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Bullying Behaviors and Medical Error Kathleen Bartholomew, RN, MN kathleenbart@msn.com Friday Harbor, Washington
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“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
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“First Do No Harm” - 1 in 10 Canadians reported receiving the wrong dose or drug - 6.4 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)
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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
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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)
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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.
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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
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Empirical Studies 1. 82% witnessed in last yr. 2. 77% saw negative RN-RN behaviors 3. 28% in survey of US occupations 4. 31% Mass. Study 5. 27.3% bullied in last 6 mo. 6. 46% reported serious LV behaviors 7. 50% encountered bullying (2006)
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Changing the Culture of Medicine Negative -Neutral-Teacher-Collaborative-Collegial
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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 …
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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
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“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”
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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)
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“ The first accountability of a leader is to know reality” Max Dupree
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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. 2005. Collapse)
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Failure to perceive in enough time to intervene Creeping Normalcy Landscape Amnesia Distant Managers
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Human Adaptability Changes that are small and incremental are not noticed
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“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)
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Myopic Embedding
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www.silencekills.com 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
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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
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How power is de-railed
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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.
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Dominant Group Oppressed Group
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OBJECTIVE SUBJECTIVE SCIENCE ART LEFT BRAIN RIGHT BRAIN
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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
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No one no matter how wise or powerful is able to control outcomes in self organizing complex systems On the Edge by Lindberg/Nash
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“What is a patient safety culture?” Leadership Teamwork Communication Evidenced Based Practice Patient Centered Learning Culture Just Culture Journal of Nursing Scholarship, Issue 42
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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
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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
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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
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"The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking." Albert Einstein
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AJN Faces of Caring
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Recommended Article: “The Quality and Economic Impact of Disruptive Behaviors on Clinical Outcomes of Patient Care”, by Rosenstein, A. http://ajm.sagepub.com/content/early/2011/04/21/1062860611400592 http://ajm.sagepub.com/content/early/2011/04/21/1062860611400592 Kathleen Bartholomew kathleenbart@msn.comkathleenbart@msn.com 206-356-2599 www.kathleenbartholomew.com
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