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Staring Down OR Bullies
Disruptive behavior among your physicians and staff is a problem you can't afford to ignore.
Irene Tsikitas
Publish Date: September 4, 2008   |  Tags:   Staffing

Surgeons throwing instruments in fits of rage and nurses sabotaging each other are nothing new to those who've spent any time in the OR. "Unless you've been there," says one circulator, "you wouldn't believe what goes on behind those closed doors." But no longer do you have to turn a blind eye to so-called doctor road rage and nurse-on-nurse hostility. Here's how you can root out unacceptable behavior — be it short-fused surgeons driven easily to extremes or nurses accomplished in the art of passive-aggressive behavior — and create a safe and civil workplace.

What would a construction worker do?
At the Outpatient Surgery Medical Center of Plano in Plano, Texas, staff are empowered and encouraged to police the surgical facility as if it were a construction site. "No one would get away with the kind of degrading behavior that you see in a hospital setting on a construction site," says nurse manager Beja Mlinarich, rn, bsn, capa. "They would be put in their place and their barbaric behavior would be handled swiftly and definitively. We don't always have the will or the ability to do that."

Next time you witness someone behaving unacceptably, in the hallway or the OR, here's what to do: "Let them know that you are on the side of reasonable behavior and will support them in change — whatever that needs to be — but you won't look the other way while they abuse those around them and put their patients at risk," says Ms. Mlinarich.

The nation's largest accreditation and certification body recently weighed in on bullying. The Joint Commission has issued a Sentinel Event Alert stating that rude language and hostile behavior among healthcare workers goes beyond unpleasant and poses a serious threat to patient safety and the overall quality of care. The alert requires that all accredited hospitals "create a code of conduct that defines acceptable and unacceptable behaviors and ... establish a formal process for managing unacceptable behavior," beginning Jan. 1, 2009. In the alert, the first of its kind to address disruptive behaviors in the workplace, the commission outlined 11 steps it expects facilities to take to prevent and address the problem, including more education and training for staff and written policies and procedures for monitoring and reporting incidents of disruptive behavior. "Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it," writes the Joint Commission.

Hospitals are also clamping down on those who misbehave. Washington (D.C.) Hospital Center, for one, has had a zero-tolerance policy specific to workplace violence since 1999 and requires all employees to take an online course on the subject yearly, says Elizabeth Wykpisz, RN, MS, MBA, senior vice president and chief nursing officer. A clause in the nursing union's contract required two surgeons to attend anger management classes after they repeatedly verbally harassed nurses, says the union's shop steward.

"Nurses who report something must receive feedback that the event is being reviewed, that it's being taken seriously and that appropriate actions will be taken," says Ms. Wykpisz.

???I felt like a battered wife'
For six months, Diane Dexter, RN, BSN, CNOR, an OR nurse at Sherman Hospital in Elgin, Ill., tolerated teasing banter and insulting remarks from a physician with whom she frequently had to work. But thanks to an understanding hospital administration and her own determination, Ms. Dexter's story has a happy ending.

She first tried to ignore the insults from this particular doctor. "I kept saying, ???If I don't feed the fire, maybe it will just go away.'" One day, it became too much for her to handle, and she was convinced that her toxic relationship with the physician was compromising patient care. "There was no open communication between us," explains Ms. Dexter. "I was afraid anything I said would be used against me."

A Bully in the Manager's Chair?

Lucy Gappen, RN, BSN, CNOR, says that in her 30 years of experience in the OR, she's noticed two opposing dynamics affecting relations among nurses. On one hand, she believes the aging workforce has prompted older nurses to adopt a more nurturing attitude toward those who'll one day have to fill their shoes. On the other hand, she's seen the financial squeeze on hospitals taking its toll, putting added pressure on management and yielding a kind of "top-down bullying" that's made an already stressful work environment even tenser.

In a presentation at this year's AORN Congress, a research team led by Beverly Kirchner, RN, BSN, CNOR, CASC, gave this problem its own name: "diagonal violence," defined as "bullying, mobbing or other related behaviors that are initialized and retaliated in a cycle, across lines of authority within a social group or organization, that cross lines of authority ???diagonally.'" Research studies and anecdotal evidence suggest that nurses who feel bullied or ignored by their superiors are more likely to take their frustrations out on their peers or simply seek employment elsewhere.

According to an analysis of comments submitted by participants in the Nurses Mutual Respect Survey at a large acute-care hospital in Boston in 2008*, some common forms of bullying that originate from the manager's desk include:

  • favoritism in scheduling and assignments;
  • discrimination against certain nurses when hiring;
  • hostility toward nurses who call out sick;
  • toleration of cliques and gossip; and
  • failure to deal with or prevent lateral violence when it was reported.

* Source: Erica Scheffler and Ann Donnelly. "Lateral Violence in Nursing: A Content Analysis." May 2008.

Many studies have shown that disruptive and abusive behaviors among medical staff can have adverse effects on patient care, precisely because they build barriers to the kind of effective communication that's needed to prevent errors and other problems in the OR. The first sentence of the Joint Commission's alert points out what's at stake if this problem goes unchecked: "Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments."

Workplace bullying can also cause lasting psychological damage to the victims, according to an online survey of about 1,100 perioperative nurses conducted in March 2007. The results, presented at the 2007 AORN Congress, showed that "poor health, post-traumatic stress disorder and severe depression were related to the amount of violence the nurses experienced in the workplace," says Beverly Kirchner, RN, BSN, CNOR, CASC, who led the research team conducting the survey.

The regular ribbing Ms. Dexter received led her to begin keeping a log of the physician's rude behavior. "I felt like a battered wife," she recalls. "It was just constant." On the day Ms. Dexter quit trying to ignore this doctor's behavior, she marched into her supervisor's office to confront the problem through the proper channels. But the hospital's policy at the time, according to Ms. Dexter, was hardly conducive to improving working relationships. Staff members had to complete a physician disruptive behavior form, a process that "felt horrible," she says. "I wanted to foster the relationship, I didn't want to send him straight to jail." Ms. Dexter eventually tore up the form when the physician, who was "stunned" by her emotional confrontation, apologized. "My relationship with him now is very collegial and professional. He respects me, and I respect him." Still, the experience inspired Ms. Dexter to reform her hospital's approach to disruptive behavior.

Recipe for respect
Ms. Kirchner advocates a holistic approach to the problem of workplace bullying that focuses on prevention, not just damage control. She uses a healthcare analogy to explain her point: "As in the case of illness, we must work to prevent the problem, manage the problem quickly to lower the severity of the illness and limit the disability occurring as a result of the violence."

So what are the essential ingredients for an effective anti-bullying policy? Two facilities that have reformed their policies in recent years — Ms. Dexter's Sherman Hospital and Maimonides Medical Center in Brooklyn, N.Y. — offer these insights.

  • A positive framework. The Joint Commission and others recommend a "zero-tolerance" policy for rude behavior and a "code of conduct" prescribing acceptable behavior, but both Maimonides and Sherman wanted to avoid the negative connotations associated with those terms, calling their programs the "Code of Mutual Respect" and "Collegiality Policy," respectively. "Rather than a code of conduct, which sort of has a disciplinary connotation to it, we call it a code of respect, which is what we're trying to do — get everyone in the healthcare arena to respect each other," says David Feldman, MD, vice president of perioperative services at Maimonides and one of the prime architects of the code.
  • Equal application. Your policy must apply to all members of the surgical team. "Our CEO stood up at the first meeting we had and said, ???Nobody's immune to this,'" says Dr. Feldman. "And she meant it — our code applies to everybody. From the chairman down to the first-year intern, they're all held to the same standard." Instead of handling complaints against surgeons and staff differently, the paperwork, and investigative and disciplinary measures written into your policy should be the same for all levels. Ms. Dexter, who spearheaded the effort to write Sherman's Collegiality Policy, recommends assembling a multidisciplinary team to help craft the rules. "You have to do it as a team approach, not just ???us against them.'"
  • Clearly defined expectations. In keeping with the theme of positive reinforcement, the first goal of your policy should be to explain exactly what type of behavior and communication you expect your surgeons and staff to engage in with one another. Maimonides' Code of Mutual Respect begins by describing in detail seven principles that the medical staff must agree to follow: professionalism, respectful treatment, language, behavior, confidentiality, feedback and communication. All physicians must acknowledge that they've read the code and agree to abide by it as part of the credentialing process. Hospital staff will soon follow suit.
  • Conflict resolution procedures. Once you've established your expectations for respectful behavior, develop a system for dealing with those who violate the code. Try a measured approach, beginning with a one-on-one or mediated conversation between the two parties involved. Kathryn Kaplan, PhD, Maimonides's chief learning officer, stresses that these meetings be held as soon as possible after the incident, while it's still fresh in everyone's mind. Most of the time, says Dr. Kaplan, this step is able to resolve the problem.

But if more complaints are lodged against the offender, or if one of the parties doesn't feel that the situation has been resolved, then the next step should be more formal meetings between the two staff members and their supervisors, with confidential but clear documentation of the process. It isn't until the last step at Sherman Hospital, when multiple complaints have been lodged against someone and several efforts have been made to address the problem, that the paperwork becomes part of the offender's permanent record.

At Maimonides, a group of physicians from various departments and specialties has been trained to conduct impartial investigations, similar to peer reviews, of serious complaints lodged against a colleague and to help counsel the offender on how to improve his behavior. The goal should always be to help foster better communication and respect between the two parties, not to punish the bullying doctor or nurse. In addition to counseling the bully, Dr. Feldman recommends trying to fix institutional problems — such as faulty equipment or inefficient processes — that contribute to staff conflicts.

  • Comprehensive training and follow-up. Having a written code of conduct and actually seeing it enforced are two different things. Dr. Kaplan says that simply bringing everyone together in a room to go over the policy one time isn't enough. Training should be a step-by-step process that recognizes the particular needs and dynamics of your facility. At Maimonides, Dr. Kaplan and Dr. Feldman started by "training the trainers," to ensure that managers from different departments could help support the code and teach their staff communication skills. They also identified "code leaders" and "code advocates" — people within the organization who would champion the policy and help oversee its enforcement. Then, staff members from every level were brought together for interactive training sessions that included skits featuring situations everyone could identify with — such as a surgeon arguing with a nurse or anesthesiologist arguing with a surgeon — and strategies for resolving them. At Sherman, Ms. Dexter helped train the managers on the new Collegiality Policy by telling the story of her conflict with a physician and giving them all a copy of the article, "Silence Kills: The Seven Crucial Conversations for Healthcare."

To ensure your policy is being followed, conduct surveys before, during and after training to gauge how staff perceptions have changed. Upon reviewing surveys at Maimonides, Dr. Feldman noted a culture shift at the hospital, which told him the new policy was working. "People are clearly more willing to speak up when there's a potential patient safety issue," he notes. "If you have a culture of safety, a culture of respect where people are listening to each other, its clearly a safer place to be."

Change you can actually feel
The noticeably more respectful atmosphere at Sherman has led administrators to introduce the perioperative collegiality policy hospital-wide. In one case, a surgeon that nobody wanted to work with before is now one of the most popular among the perioperative staff. "Culture-wise, we've changed. You can see that, and you can feel it within the walls of the hospital," says Ms. Dexter. "Being able to speak to each other and not be afraid is so important. It's incredible."

Nurse-on-nurse Bullying: Knowledge Is Power

The healthcare hierarchy, which seats predominantly male surgeons at the top and predominantly female nurses and staff at the bottom, is largely to blame for the cycle of lateral violence and disruptive behavior that exists in ORs, says Martha Griffin, RN, CS, PhD, director of nursing education and research at Boston Medical Center. She says that until recently, there's been very little examination of this bullying behavior by the nursing profession. Instead, the behavior has been legitimized as a "rite of passage," and many nurses still tell stories about this abuse in endearing terms. Some nurses, mostly in elite positions, won't talk about lateral violence or bullying because they think it's denigrating to the profession. In reality, says Dr. Griffin, it's denigrating for this behavior to continue.

The most powerful weapon in the OR bully's arsenal is knowledge. Nurses who bully, particularly those with more experience, tend to "lord knowledge over people" rather than share it with their newer, less experienced colleagues, says Dr. Griffin. "That becomes their power base — knowledge they have in an area that other people don't." It's a way for the bullies, who often have low self-esteem, to feel better about themselves in an oppressive environment. Just as knowledge can be used to bully others, it can also serve as a tool to prevent and stop disruptive behavior. Dr. Griffin's research on lateral violence, and a form of anti-bullying training called "cognitive rehearsal," with new-to-practice nurses* found that knowledge of what lateral violence is and how to confront it behaviorally "served to empower" the new nurses and "positively influenced changes in actions of laterally-violent nurses." For example, when lured into a public fight or contentious discussion with a co-worker, nurses were advised to say, "This is not the time or the place. Please stop," and then physically walk away. — Irene Tsikitas

* Source: "Teaching Cognitive Rehearsal as a Shield for Lateral Violence." Journal of Continuing Education in Nursing. Nov./Dec. 2004.

On the Web

See the following Web pages for more information on workplace violence and how to stop it: