Bullying takes toll on staff and patients

Joint Commission: Zero tolerance for intimidation

Compared with carcinogenic chemicals and infectious diseases, workplace bullying might 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. As of 2009, accredited hospitals and surgery centers 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, might 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. "It's part of the whole violence spectrum we see in health care," Bain says.

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. Loraleigh Keashly, PhD, associate professor in the department of communication at Wayne State University in Detroit, says, "We argue that workplace bullying is a systemic issue, not a purely personal one." Keashly has researched workplace bullying and directs a graduate program in dispute resolution.

The Joint Commission requires accredited organizations to educate health care workers at all levels and to adopt a "zero-tolerance" stance toward the worst behaviors.


  1. Rospenda KM, Richman JA, Ehmke JLZ, et al. Is workplace harassment hazardous to your health? J Bus Psychol 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.

The ins and outs of bullying at work

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 Paul Schyve, MD, senior vice president of The Joint Commission. "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, 10-14% of the working population in the United States was exposed to workplace bullying in the past 12 months, says Loraleigh Keashly, PhD, associate professor in the Department of Communication at Wayne State University in Detroit. Even those who are not the direct target of the aggression are negatively affected, Keashly 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. 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, by staff and leaders at health care organizations. Keashly learned of one surgical unit that addressed rising hostility and tension. Anyone on the surgical team could yell out, "Tempo!" Everyone then would 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.

Take 4 steps to stop bullying, intimidation

Managers should take the following steps address bullying and intimidation in the workplace:

• Look for indications of human resource problems.

A department with unusually high levels of sick leave or turnover might warrant a closer look, says Loraleigh Keashly, PhD, associate professor in the Department of Communication at Wayne State University in Detroit. Job satisfaction surveys might be one way to monitor the workplace climate, Keashly adds.

• Allow for informal feedback.

Ideally, employees work with a team approach and feel comfortable airing their concerns. For example, some departments might 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 Paul Schyve, MD, senior vice president of The Joint Commission. "Sometimes there's a tendency to take more severe action against a nurse than against a physician who is bringing in patients," Schyve 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.

Joining the CREW builds civility at VA

Culture change being better outcomes

You can't just mandate a civil workplace. You have to build one.

That is what the Veterans Affairs (VA) health system is doing, one unit at a time. Today, more than 750 units at 150 facilities have adopted Civility, Respect, and Engagement in the Workplace (CREW), a program that is supported by psychologists and specialists in culture change at the VA's National Center for Organization Development in Cincinnati.

CREW pays off in better outcomes, says Linda Belton, FACHE, director of organizational health at the Veterans Health Administration in Ann Arbor, MI. "The higher the level of civility in your work unit, the lower your sick leave . . . [and you have] lower EEOC [Equal Employment Opportunity Commission] complaints, higher employee satisfaction, higher patient satisfaction," Belton says. Units are also more likely to meet their performance requirements and be safer, she says.

CREW began in 2005 with a pilot project involving eight units at eight facilities. "It's really engaged around the people you work with every day," says Belton.

It begins with a commitment of support from hospital leaders, in writing. The facility conducts an assessment, which includes a short Civility Scale given to the unit's members. (See Civility Scale, below.) The items are rated on a 5-point scale from strongly disagree (1) to strongly agree (5).

Facilitators or "champions" from the unit attend face-to-face training sessions and provide monthly updates via phone calls and written reports. The unit also has regular CREW meetings, which are a critical aspect of the program, says Belton. "[Employees] are asked their opinions. They're given a platform, sometimes for the first time in their employment," she says. "We talk about having honest conversations where you can say the difficult things that need to be said."

In one unit, for example, a physician aired a
gripe about how long it took nurses to retrieve an EKG machine when a patient was crashing. The physicians envisioned nurses walking slowly despite the dire need. A nurse explained that they literally ran across the multi-acre campus to borrow the machine from the emergency department. As a result of the conversation, the unit requested the purchase of an EKG machine, which was approved.

No one had ever realized that solving the problem would be that easy, says Belton.

CREW does not specifically address intimidation and bullying; its focus is on the positive. "We visualize what civil behavior is and that's what we go for," she says.

There are some cases in which an individual is causing problems on a unit. That must be dealt with through human resources procedures, Belton says.

CREW simply sets the stage for a workplace that values respectfulness. "If you can create that environment where people have honest conversations, some level of trust and respect one another, then they're less likely to engage in bullying and they're less likely to permit bullying to occur," she says. "A healthy organization is a place where patients want to come to receive care and employees want to work."

Attaining a culture change by working with one unit at a time might seem like a long, slow process. But eventually, the entire organization has a new climate, Belton says. "When you have a certain percentage of your work units participating in CREW, that becomes a tipping point," she says. "Satisfaction and other metrics go up all around the facility."

Civility Scale

Rate the following items on a 5-point scale from strongly disagree (1) to strongly agree (5):

  • Respect: People treat each other with respect in my workgroup.
  • Cooperation: A spirit of cooperation and teamwork exists in my workgroup.
  • Conflict resolution: Disputes or conflicts are resolved fairly in my workgroup.
  • Co-worker personal interest: The people I work with take a personal interest in me.
  • Co-worker reliability: The people I work with can be relied on when I need help.
  • Antidiscrimination: This organization does not tolerate discrimination.
  • Value differences: Differences among individuals are respected and valued in my workgroup.
  • Supervisor diversity acceptance: Managers/supervisors/team leaders work well with employees of different backgrounds in my workgroup.

Source: Veterans Health Administration in Ann Arbor, MI.

Joint Commission offers advice on action steps

16 tips on intimidating behavior

[Editor's note: While the Accreditation Association for Ambulatory Health Care (AAAHC) does not have standards specifically related to bullying/intimidating behavior, this issue falls under their general administration and governance standards.]

The Joint Commission suggests accredited organizations take actions to address the issue of bullying and intimidation:

• Educate all team members — both physicians and nonphysician staff — on appropriate professional behavior defined by the organization's code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.

• Hold all team members accountable for modeling desirable behaviors. Enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline. Enforce it in a positive fashion through reinforcement as well as punishment.

• Develop and implement policies and procedures/processes appropriate for the organization that address.

• Allow "zero tolerance" for intimidating and/or disruptive behaviors. Zero tolerance is especially important with the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero-tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.

• Develop medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization that are complementary and supportive of the policies that are present in the organization for nonphysician staff.

• Reduce fear of intimidation or retribution and protect those who report or cooperate in the investigation of intimidating, disruptive, and other unprofessional behavior. Nonretaliation clauses should be included in all policy statements that address disruptive behaviors.

• Respond to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.

• Determine how and when to begin disciplinary actions such as suspension, termination, loss of clinical privileges, and reports to professional licensure bodies.

• Develop an organizational process for addressing intimidating and disruptive behaviors that solicits and integrates substantial input from an interprofessional team including representation of medical and nursing staff, administrators, and other employees.

• Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution. Cultural assessment tools also can be used to measure whether attitudes change over time.

• Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.

• Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services and patient advocates, both of which provide important feedback from patients and families who might experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods. Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.

• Support surveillance with tiered, nonconfrontational interventional strategies, starting with informal "cup of coffee" conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. These interventions initially should be nonadversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety. Make use of mediators and conflict coaches when professional dispute resolution skills are needed.

• Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.

• Encourage interprofessional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.

• Document all attempts to address intimidating and disruptive behaviors.