’s important to get to know our people to build trust and create an environment where they feel comfortable coming to us and speaking openly.”

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