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ECRI Strategies

Disrespectful Behavior in Long-Term Care: New Survey From ISMP

Disrespectful behavior has flourished in health care for years. In fact, disrespectful behavior occurs more frequently in health care than in other industries, largely because of the demands and pace of the dynamic, complex, and often stressful work environment along with dysfunctional hierarchies that nurture a sense of status and autonomy.1-3

Defining Disrespectful Behavior in Health Care

Disrespectful behavior encompasses a broad array of conduct, from aggressive outbursts to subtle patterns of disruptive behavior so embedded in our culture that they seem normal (Table).1-7

Table. Categories of Disrespectful Behavior in Health Care1-7

 Behavior Category

 Definition or Description

  Examples

 Bullying

Negative, repetitive, aggressive, and intentional abuse or misuse of power

Malicious personal attacks, belittling comments, verbal threats, intimidation, exclusion or isolation

 Incivility

Low-intensity deviant behavior that destroys mutual respect in the workplace

Interruptions, hostile looks, public criticism, eye rolling, abrupt emails, blunt phone calls, sarcasm

 Disruptive Behavior

Egregious conduct clearly evident in behavior and/or speech

Angry or rude outbursts, swearing, throwing objects, threats, infliction of physical force

 Demeaning Treatment

Patterns of debasing behaviors that exploit the weakness of another

Shaming, humiliation, demeaning comments, ignoring behavior, distorted or misrepresented nitpicking/faultfinding

 Passive-Aggressive Behavior

Negative attitudes and passive resistance to demands for adequate performance

Unreasonably critical of authority, negative comments about colleagues, work interference, refusal to assist or do tasks, deliberate delay in responding to calls, covert retaliation, undermine another’s status or value

 Passive Disrespect

Uncooperative behaviors that are not malevolent

Chronic lateness to meetings/rounds, sluggish response to requests, resistance to follow safety practices, non-participatory in improvement efforts

 Dismissive Treatment

Behavior that makes patients or staff feel unimportant and uninformed

Condescending comments, patronizing comments/attitude, invalidating the efforts of others, resistance to working collaboratively, refusal to value or praise the contributions of others, exclusionary and overruling behavior

 Systemic Disrespect

Disruptive behaviors so entrenched in the culture that the element of disrespect may be overlooked

Making patients/staff wait for services, requiring long work hours, excessive workloads

Effects of Disrespectful Behavior

The adverse effects of disrespectful behavior are widespread. Disrespectful behavior can jeopardize an individual’s psychological safety, emotional health, and overall wellbeing.1-11 It causes the recipient to experience fear, vulnerability, anger, anxiety, humiliation, confusion, loss of job satisfaction, professional burnout, uncertainty, isolation, self-doubt, depression, suicidal ideation, and physical ailments such as insomnia, fatigue, gastrointestinal discomfort, hypertension, palpitations, and chest pain.1,3 Disrespectful behavior also damages the individual’s professional identity, potentially limiting career opportunities.1

On an organizational level, disrespectful behavior can significantly impact expenses and often creates an unhealthy or even hostile work environment.1 Lower staff morale, productivity, and attendance may lead to increases in employee attrition, exacerbating staffing shortages and leading to increased operating costs.1-11 Disrespectful behavior also erodes professional communication, teamwork, and collaboration, which is essential to resident safety and quality; indeed there is a clear link between adverse resident/patient outcomes and disrespectful behaviors.1,9,12-15 Further, if disrespectful behavior has led to an unhealthy team dynamic, individuals may be hesitant to raise resident safety issues.16

To cite one example, a nurse had called a physician several times to ask him to come into the facility to see a resident whose condition was declining. Each time, the physician became verbally abusive and refused to come into the facility. After multiple attempts, the nurse hesitated to call the physician again despite the resident’s continued deterioration. By the time she called again, the situation was emergent. The patient was rushed to a hospital and the operating room to stop internal hemorrhaging but died.15

Prior Survey Results

Results from 200317 and 201318 Institute for Safe Medication Practices (ISMP) surveys on disrespectful behavior showed that disrespectful behavior was not an isolated event, was not limited to a few difficult practitioners, involved both lateral and managerial staff (not just physicians), and involved both genders equally. In 2003, 88% of respondents reported that they had encountered condescending language or voice intonation; 87% encountered impatience with questions; and 79% encountered a reluctance or refusal to answer questions or phone calls. A decade later, little improvement was seen in the 2013 survey.

2021 ISMP Survey

To measure progress with managing disrespectful behaviors, ISMP is again surveying readers. We encourage long-term care nurses, physicians, pharmacists, and other health care professionals to participate anonymously in the 15-minute survey by visiting https://www.ismp.org/ext/781. Responses must be submitted by November 19, 2021.

Correspondence

Judy Smetzer, BSN, RN, FISMP
Vice President
Institute for Safe Medication Practices
200 Lakeside Drive, Suite 200
Horsham, PA 19044
Phone 215-947-7797

References

  1. LaGuardia M, Oelke ND. The impacts of organizational culture and neoliberal ideology 1) on the continued existence of incivility and bullying in healthcare institutions: a discussion paper. Int J Nurs Sci. 2021;8(3):361-6.
  2. Ariza-Montes A, Muniz NM, Montero-Simó MJ, Araque-Padilla RA. Workplace bullying among healthcare workers. Int J Environ Res Public Health. 2013;10(8):3121–39.
  3. Nielsen MB, Notelaers G, Einarsen S. Measuring exposure to workplace bullying. In: Einarsen SV, Hoel H, Zapf D, Cooper CL, eds. Bullying and harassment in the workplace: developments in theory, research, and practice. 2nd ed. Boca Raton, FL: CRC Press; 2011:140–76.
  4. Fink-Samnick E. The new age of bullying and violence in health care: part 2: advancing professional education, practice culture, and advocacy. Prof Case Manag. 2016;21(3):114-26.
  5. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-52.
  6. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-8.
  7. Elena Power Simulation Centre. Make or break: incivility in the workplace [Video]. Epsom and St. Helier University Hospitals. YouTube. Published September 17, 2019. Accessed September 6, 2021. http://www.ismp.org/ext/755
  8. Workplace Bullying Institute. 2021 WBI US workplace bullying survey: the fifth national scientific WBI study: Zogby Analytics, pollster: the complete report. Published 2021. Accessed September 6, 2021. http://www.ismp.org/ext/756
  9. Pellegrini CA. Workplace bullying is a real problem in health care. Bull Am Coll Surg. 2016;101(10):65-6.
  10. American Medical Association. Bullying in the health care workplace. A guide to prevention and mitigation. Published 2021. Accessed September 6, 2021. http://www.ismp.org/ext/757
  11. NHS Employers. Bullying in healthcare: resources and guidance to help build a positive culture and a supportive environment. Guidance from the NHS Council’s Health Safety and Wellbeing Partnership Group (HSWPG). Published January 1, 2019. Accessed September 6, 2021. http://www.ismp.org/ext/758
  12. Garth K, Todd D, Byers D, Kuiper B. Incivility in the emergency department: implications for nurse leaders. J Nurs Adm. 2018;48(1):8-10.
  13. Edmonson C, Bolick B, Lee J. A moral imperative for nurse leaders: addressing incivility and bullying in health care. Nurse Lead. 2017;15(1):40-4.
  14. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-71.
  15. Johnson C. Bad blood: doctor-nurse behavior problems impact patient care. Physician Exec. 2009; 35(6):6-11.
  16. Murphy B. Why bullying happens in health care and how to stop it. AMA Web site. Published April 2, 2021. Accessed September 6, 2021. http://www.ismp.org/ext/759
  17. Institute for Safe Medication Practices (ISMP). Intimidation: practitioners speak up about this unresolved problem—part I. ISMP Medication Safety Alert! Acute Care. 2004;9(5):1-3. http://www.ismp.org/node/27392
  18. Institute for Safe Medication Practices (ISMP). Unresolved disrespectful behavior in healthcare: practitioners speak up (again)—part I. ISMP Medication Safety Alert! Acute Care. 2013;18(20):1-4. http://www.ismp.org/node/615

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