A common perception is that a lot of the toxic culture in health care is directed by physicians toward nurses. Surprisingly, nurses appear to observe a hierarchy within their own ranks that may be just as mean spirited, says Elaine Larson, PhD, RN, FAAN, CIC, associate dean for research at the Columbia School of Nursing in New York.
"A doctoral student who just graduated did her dissertation on bullying among nurses," Larson says. "Actually, there is quite a body of literature on bullying within the profession of nursing, and it is rather common. What she found was that a majority of nurses at some time in their career have been harassed or bullied by a colleague in nursing. So I don’t think it is specifically just physicians to nurses."
Patti Grant, RN, MSN, CIC, 2013 president of the Association for Professionals in Infection Control and Epidemiology, saw some of this first hand when she was just beginning her career. She was shocked to learn that a nursing assistant would not correct an RN even if witnessing a clear breach in protocol.
"That told me right there how much of a challenge I had in my own facility," Grant says. "I think it is just the way that health care traditionally has been. It’s kind of paramilitary, but I don’t think it’s horrific. I don’t think it should be used as an excuse. It’s a reality, but one that can be dealt with. I have had success addressing it."
Factors contributing to such behavior include a high stress work environment where lives could literally be at stake.
"Also, the tradition in medical education has been much more confrontational," Larson says. "There is such a high level of stress and rushing around that a sense of respect and mutual kindness [is lost]."
As a result, some health care cultures "eat their young," to borrow a disturbing phrase from the aforementioned dissertation. "Some of the rude and aggressive behaviors probably have to do with self-protection," Larson adds. "There are some people who have learned to move along the blame as much as possible and cover their backs."
That said, the operating room is one of the environments in health care that accepts people speaking up and pointing out potential hazards. "If a surgeon comes into the OR without doing a hand prep or scrub everybody feels perfectly comfortable saying something," she says. "The culture there has accepted that we are in this together; we’re a team and we have each other’s back. It’s not just blaming."