JULY 2004, VOL 80, NO 1 Patient Safety First

P A T I E N T S A F E T Y F I R S T 1

Intimidation in health care settings and patient safety

hat constitutes intimida- tion in health care envi- ronments and what is its relationship to patient safetv? Some experts have

described intimidation in h e h h care settings as bullying.’ Others have char- acterized this phenomenon as horizon- tal violence2 or ”eating our One author defines workplace intimi- dation as

not being treated with respect, or any behavior, no matter how small that causes another to doubt their self-worth . . . or causes harm in the workplace.4

Intimidation may be subtle or overt and may affect many clinical processes that cut across all specialties and set- tings. Clinicians and safety experts must determine how to address the problem of intimidation and minimize its effects on processes of care and its potential to cause medical errors.

THE SCOPE OF THE PROBLEM There are no statistics about the

scope of intimidation in health care organizations, although a number of recent reports suggest that it occurs fre- quently. One author suggests that intimidation may be a factor in the international nursing ~hortage.~ Another author says that understand- ing the relationship between disruptive physician behavior and nurse satisfac- tion and retention is helpful because ”physicians’ behavior can have pro- found effects on nurses’ working condi- tions and job satisfaction.”6

Medication Practices (ISMP) examined the issue of intimidation. In a Novem- ber 2003 survey of more than 2,000 health care providers, researchers found

Recently, the Institute for Safe

that physicians and other prescribers, pharmacists, nurses, and supervisors all engage in behaviors that have been characterized as intimidation.‘.s

The survey covered the topics of verbal and physical abuse and intimi- dating behaviors, such as using conde- scend’mg language or voice intonation, express- ing impatience with questions, displaying negative or threatening body language, reporting a staff member to his or her manager, and telling a nurse or pharmacist to ”just give what was ~ r d e r e d . ” ~ ~ Findings from this survey suggest that intimidating behav- iors are integral in clini- cal care processes and have been experienced by all categories of clini- cians. Perhaps the most alarming finding, how- ever, is that 7% of respondents reported being involved in a med- ication error in which intimidation contributed to the outcome.’

THREATS TO PATIENT SAFETY In the OR, nurses com-

monly experience situa- tions in which a surgeon rushes staff members or

Clinicians and safety experts

must address the problem of

intimidation in health care settings to

minimize its efiect on

processes of care and its potential for resulting in m ed ica I errors.

1 dismisses suggestions or comments. A procedure may start before team mem- bers feel ready or believe they have adequately prepared for the planned surgery. A nurse new to the OR may neglect to do the right thing for a patient in an effort to avoid making the surgeon unhappy.

These types of situations occur every

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JULY 2004, VOL 80, NO 1 Patient Safety First

day. Perhaps the nurse is

indwelling catheter in a patient who is about to under- go a total hip replacement. The nurse cannot idenhfy the urinary meatus, and despite multiple attempts, the patient still is not catheterized. The surgeon asks, “What‘s the

struggling to insert an

d m hold-up?” The nurse knows that the

elderly patient will need a catheter during surgery and postoperatively, but feels pres- sure to let the surgery start. When the surgeon tells the nurse, “The patient doesn‘t need a catheter. Let’s get going,” the nurse yields to the surgeon and makes a decision that is not in the patient’s best interest.

Nurses may intimidate other nurses as well. Nurses and other clinicians often teach the way they were taught. If a nurse experienced intimidation, it may affect the next generation of staff nurs- es. This may occur during orientation of a new staff member or when working with someone who is unfa- miliar with a certain specialty.

For example, a new nurse has learned about the value of smoke evacuators. As the nurse is setting up for the next procedure, her preceptor stem- ly says, “Don’t worry about that. I don’t like the noise it makes.” The new nurse may feel too unsure to respond and may simply follow the more senior staff member’s direc- tion. Many perioperative nurs- es can relate stories describing events they considered intimi-

dation or “bullying” by senior staff members, colleagues, or even peers.

dated, the problem rarely is addressed in a timely and effective manner. An intimat- ed clinician simply may feel

When clinicians feel intimi-

Clinicians may not recognize or

charactedze certain behaviors as

intimidation. The problem with

accepting these behaviors, howevec

is that they may cause other

clinicians to hesitate to address a

patient need or safety concern.

bad and make an effort to not evoke a similar response from a specific clinician in the future, even if this means tak- ing actions that are not in the best interest of the patient. When intimidation is not addressed, patient safety may be compromised.

RECOGNIZING INTIMIDATION Clinicians may not recog-

nize or characterize certain behaviors as intimidation. Certain intimidating behav- iors may be considered by many clinicians as ”business as usual” or be attributed to a particular clinician’s personal- ity style. Some clinicians do not believe intimidation has occurred unless someone yells or uses offensive language. The intimidating clinician may not even be aware that his or her behavior has caused distress in another.

Many clinicians were socialized into a health care system in which what now is called intimidation was simply the way members of the team communicated and behaved toward one anoth- er. Certain behaviors were and continue to be accepted. The problem with accepting these behaviors and atti- tudes is that they may cause other clinicians to hesitate to address a patient need or safety concern.

COMBATTING INTIMIDATION Intimidation will persist as

long as clinicians accept it and fail to collaborate to cre- ate approaches that ensure effective communication processes. No clinician should assume that he or she can solve this problem alone. Developing a shared mental model about intimidation and its characteristics is a first step. Furthermore, clinicians need to learn and use effec- tive communication strategies that increase situational

11 6 AORN JOURNAL

awareness of clinical process- es and environments.

When intimidation occurs despite these activities, health care organizations need to have written policies and pro- cedures that address the prob- lem? Clinicians need to feel safe reporting intimidating behaviors and feel confident that their concerns will be addressed in an effective manner.

Nurses must consistently address behaviors that they consider intimidating. Mini- mizing another nurse's feel- ings by saying, "Dr Smythe always acts that way. Just get used to it," will not help em- power that nurse or lead to assertive communication.

Perioperative nurses need to discuss their work environ- ment and identify situations in which intimidation occurs. New nurses may be intimi- dated by senior expert nurses or experienced nurses may be bullied by certain physician colleagues.

Intimidation cannot be addressed unless all members of the health care team work together to develop approach- es and strategies. Each mem- ber of the team needs to reflect on his or her own behavior to determine if sub- tle or overt intimidation is used in his or her daily prac- tice. Self-awareness is the first step toward overcoming intimidation.

Next, team members need

to consider how patterns of intimidation may influence clinical care and the safety of patients. Defining intimida- tion and identdymg behaviors that are specific to the periop- erative environment are inte- gral components of improv- ing the work environment.

Addressing intimidation provides an opportunity to create a healthier work envi- ronment for all members of

Clinicians need to feel safe reporting

intimidating behaviors and

confident that their concerns will be addressed in an

effective manner.

the health care team as well as to enhance patient safety. Respect for each member of the team provides a pathway for eliminating intimidation and medical errors that result from a staff member's hesita- tion to speak up. *3

SUZANNE C. BEYEA RN, PHD, FAAN

DIRECTOR OF NURSING RESEARCH

DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH

NOES 1. J Randle, "Bullying in the nursing rofession," Journal of AdvancefNursing 43 (August 2003) 395-401. 2. B G McKenna et al, "Horizontal violence: Experiences of registered nurses in their first year of practice," Journal of Advanced Nursing 42 (April 2003) 90-96. 3. J B Cornelius, "Don't eat our young alive," Virginia Nurses Today 10 (August-October 2002) 18. 4. M Kaeter, "Medicine confronts workplace abuse," Minnesota Medicine 82 (February 1999). Also available at http://m.mmaonline .net/pu blications/MnMedl999/Feb rua yheter.cfm?PF=l (accessed 12 May 2004). 5. S Stevens, "Nursing workforce retention: Challen culture," Health A K s (Millwoo ) 21 (September/October 2002)

6. R Welton, "Nurses' working conditions and the nursing short- age," JAMA 289 (April 2,2003) 1632. 7. "Intimidation: Practitioners speak up about this unresolved problem (Part I)," ISMP Medication Safety Alert! (March 11,2004). Also available at http://wwzu. ismp.org/MSAurticles /intimidation.htm (accessed 12 May 2004). 8. ' Intimidation: Map in a plan for cultural change in Eeafthcare (Part II)," ISMP Medication Safety Alert! (March 25,2004). Also available at http://m.ismp.org /MSAarticles/intimidation. htm (accessed 12 May 2004). 9. J H Barnsteiner, C Madigan, T L Spray, "Instituting a disruptive conduct olicy for medical staff," AACN Chicul Issues 12 (August

a bullyinf

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2001) 378-382.

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