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Standing Up to the Bully

Maureen Larkin, for HealthLeaders Magazine, December 11, 2008
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Kicking out bad behavior is about more than ensuring people are nice—your organization's financial health could be at stake.

Did you hear about the physician who repeatedly hit a patient? Or the story about the surgeon who threw a sharp instrument in the operating room, narrowly missing a nurse? Such instances represent the extremes of bully behavior. Chances are, you think that disruptive behavior isn't a problem at your hospital.

Think again.

Physicians and employees at your hospital may not be pitching fits of rage or causing each other physical harm, but that doesn't mean someone's behavior isn't disrupting your organization's ability to offer patients top-notch care. In many cases, says Paul L. Green, MS, RN, director of performance improvement at Scripps Memorial Hospital in La Jolla, CA, it's the more subtle behaviors that can do the most damage.

"There are graduations in severity in terms of the kind of behavior you see," says Green. "There are the behaviors that you'd interrupt immediately for the safety of the people around you . . . but they're just the tip of the iceberg. The ones you need to look out for are the snotty, rude, you're-not-paying-attention-to-me behaviors. That stuff's more dangerous, and it's often insidious and harder to deal with."

When doctors repeatedly treat nurses inappropriately, or a unit manager talks down to a member of the environmental staff, it often fails to reach the top of the organization, Green says. Staff members are afraid of retaliation, and therefore won't report the incidents.

"Perception of retaliation may be very different at the top than for those on the front line. Employees ask themselves, 'Will leadership and administrators stand up for me and protect me if I report this?' The only way they learn the answer is by past experience," Green says.

Forcing attention
Earlier this year The Joint Commission issued a sentinel event alert about disruptive behavior in the healthcare setting. The alert requires hospitals to have a code of conduct in place by Jan. 1, 2009, to discourage disruptive behavior by physicians, nurses, and other hospital personnel. The Joint Commission defines disruptive behaviors as not only verbal outbursts and physical displays, but also passive behaviors, such as the refusal to perform specified duties, failure to return messages, and impatience with questions.

Passive behaviors can be particularly damaging to the ability of clinicians to communicate effectively—something that's essential for patients to get quality care, Green says.

"If you're intimidated, you're going to hesitate calling someone out when you see that something isn't right," Green says. "We see time and time again a nurse who is afraid to call a physician in the middle of the night when a patient's condition is changing, because the last time she did, she was yelled at."

And it's that hesitancy that can place patients in danger and compromise safety, Green says.

Disrupting the bottom line
Allowing disruptive behavior to continue at your organization will do more than drive away good employees or pose dangers to patient safety, says Gerald Hickson, MD, associate dean of clinical affairs and director of the Vanderbilt Center for Patient and Professional Advocacy, part of Vanderbilt University Medical Center in Nashville, TN.

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