Bullied into Botched Care

The Hospitalist. 2007 September;2007(09):

September 1, 2007 | The Hospitalist

“Our study looked at the nurse-physician relationship globally, not intimidation or abuse specifically,” says Dr. Rappaport. Along with their nurse colleague Norine Watson, RN, Drs. Pressel and Rappaport are examining the relationship between nurses and different categories of physicians: how nurses perceive interactions between nurses and surgical residents, surgical attendings, community physicians, pediatric residents, and pediatric hospitalists.

“Early data suggest that hospitalists may work more effectively with nurses because they share many of the same goals,” says Dr. Rappaport. “As hospital leaders, hospitalists can also improve working conditions for nurses by providing more accessible, efficient, and effective care. Presumably, improved collaboration will also include decreased intimidation or abuse from physicians and also probably from dissatisfied patients and families.”

Avoiding the trap of communicating in a manner that is too direct and might be construed as abusive requires self-awareness and the realization that people receive information in different ways, says Dr. Pressel. Standard professional behavior is the key. Beyond that, the challenge is giving feedback constructively and in a positive manner.

“Hospitalists [may be] more in tune with the needs of nurses than nonhospitalists,” says Dr. Rappaport. “I think that is one of our strengths. We need to continue to facilitate very strong relationships between nurses and physicians because without good nursing care, hospitalists simply cannot provide good medical care.”

There is another way hospitalists can help address verbal abuse. “Studies consistently show that nurses are hesitant to report episodes of verbal abuse,” Dr. Rappaport says, “whether it is from a family, a patient, a physician, or a fellow nurse. Fewer than one in five nurses reports these episodes. One thing that hospitalists can do is work with hospital administration to create an environment that is more proactive in addressing these concerns and allowing nurses to feel more support in this area.”

Only 60% of respondents to the ISMP survey felt their organization had clearly defined an effective process for handling disagreements with a medication order’s safety. Only about a third felt the process facilitated their bypassing an intimidating prescriber or their own supervisor if necessary. Although 70% of respondents reported that they thought their organization or manager would support them if they reported intimidating behavior, only 39% of respondents believed their organization was dealing effectively with intimidating behavior.

The ISMP Survey

The ISMP survey was open to all hospital nurses, pharmacists, and others who received or read the ISMP newsletters or visited their Web site. The 2,095 healthcare providers who responded reported the following:

Subtle intimidation occurred more than in explicit forms.

88% reported encountering condescending language or vocal intonation (21% said often) in the workplace;
87% experienced impatience from others with their questions (19% said often); and
79% encountered a reluctance or refusal to answer their questions or phone calls (14% said often).

Almost half the respondents reported more explicit forms of intimidation.

48% had been subjected to strong verbal abuse by healthcare providers;
43% had been subjected to threatening body language; and
4% reported physical abuse.

Physicians/prescribers were cited at least twice as often as other healthcare providers as exhibiting intimidating behaviors. When asked about a medication order, 69% said physicians/prescribers had often (12%) or at some time (57%) said: “Just give what I ordered.”

49% of all respondents indicated that their experiences with intimidation had altered the way they handle order clarifications or questions about medication orders;
About 40% of respondents who had concerns about a medication order assumed at least once that it was correct or asked another professional to talk to the prescriber rather than interact with the intimidating prescriber;
75% had asked colleagues to help them interpret an order or validate its safety so they could avoid interacting with an intimidating prescriber;
34% reported that they found the prescriber’s stellar reputation intimidating and had not questioned an order for which they had concerns;
31% of respondents had suggested or allowed the physician to give the medication, even when the prescriber had been questioned about an order’s safety;
49% felt pressured to accept the order, dispense a product, or administer a medication despite their concerns;
40% of less-experienced nurses versus 54% of nurses with two to five years’ experience reported that their experiences with intimidation had altered the way they handle order clarifications;
64% of pharmacists and 34% of nurses reported having assumed a medication order was correct and safe rather than interact with an intimidating prescriber;
56% of pharmacists versus 29% of nurses reported having assumed a medication order was correct because of the prescriber’s stellar reputation; and
49% of pharmacists, compared with 38% of nurses, had asked another professional to talk to an intimidating prescriber about an order instead of doing it themselves.