Bullying Behaviors and Medical Error Kathleen Bartholomew, RN, MN Friday Harbor, Washington

“Alas, culture is not what we say, what we think, what we mean, or even what we intend; it's what we do.” Jon Burroughs, MD

“First Do No Harm” - 1 in 10 Canadians reported receiving the wrong dose or drug hrs. OT nurses are more than 3 times likely to make an error - 9,000-24,000 deaths per yr. in Canada due to medical errors - 2 million adverse drug effects with 100,000 deaths per yr. (Univ. of Toronto)

Disruptive Relationships 21% linked DB to adverse events 76% saw negative RN-RN behaviors 67% saw link btw behaviors and errors 71% resulted in med error 29% resulted in death (Rosenstein) 2009 survey of 13,000 physicians & nurses 98% saw MD/RN problems in the last year; 30% weekly and 10% daily

32.8% linked DB with adverse events 35.4% linked to medical error 24.7 % to compromising patient safety 12.3% to mortality (Rosenstein, 2011)

Overt : name-calling, sarcasm, bickering, fault- finding, back-stabbing, criticism, intimidation, gossip, shouting, blaming, put- downs, raising eyebrows, etc. Covert: unfair assignments, eye-rolling, ignoring, making faces (behind someone’s back), refusal to help, sighing, whining, sarcasm, refusal to work with someone, sabotage, isolation, exclusion, fabrication, etc.

U.S. vs. Canada “ 50% of Canadians told us that they suffered incivility directly from their fellow employees at least once per week. 99% witnessed incivility at work 1 in 4 reported seeing incivility occurring between other colleagues every day.” Porath and Pearson, The Cost of Bad Behavior

Empirical Studies 1. 82% witnessed in last yr % saw negative RN-RN behaviors 3. 28% in survey of US occupations 4. 31% Mass. Study % bullied in last 6 mo % reported serious LV behaviors 7. 50% encountered bullying (2006)

Changing the Culture of Medicine Negative -Neutral-Teacher-Collaborative-Collegial

67% saw linked behavior and mistakes 18% knew of a mistake that occurred because of an obnoxious doctor (Rosenstein) 40% withheld medication concerns 64% Pharmacists/ 34% nurses assumed an order from an intimidating provider was correct (Institute of Safe Medication Practices) Link safety and the relationship …

Effects Psychological, physical, emotional, social 3 out of 4 scored above threshold for PTSD Long lasting, exaggerated, effects future behaviors Sleep disorders, poor self esteem, eating disorders, nervous conditions, low morale, apathy, feeling disconnected, depression, impaired personal relationships

“NORMAL” They also do it Too close – focus is on workload Don’t know how to confront behavior Low confidence/self-esteem “Herd Mentality” Farrell, 2000 Perceived as personality difference That’s the way it’s always been e.g. “You gotta expect some harm”

Aftermath of Bullying “Nearly everyone got even” Intentionally lower productivity Cut back hours Give minimal effort Left the job – months afterward Lost respect for boss (The Cost of Bad Behavior, Porath and Pearson)

“ The first accountability of a leader is to know reality” Max Dupree

Failures of Group Decision Making Failure to anticipate a problem before it arrives When the problem does arrive, the group fails to perceive it After perception, failure to solve Try to solve, and don’t succeed (Diamond, J Collapse)

Failure to perceive in enough time to intervene Creeping Normalcy Landscape Amnesia Distant Managers

Human Adaptability Changes that are small and incremental are not noticed

“Work Complexity” Multiple goals, unpredictability and constant change  Disjointed work supply sources  Missing equipment/supplies  Repetitive travel  Multiple interruptions  Waiting – for system or processes  Difficulty in accessing resources  Inconsistent communication  Breakdown in communication (Ebright)

Myopic Embedding

84% of MD’s have seen coworkers taking shortcuts that could be dangerous to patients 88% of MD’s say they work with people who show poor clinical judgment Fewer than 10% of MD’s, RN’s and clinical staff directly confront their colleagues about concerns

Culture of Silence Fear of retaliation: isolation, gossip, bad assignment, refusing help, sabotage Fear of hurting others feelings, or making things worse Fear of the unknown; or emotional response Why bother: nothing will change anyway Too uncomfortable No time

How power is de-railed

Theoretical Framework Oppression Theory Major characteristics of oppressed behavior stem from the ability of dominant groups to identify the “right” norms and values and from their power to enforce them.

Dominant Group Oppressed Group

OBJECTIVE SUBJECTIVE SCIENCE ART LEFT BRAIN RIGHT BRAIN

Hierarchy “ … fewer physicians and CEO’s saw a major impact on patient safety, early detection of patient complications or time for team collaboration.” Buerhaus, 2007

No one no matter how wise or powerful is able to control outcomes in self organizing complex systems On the Edge by Lindberg/Nash

“What is a patient safety culture?” Leadership Teamwork Communication Evidenced Based Practice Patient Centered Learning Culture Just Culture Journal of Nursing Scholarship, Issue 42

Current Cultural Norms Different rules for different roles Behaviors excused from clinically competent Culture of silence: inability to confront Failure to understand human factors Power differential - unsafe for staff Leadership failure to address core values, perceive or act, educate to belief level

39 Birthing Employee / Medical Staff Alignment Privilege Limitation or Loss MEC / Disciplinary Action MEC Action Collegial Guidance STARS / Thank You Notes A B C D E Termination Suspension Written Warning Document: Verbal or Written Warning PhysiciansEmployees 61% nurses terminated compared to 22% of physicians for similar behavior (Johnson, 09) STARS / Thank You Notes

Set the stage for cultural change…. Flatten the hierarchy Organizational commitment - and resources Focus on Language and Behavior Zero Tolerance Policy - 100% compliance “Chase ZERO” as goal Lead Physicians to critical mass Adopt new education curriculum

"The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking." Albert Einstein

AJN Faces of Caring

Recommended Article: “The Quality and Economic Impact of Disruptive Behaviors on Clinical Outcomes of Patient Care”, by Rosenstein, A. Kathleen Bartholomew