Bullying takes toll on HCWs and patients

Joint Commission: Zero tolerance for intimidation

Compared with carcinogenic chemicals and infectious diseases, workplace bullying may seem like more of an annoyance than a health risk. Yet bullying is a hazard in health care that is linked with poor outcomes for employees and patients alike. Workplaces that allow bullying and intimidation suffer from low satisfaction ratings as well as injuries and poorer patient care.

Concern about bullying was strong enough to inspire new performance requirements in the leadership standards of The Joint Commission, the Oakbrook Terrace, IL-based accrediting body. As of 2009, hospitals must have a code of conduct that defines "acceptable and disruptive and inappropriate behaviors" and must have a process for dealing with the inappropriate behaviors.

The standards apply to managers and employees alike — as well as to physicians. They are an important aspect of the leadership standard that calls for hospital leaders to create a culture of safety, says Joint Commission senior vice president Paul Schyve, MD.

Intimidating behavior "destroys the culture of safety," he says. "If you want to have consistent safety, you need to have a culture of safety. There is a cycle of being able to report [errors], to talk about things, to trust that it won't be held against you, but in fact will be used to make improvements."

The Joint Commission's strong stance is bolstered by recent studies that reveal the impact of workplace bullying. For example, researchers at the University of Illinois at Chicago found that higher levels of workplace harassment were associated with illness, injury, and assault. Other stress factors, such as not having as much decision-making latitude, did not have the same link.1

"Sometimes you're going to feel overwhelmed or not have enough time, but you don't expect someone to yell at you or swear at you," explains Kathleen Rospenda, PhD, associate professor of psychology at the University of Illinois at Chicago.

Bullying does not differ by gender — men are as likely to be bullied as women, studies show. But unskilled employees and those who work with clients or patients, including health care workers, face higher rates of bullying, one study showed.2

The stress in health care, particularly coupled with staffing constraints, may set the stage for intimidation and retaliation, says Evie Bain, RN, MEd, COHN-S, FAAOHN, associate director and coordinator of the health and safety division of the Massachusetts Nurses Association in Canton, MA. "It's part of the whole violence spectrum we see in health care," she says.

Bullying is 'systemic'

The bottom line: When a physician blows up at a nurse or a supervisor belittles an employee, it is not just a clash of personalities or a reaction to a stressful day. "We argue that workplace bullying is a systemic issue, not a purely personal one," says Loraleigh Keashly, PhD, associate professor in the department of communication at Wayne State University in Detroit, who has researched workplace bullying and directs a graduate program in dispute resolution.

That view is shared by The Joint Commission, which requires hospitals to educate health care workers at all levels and to adopt a "zero-tolerance" stance toward the worst behaviors.

Bullying often stems from a power play — a more powerful person acting aggressive or asserting his or her control over someone else. But co-workers also can intimidate.

"If you look at the statistics the studies have tended to show that it's more likely to come from somebody higher in the hierarchy," says Schyve. "But it's actually widespread across all levels, including from nurse to nurse. Any time it occurs, no matter what the relation is, [bullying] will decrease the trust of the culture."

Bullying and intimidation are widespread. Based on research literature, Keashly says 10% to 14% of the working population in the United States was exposed to workplace bullying in the past 12 months. Even those who are not the direct target of the aggression are negatively affected, she adds.

Meanwhile, failing to act to stop aggression or harassment in the workplace just leads to more of the same, she says. "I think some people start taking on these behaviors because there are no consequences and it's permitted," Keashly says.

Changing the organization's culture isn't easy. That's why The Joint Commission released the new performance standards about 18 months before they became effective.

But now when surveyors visit hospitals, they look for the written code of conduct and they ask employees if they feel they can speak up about concerns, errors or near-misses without fear of retribution, says Schyve.

The Joint Commission does receive complaints. "We continue to have reports of intimidating behavior," says Schyve. "Changing the culture in this way is not something that happens overnight."

There are effective steps that can be taken, both by individuals and organizations. Keashly learned of one surgical unit that addressed rising hostility and tension. Anyone on the surgical team could yell out, "Tempo!" Everyone would then tone down their behavior. "It's a very gentle way of letting someone know that everyone needs to stop and look at their behavior, because we're heading on the wrong track," says Keashly.

In another case, nurses created a "code white." If a nurse was being mistreated by a physician, a nurse would call out a "code white," and the location on the address system and available nurses would gather to observe. Their presence alone would support the nurse who was being intimidated and would put the physician on notice to moderate his or her behavior.

Veterans Affairs is taking a systemic approach to improving civility through its program called CREW (Civility, Respect, and Engagement in the Workplace)." An organization can have a profound influence on the quality of the working environment," says Keashly.

Some steps to take to address bullying and intimidation in the workplace include:

• Look for indications of human resource problems. A unit with unusually high levels of sick leave or turnover may warrant a closer look, says Keashly. Job satisfaction surveys may be one way to monitor the workplace climate, she adds.

• Allow for informal feedback. Ideally, employees work with a team approach and feel comfortable airing their concerns. For example, some units may begin a shift with a short "huddle" in which employees can raise issues. But informal mechanisms also are valuable, says Keashly. That includes peer advisers or ombudsmen, who can be a conduit to management and can provide confidentiality to the employee bringing the concern. Some health systems have contracted with outside providers, such as EthicsPoint of Lake Oswego, OR (www. ethicspoint.com), to provide a confidential reporting hotline.

• Be prepared to take action, when necessary. The policy should apply to all members of the health care team, from physicians to nurses to managers, says Schyve. "Sometimes there's a tendency to take more severe action against a nurse than against a physician who is bringing in patients," he says. "For this to really be a culture in which there is trust, it needs to be just. 'Just' means you need to treat people equally."

• Take a proactive approach. Don't just respond to problems when they arise, but actively seek to build a collaborative atmosphere that encourages openness, says Schyve. "If you're trying to create a culture of safety, you as the leaders need to really be on top of this issue," he says.


1. Rospenda KM, Richman JA, Ehmke JLZ, et al. Is workplace harassment hazardous to your health? Journal of Business and Psychology 2005; 20:95-110.

2. Ortega A, Hogh A, Pejtersen JH, et al. Prevalence of workplace bullying and risk groups: A representative population study. Int Arch Occup Environ Health 2009; 82:417-426.