On Wednesday, I discussed bullying, mobbing, and incivility in healthcare workplaces at a Grand Rounds session hosted by the Icahn School of Medicine at Mount Sinai, Department of Environmental Medicine and Public Health, in New York City. It was a welcomed opportunity to discuss the challenges of the current healthcare work environment with physicians and other professionals.
Grand Rounds are a form of continuing professional education for those who work in healthcare settings. Sessions typically feature a presentation plus Q&A. Although many Grand Rounds presenters are experts in specific areas of healthcare practice and delivery, at times folks from related fields are invited to present.
When I first became involved with anti-bullying work in the late 1990s, it soon became evident that many healthcare workplaces were sites of significant bullying and related behaviors. I first started hearing accounts of bullying from nurses. Then came the stories from physicians, residents, and medical students. These streams of reports have remained consistent over the years.
Fortunately, some positive signs have appeared as well, at least at the bird’s eye level. Here in the U.S., two significant professional bodies — the Joint Commission and the American Medical Association — have now weighed in strongly against bullying-type behaviors.
The Joint Commission
In 2008 (modified and reaffirmed in 2021), the Joint Commission — an independent, non-profit organization that accredits health care organizations and programs — issued a standard on intimidating and disruptive behaviors at work, citing concerns about patient care (link here):
Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.
As you can see, the Joint Commission’s primary focus was on how bullying-type behaviors can have a negative impact on patient care.
American Medical Association
More recently, the American Medical Association — the largest national association representing the interests of doctors and other healthcare stakeholders — has issued statements, reports, and training materials covering bullying and related behaviors. The AMA defines workplace bullying as (link here):
…repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target.
These 2020 developments are shared on the AMA website (link here):
- “‘Bullying in the workplace is a complex type of unprofessional conduct. Bullying in medicine happens as a result of a combination of individual, organizational and systemic issues,’ says an AMA Board of Trustees Report on the topic. ‘The first line of defense against this destructive behavior are physicians, residents and medical students. There is no justification for bullying, disrespect, harassment, intimidation, threats or violence of any kind to occur among professionals whose primary purpose is to heal. Physicians choose medicine as their life’s work for many reasons, one of the most important being their desire to help and care for people.'”
- The AMA House of Delegates “adopted guidelines for the establishment of workplace policies to prevent and address bullying in the practice of medicine, saying that ‘health care organizations, including academic medical centers, should establish policies to prevent and address bullying in their workplaces.'”
In 2021, the AMA published a short training guide, Bullying in the Health Care Workplace: A Guide to Prevention and Mitigation, which can be accessed here.
I closed my prepared remarks with recommendations on how healthcare institutions can address bullying behaviors, adapting them from a recently published piece on bullying in the legal profession, written for the American Bar Association:
- “Understand that health care professionals have not necessarily been trained to work well with others. Some may not grasp the distinctions between assertive, aggressive, and abusive behaviors.”
- “Include all stakeholders, recognizing that bullying can be vertical (typically top-down) and horizontal/lateral (peer(s) to peer(s)).”
- “For healthcare employers, start at onboarding and orientation, messaging to new hires that everyone should be treated with dignity and respect.”
- “Include bullying in employee handbooks and employee training programs, per AMA recommendations.”
- “Use climate surveys and 360 feedback mechanisms to help identify problems concerning bullying and related behaviors. Don’t sweep bad reports under the rug.”
- “Consider coaching, counseling, and – if necessary – termination for abusive individuals, even if they are proficient in other areas of their performance.”
- “Medical and nursing schools should include bullying and incivility in their curricula.”
- “Especially during the pandemic, incivility and bullying behaviors from patients and their families should be part of education, training, and institutional responses.”
As I noted during my presentation, all the best practices and policies aren’t worth a thing if they are not implemented and followed with good intentions. But the fact that national healthcare associations are recognizing the harms caused by bullying behaviors to workers and patients alike is encouraging.
The Mount Sinai event attracted a strong turnout, and I received very positive feedback on the session from the program organizers. As I said to those who attended, I am especially grateful to all healthcare providers during this pandemic. I hope that they found the hour we spent together useful and interesting.
Phenomenal list of recommendations (advice). My concern/hope is that leaders will recognize the need to seek help from knowledgeable resources to understand the dynamics of workplace abuse so they can effectively identify and respond to the needs of their organization.
I tried to introduce 360 evaluations at my hospital in 2011. It was viewed as a threat. I would have thought since we had more PhD’s than Los Alamos, somebody might have got it. By the end of that year I was gone.
Your point is well taken, Pat. I am nearing retirement and I cannot remember a time when I have ever participated in systemic activities where my feedback was asked re: my supervisors or upper management. Many are threatened. Understandable why that is. And, truth be told, I am not 100% sure I’d feel comfortable giving candid feedback, especially if I would be identified. I have limited trust in “this isn’t going to be held against you” prompting. At the same time, I am not a great believer in anonymity either – when it comes to talking about other people. This stuff is difficult and for it to work, it sure seems that a whole lotta work needs to be done to ensure more good than harm is accomplished.
I went head to head with my boss. Reported to human resources. Showed an employee satisfaction survey was valid. Thus, it had to be discussed in meetings. Did a peer review to challenge what I believed an unsafe training program via Safe Harbor. Two years after I left, I heard they were no longer in management. Tragic that I loved the job and had hoped to retire from there. I consulted many experts in nursing and regulatory. Nobody could help me. I wish I had known what emotional intelligence was back then.
Unfortunately, the onus is on the target to know how to survive work abuse, even though the target is often under considerable stress. The learning I did occurred after the abuse/damage. I spent years soaking in as much as I could in order to try to understand the ‘whys.’ What I learned helped me avoid a couple of situations that had the potential to not go well. I was able to help a friend too (who was a nurse in a very toxic situation). I don’t know how a person can truly prepare someone who has not experienced being a target and hasn’t had the desire to learn why. Prior to the abuse I experienced, I was clueless in how things actually worked. They don’t teach that stuff in college. Not sure “the system” is ready to be that honest/self-examining.
Reblogged this on Digital learning PD Dr Ann Lawless and commented:
health systems and bullying
Very interesting and encouraging that JCAHO and the AMA recognize workplace bullying
I am considered a threat at my employer as I do exceptional work. Yes, a threat for doing my job well I am an acct and they want someone who hates math and hates Excel to help me so she can feel better about HER life. Unreal.
I currently work in a mental health Clubhouse and the bullying of older staff by the director has been intense. I took the WBI (Workplace Bullying Institute) class to understand it better and to start to take action. I have seen it in multiple workplaces now.
Thank you for addressing bullying in healthcare. I was disappointed that you only mentioned the Joint Commission and the AMA in your remarks. Missing is any reference to nurses as the primary target of bullying. The American Nurses Association has taken a strong stance against bullying and their nursing standards address the requirement to treat all with dignity and respect. I hope that in the future you will include nurses in your remarks. Thank you.
Hi Susan, thank you for your comment. Although I did mention that nurses are bullying targets, I confess that because of the circumstances leading to the invitation and the likely audience at Grand Rounds, I emphasized the experiences of MDs and medical students.
Thank you for reminding me about the ANA statement. I’m also aware that ACHE and AHA have weighed in against bullying, though less directly (i.e., as a form of workplace violence). I should’ve mentioned all of these but was rushing to get something posted in the midst of a very busy time.
Thanks for your quick response, David. I’m glad you are doing the work you do. My doctoral research dealt with the abuse physicians direct to female and male RNs in the OR and if there is a difference based on the gender of the nurse. There is.