Workplace intimidation affects patient safety

Poll reveals intimidation of most health care staff

According to newly released survey data from the Huntington Valley, PA-based Institute for Safe Medication Practices (ISMP), intimidating behavior is a common element of many health care practice settings, and such behavior is a factor in the occurrence of many medication errors.

More than 2,000 health care professionals, including nurses, pharmacists, and other providers, responded to ISMP’s November 2003 survey. Seven percent of the respondents indicated they were involved in a medication error during the past year in which intimidation clearly played a role.

"It is not an easy thing to talk about. No one likes to admit that they’ve been intimidated at work, or that they’ve been intimidated into changing their decisions," says Judy Smetzer, vice president of ISMP and author of the survey’s report.

"One of the surprising results is that it is not just physicians — health care workers intimidate each other," she adds. "It is not just one or two physicians in a hospital that everyone knows [and] no one likes to interact with. It is a pretty pervasive problem."

ISMP is a nonprofit organization that works with health care practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. The organization administers a voluntary medication error database and also does consulting for health care organizations on ways to improve procedures to prevent medication errors.

It was during several consultation visits, that ISMP officials noticed that cultures of intimidation were common in many health care settings, but they were rarely consciously acknowledged, she says.

When asked, health care personnel would claim to have "wonderful" working relationships with their supervisors and other providers. However, they also created complex processes for communicating with certain intimidating people, Smetzer says.

For example, some staff asked more experienced nurses to call particular physicians with questions about a medication order. Or pharmacists often asked nurses to call a provider known to be unwilling to return their calls.

A common thread that ran through several reports to the ISMP volunteer database revealed that members of the health care team often had a feeling that something was not right, but were too afraid to speak up. The result was a preventable error.

"One of the things we see over and over again, and we were starting to pick up on, is that somebody knew something was wrong or had a feeling that something was wrong, but they proceeded," Smetzer says. "They were easily convinced that they were wrong. Or they followed unsafe practices because they didn’t want to appear to be difficult or to be stupid. And it is sad."

ISMP decided to publish a survey in two of its newsletters, asking health care personnel about their experiences with workplace intimidation. The organization has distributed several similar surveys in the past, each receiving about 300-500 responses.

They were shocked that 2,000 people responded to this one.

"We were amazed at the response we got," she says. "It probably isn’t the greatest response rate when you realize our newsletter is probably read by millions. Our surveys are more or less straw polls, not something scientific we can hold up and say, This reflects the population.’ But it really opened up a lot of issues and allowed people to start talking about things that they would not have talked about before."

Almost half of the survey respondents (49%) indicated that past experiences with intimidation altered the way they handle order clarifications or questions about medication orders. About 40% of all respondents indicated that, at least once during the past year, they had concerns about the safety of a medication error and assumed it was correct rather than interact with an intimidating prescriber. Even when the prescriber was questioned about safety, almost half (49%) of respondents felt pressured into dispensing a product or administering a medication despite their concerns.

According to the respondents, physician-prescribers used condescending language or were impatient with questions twice as often as other health care providers. Sixty-nine percent said a prescriber had at least once in the last year responded, "Just give what I ordered," when faced with a question, while 34% of respondents encountered similar pressure from other practitioners.

On the other hand, respondents made it clear that intimidating behaviors were not limited to just physician-prescribers. They encountered a surprising degree of intimidation among other providers as well.

Intimidation takes many forms

Methods of intimidation ranged from subtle questioning of judgment to more explicit threatening behavior. Nearly a quarter of respondents often encountered condescending language or voice (21%) or impatience with questions (19%). And almost half of the respondents reported were the recipients of strong verbal abuse (48%) or threatening body language (43%) at least once during the last year.

Furthermore, Smetzer says, repeated occurrences of intimidating behavior did not arise from a single, menacing individual. Thirty-eight percent reported that three to five individuals were involved, and 19% reported repeat occurrences with more than five individuals during the past year.

These findings suggest that the problem cannot just be chalked up to "one or two bad apples" in an organization, but a prevailing culture that permits intimidation, Smetzer says.

"When almost half of your respondents can name three to five individuals and repeated instances in the last year alone, that’s a pretty big problem," she notes.

Although pharmacists and nurses reported encountering about the same frequency of intimidating behaviors by physician-prescribers, pharmacists reported more frequent intimidating behaviors by other providers, especially strong verbal abuse (encountered by 50% of pharmacists, and 38% of nurses) and a reluctance to answer questions or return phone calls (83% of pharmacists and 69% of nurses). They also reported more frequent effects from intimidation than nurses.

Pharmacists (49%) had also asked another professional to talk to an intimidating prescriber about an order more frequently than nurses (38%). While more nurses than pharmacists felt that their organizations had defined an effective process for handling disagreements about the safety of an order, both reported equal dissatisfaction with their organizations’ ability to deal effectively with intimidation (61% dissatisfied).

Defining bad behaviors

Not much information is available in the professional literature about workplace intimidation in health care settings, says Smetzer, so it is hard to make definite recommendations.

However, an important first step is to acknowledge the problem and work toward talking about it openly, instead of remaining in denial, she adds.

Smetzer also recommends that health care organizations develop clear policies stating that intimidating behavior will not be tolerated and establish procedures that allow health care workers to freely report intimidating behavior.

"It’s important that providers who exhibit intimidating behaviors be dealt with constructively and not in a purely punitive manner because this will be counterproductive in the long term," she says. "We need to have ways of demonstrating and supporting effective and appropriate modes of communication."

It’s also important, Smetzer contends, to spend significant time developing clear definitions of intimidating behavior.

While verbal abuse and threatening behavior are obvious modes of intimidation, there are other modes that more subtle. For example, several pharmacists reported asking nurses to call prescribing physicians because the physicians did not return pharmacists’ calls. "Now, that is intimidation too, when they decide you are not important enough to call you back, you are going to start doubting the importance of calling," says Smetzer.

ISMP recommends that health care organizations develop codes of conduct and values that encourage behaviors that safeguard team cohesion and staff morale, sense of self-worth, and safety. The institute also suggests establishing a conflict resolution process that ensures effective communication, protects patients, and strictly enforces a zero-tolerance policy for intimidation, regardless of the offender’s status in the organization.

More information on the survey is available on the institute’s web site at


  • Judy Smetzer, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntington Valley, PA 19006.