November 6, 2015
Let’s face it. We’ve all worked with our share of jerks.
As adults we’re expected to have a certain level of coping skills when it comes to dealing with socially inept or just plain disagreeable individuals. That said, research shows rude and cutting behavior in a healthcare setting can hurt concentration, collaboration and information transfer and therefore endanger patients.
Is Someone a Bully, or Merely Unpleasant?
We've all worked with our share of thoughtless or disagreeable people—and as adults, we're expected to have a certain level of coping skills when it comes to dealing with socially inept individuals or just plain disagreeable individuals. That said, research shows rude and cutting behavior in a healthcare setting can hurt concentration, collaboration and information transfer and therefore endanger patients.
So where’s the line? When do you slip on a thicker skin and shrug off an inappropriate remark -- after all, we all we all have bad days and sometimes say things we don't mean -- and when do you seek organizational intervention to rein in the offending person? The answer probably has a lot to do with whether you’re dealing with a bully or just a person behaving badly that day.
Intimidation in the Workplace
Intimidating and disruptive behaviors in healthcare organizations have garnered a lot of ink since the Joint Commission issued a sentinel event alert in 2008 tying them to medical errors, poor patient satisfaction, preventable adverse outcomes, increased costs, and employee turnover.
In surveying healthcare workers in 2013 regarding workplace intimidation, the Institute for Safe Medication Practices (ISMP) found that intimidating behaviors eroded professional communication and thus had the potential to endanger patients. More than four out of 10 healthcare workers surveyed (44%) said that their experiences with intimidation had altered the way they handle order clarifications or questions about medication orders, such as leading them to assume that an order was correct rather than interact with a disruptive prescriber.
The fact that nasty behavior negatively affects teamwork and communication isn't surprising. But it's noteworthy that some of the "potentially intimidating behaviors" identified by the ISMP aren't matters of overt verbal or physical abuse. Rather, they include passive-aggressive behaviors, such as a reluctance to answer questions, calls, or pages, and rudeness in communication, such as condescension and impatience with questions.
It's also noteworthy that doctors, nurses, pharmacists, and administrators are all at times guilty of disruptive behavior. In a study published in the August 2008 edition of the Joint Commission Journal on Quality and Patient Safety, nearly 77% of the hospital workers surveyed said that they've seen physicians act disruptively, and 65% said they've seen nurses do so.
What Defines Aggressive Behavior?
But these culprits aren't necessarily bullies.
"'Bullying' is a word that gets tossed around more and more these days," says Marie McIntyre, author of Secrets to Winning at Office Politics (St. Martin's Griffin, 2005). "People are often a little too quick to label annoying or frustrating behavior as bullying. Bullying is a form of aggressive behavior in which someone intentionally and repeatedly causes another person harm."
Gary Namie, director of the Workplace Bullying Institute, uses a continuum to describe aggressive behavior. At the lowest level, there's inappropriateness, followed by incivility, which he describes as rude or boorish behavior. Although these people may be unpleasant to be around, he says, they aren't targeting anyone personally. Next comes disrespect, a more targeted form of aggression, followed by outright bullying, which he describes as "a systematic campaign of interpersonal destruction."
Anyone can have a bad day, and at times we may all be jerks. Our flares—a temper tantrum, an exasperated remark, an inappropriate joke—may be unprofessional and unacceptable, but they don't make us bullies. Likewise, some people may be blunt to the point of rudeness, but they aren't singling anyone out with the intent of hurting them.
"There are certain people who are not going to be supportive, warm and fuzzy, or even polite," says Robert Sutton, a professor of management science and engineering at Stanford University and author of The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn't (Business Plus, 2010). "Some people take that to be abusive."
But the perceived offense may reflect cultural and personality differences. People need to take a step back, acknowledge that interaction is a two-way street, and consider their own behaviors, he says. "I don't want to get into a blame-the-victim situation, but people need to look in the mirror and ask themselves, 'Am I being thin-skinned? Am I doing things to create a situation or make it worse?'"
Marty Martin, author of Taming Disruptive Behavior (American College of Physician Executives, 2013), agrees that sometimes, you probably want to let a condescending comment or an insensitive response slide. "If it only happens once or twice—and unless you have evidence to the contrary—you might need to tell yourself, 'This isn't really about me.' Give the person the benefit of the doubt. Reflect on the situation and what might have triggered it."
Nearly everyone is guilty of temporarily behaving badly at some time or another. Problems at home, lack of sleep, a demanding assignment, or any number of problems can cause someone to lash out, particularly in the stressful setting of a healthcare environment.
Practical Approaches to Dealing With Tough Personalities
McIntyre coaches individuals on how to manage overbearing personalities in the workplace.
First, she says, don't think of the culprit as a bully. "As soon as you label someone a bully, you label yourself as a victim. Instead, let's talk about him or her as a difficult person and how you can handle the situation."
Second, she says, understand that power differentials are real. Whereas you may be able to informally address a situation with a colleague, you probably don't want to take the same approach with the hospital medical director or your supervisor.
Among the strategies she recommends:
• Identify people in your organization who can't be bullied. Think about what aspects of their behavior or personality that make them "bully-proof," and emulate that behavior.
• Wait for calm. After the situation has abated, if the culprit is a peer or someone you feel comfortable confronting, address the situation in a confident but respectful way. Don't get adversarial ("You can't talk to me like that!") or parental ("That's not a very nice way to talk to someone"). It will just make them angry all over again.
• Present your shared concerns as they relate to the business issue. "If the issue is patient safety, then don't make it about Dr Smith and the way he talks to you. Explain that if he yells at people, they are going to be afraid to bring problems to his attention," she says.
• Keep your sense of humor.
• Know your limits. "If you work in a small practice and the owner is a tyrant, you don't have much recourse, and you will probably be happier working elsewhere," she says.
Bad Apples Have an Outsized Impact
Although coping skills may helpful, Dr Gerald Hickson, senior vice president for quality, safety, and risk prevention at Vanderbilt Health System, emphasizes that no one should have to be the Lone Ranger or put up with a bully at work.
The Joint Commission mandates that accredited healthcare institutions have a policy for identifying, preventing, and addressing disruptive behavior and individuals need to seek organizational support and intervention when appropriate.
Research estimates that only between 3% and 5% of physicians regularly cause interpersonal issues. Although small in number, those physicians can cause a lot of problems. Hickson cites not-yet-published data from a study conducted by Vanderbilt's Center for Patient and Professional Advocacy of 8000 physicians across six healthcare institutions. The findings: Less than 3% of physicians accounted for more than 40% of staff complaints. The overwhelming majority of doctors (85%) received no complaints at all. With proper training using a peer-intervention model, Hickson says, those physicians can help their disruptive colleagues improve their behavior.
"When you send out peers to deal with these folks, most respond," he says. "You are dealing with individuals who haven't looked in the mirror." A cup of coffee, an informal "this seems to be a problem," and an appeal that the individual regulate his or her behavior is often all it takes, he says. "You're giving the person a chance to have an 'Aha' moment. If they're unable or unwilling to respond, then we escalate to more directive intervention," which may include referrals for comprehensive mental and physical screenings.
Unfortunately, snappish behavior—even if it's an aberration—creates difficulties for both healthcare workers and the patients they treat. Respondents to the 2008 survey in the Joint Commission journal said that disruptive behavior added to stress and frustration and interfered with concentration, collaboration, information transfer, and communication. But the majority also blamed it for contributing to adverse events (67%), errors (71%), impairing patient safety (51%), reducing quality of care (71%) and increasing patient mortality (27%).
For that reason, there's a takeaway for everyone, says Hickson, because we all have bad days.
When it comes to disruptive behavior, "we've had such a focus on throwing, spitting, and cussing that we've missed the nuance," he says. "The litmus test is whether the behavior brings any kind of threat to safe outcomes of care. You don't have to be sweet or smile; you just have to do what's in the best interests of patient safety."
At the same time, he says, "all of us need to be reasonably able to cut each other slack."
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3. 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;34:464-471. http://www.mc.vanderbilt.edu/root/pdfs/nursing/ppb_article_on_disruptive.pdfAccessed October 6, 2015.
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Cite this article: Shelly Reese. Are We Too Quick to Call People 'Bullies?'. Medscape. Oct 22, 2015. http://www.medscape.com/viewarticle/852368_2