Intimidation in health care settings and patient safety

AORN Journal, July, 2004 by Suzanne C. Beyea

What constitutes intimidation in health care environments and what is its relationship to patient safety? Some experts have described intimidation in health care settings as bullying. (1) Others have characterized this phenomenon as horizontal violence (2) or "eating our young." (3) One author defines workplace intimidation 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 settings. 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 frequently. One author suggests that intimidation may be a factor in the international nursing shortage. (5) Another author says that understanding the relationship between disruptive physician behavior and nurse satisfaction and retention is helpful because "physicians' behavior can have profound effects on nurses' working conditions and job satisfaction." (6)

Recently, the Institute for Safe Medication Practices (ISMP) examined the issue of intimidation. In a November 2003 survey of more than 2,000 health care providers, researchers found that physicians and other prescribers, pharmacists, nurses, and supervisors all engage in behaviors that have been characterized as intimidation. (7,8)

The survey covered the topics of verbal and physical abuse and intimidating behaviors, such as using condescending language or voice intonation, expressing 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 ordered." (7,8) Findings from this survey suggest that intimidating behaviors are integral in clinical care processes and have been experienced by all categories of clinicians. Perhaps the most alarming finding, however, is that 7% of respondents reported being involved in a medication error in which intimidation contributed to the outcome. (7)

THREATS TO PATIENT SAFETY

In the OR, nurses commonly experience situations in which a surgeon rushes staff members or dismisses suggestions or comments. A procedure may start before team members 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 day. Perhaps the nurse is struggling to insert an indwelling catheter in a patient who is about to undergo a total hip replacement. The nurse cannot identify the urinary meatus, and despite multiple attempts, the patient still is not catheterized. The surgeon asks, "What's the damn hold-up?"

The nurse knows that the elderly patient will need a catheter during surgery and postoperatively, but feels pressure 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 nurses. This may occur during orientation of a new staff member or when working with someone who is unfamiliar 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 sternly 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 direction. Many perioperative nurses can relate stories describing events they considered intimidation or "bullying" by senior staff members, colleagues, or even peers.

When clinicians feel intimidated, the problem rarely is addressed in a timely and effective manner. An intimated clinician simply may feel bad and make an effort to not evoke a similar response from a specific clinician in the future, even if this means taking 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 recognize or characterize certain behaviors as intimidation. Certain intimidating behaviors may be considered by many clinicians as "business as usual" or be attributed to a particular clinician's personality 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.