The Side Effects of Workplace Bullying in Healthcare

A phenomenon that affects more than a third of American workers is hitting the medical sector particularly hard.

Thirty-seven percent of American workers are affected by workplace bullying (WB), amounting to roughly 54 million people. When you include coworker bystanders of those persons bullied, the numbers total nearly 50 percent of all employees in the United States. Healthcare organizations have among the highest incidence of WB across sectors. These disruptive behaviors have the industry and all of its stakeholders on high alert.

Definitions

To get everyone on the same page, WB refers to the repeated, health-harming mistreatment of one or more persons (targets) by one or more perpetrators. This behavior is marked by abusive conduct that is:

• Threatening, humiliating, or intimidating;
• Work interference – sabotage – that prevents work from getting done; or
• Verbal abuse

Addressing this issue is not about setting high standards for employees or having differences of opinion. It is not about the momentary effects of feeling rough around the edges after a tough week. However, WB does involve the consistent devaluing of employees and colleagues, whether in private or public. It also involves holding staff to unattainable expectations, or treating them unequally, such as when one staff member is consistently denied their vacation requests while others are not.

Workplace bullying can take several different forms. Lateral violence is a common occurrence in healthcare. It manifests when two people who are both victims of a situation of dominance turn on each other rather than confront the system that oppressed them both. Those affected internalize their anger and frustration, then deal with these feelings through negative actions (e.g. gossip, jealousy, putdowns, and blaming).

Front-line professionals are poster children for all forms of WB, especially lateral violence. Their capacity to cope is challenged repeatedly by chronic stressors experienced across the industry, from keeping pace with regulatory changes and pressures to demonstrating successful outcomes, to managing complex patient or family dynamics. Every member of the interprofessional workforce constantly swims against a rising tide.

WB also can involve sexual harassment,  unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. The recently released Medscape Report on Sexual Harassment of Physicians 2018 yielded concerning results from 3,700 respondents: one in 10 female physicians and 16 percent of female residents admitted to being victims over the past three years. The data was further broken down to show the perpetrators of sexual harassment:

• 47 percent by another physician;
• 29 percent by administrators, non-medical personnel, or patients;
• 17 percent by nurses or nurse practitioners;
• 4 percent by medical residents and fellows; and
• 1 percent by medical students.

It is unconscionable to allow the epidemic that has emerged across the industry to continue, along with the impact for all involved.

The Impact of Misused Power

 Experts view bullying in healthcare environments as a direct reflection of the power that stems from the traditional hierarchical stratification that is a hallmark of many organizations. Those individuals at the top of the hierarchy have the power to bully those below them, solely by virtue of their position. From top to bottom are the following:

• C-Suite leadership, department leadership, physicians
• Clinical professionals
• Paraprofessionals
• Non-clinical staff

Those who have walked the halls of health and behavioral health organizations are intimately aware of this pecking order.

All forms of WB stem from power that is misused. This dysfunctional power dynamic can root itself in an organization and become the cultural norm. Misused power and WB can become intertwined in a dysfunctional dance that occurs across every practice setting. It is one reason the industry has among the highest incidence of WB of any sector. Most professionals have directly experienced or witnessed bullying in some form: over 75 percent of the workforce, in fact Over 72% percent of employers deny, discount, encourage, rationalize, and/or defend the behaviors.

Industry Evidence

An abundance of literature focuses on the rapidly escalating incidence of bullying in our sector, though much is from a discipline-specific perspective (e.g. nurse against nurse, attending physician against resident, etc.). Experts note how traditional and often outdated models of professional education enable WB as opposed to negate it. Most nurses can share at least one story reflecting the well-known stereotype that they “eat their young.” I’ve heard countless physicians share their “war stories,” recounting how they were “toughened up” early in their education and careers by having surgical instruments spontaneously thrown at them by senior attendings. Social workers, as helping professionals, can easily find themselves at the bottom of the power hierarchy in organizations, thus finding themselves often prone to bullying behaviors by others.

Workplace bullying is an interprofessional team sport that nobody gets to refuse. It grossly impacts patient quality and safety, and traumatizes the workforce, with compelling numbers to affirm this factor. The intimidating and disruptive behaviors associated with WB fuel medical errors and lead to preventable adverse outcomes:

• Patients of disruptive physicians have 14 percent more complications in the month post-surgery than those patients treated by surgeons with better bedside manners.
• Over 75 percent of disruptive behaviors led to medical errors, with 30 percent contributing to patient deaths.

Workplace bullying counters each element of the Triple Aim (i.e. improving health, the patient experience, and reducing cost), negating quality performance at every turn. Even the new Quadruple Aim, with the added goal of improving the work-life balance, is at issue. The incidence of workforce trauma specific to bullying has a hefty toll:

• 20 percent of targets meet the criteria for post-traumatic stress disorder

• Suicidal ideation related to WB has been recorded at greater than 30 percent
• Suicides related to WB have been recorded at greater than 15 percent
• Staff subjected to WB are twice as likely to commit suicide

The fiscal costs are equally high:

• $30,000 per lawsuit; $60,000 if the case goes to court
• Workforce attrition due to WB is greater than 20 percent

Moving Forward

The robust evidence gathered by individual disciplines about their own WB situations is valuable, and validates the problem. However, these outcomes serve to address the involved discipline only. Long-lasting industry change will only be achieved when WB is addressed collaboratively, and by the workforce as a whole. Otherwise, the efforts to propel change become siloed, which perpetuates the hierarchical system that helped to create the bullying culture in the first place.

At this point in time, WB is not illegal. No federal laws address WB, but the Healthy Workplace Bill is a promising template of legislation gaining popularity across the states and in Canada. The promising work of the Interprofessional Education Collaborative (IPEC) is promoting the evolution of team-based care across the industry. Comprised of national professional associations and accrediting entities in healthcare, IPEC works with academic institutions to shift the practice culture of the interprofessional workforce and better prepare health professionals for those collaborative practices that drive population-focused care.

Professional associations and regulatory entities have taken a firm stance against incivility by developing new standards, ethical codes, and guidelines for practice. Among them are the following:

• American Medical Association: Code of Medical Ethics and Interprofessional Relationships
• American Nurses Association: Incivility, Bullying and Workplace Violence Position Statement
• Case Management Society of America: Standard K: Ethics
• National Association of Social Workers: Standard 2.04 Disputes Involving Colleagues
• The Joint Commission: LD.03.01.01.
• US Department of Veterans Affairs: EEO, Diversity and Inclusion, No FEAR, and Whistleblower Rights and Protection Policy Statement

When professionals feel disempowered to address the dynamics of bullying, the outcomes can be deadly. Consider this fact: Medical errors are the third-leading source of patient deaths, with a high incidence of these incidents directly caused by poor team communications that were hampered by WB.

With more 250,000 medical errors annually, can the industry afford to wait to address this issue? #StopBullying #MustDoBetter

Program Note

Listen today for a report on sexual harassment of women physicians during Talk Ten Tuesdays at 10 a.m. EST

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