acute care hospital

ullying, incivility, intimidation, and other forms of disrespectful behavior have run rampant in healthcare, allowed to exist while

many remain silent or make excuses— “That’s just the way he/she is”—in an attempt to minimize the profound deva- station disrespectful behavior can cause. “Disrespectful behavior” encompasses a broad array of conduct, from aggressive outbursts to subtle patterns of disruptive behavior so embedded in our culture that they seem normal (Table 1, page 2).1,2 Disrespectful behavior causes the recipient to experience fear, vulnerabili- ty, anger, anxiety, humiliation, confusion, job dissatisfaction, professional burnout, uncertainty, isolation, self-doubt, depression, and a whole host of physical ailments such as insomnia, fatigue, nau- sea, and hypertension.1-8 The presence of disrespectful behaviors erodes profes- sional communication and collabora- tion, which is essential to patient safety and quality, and creates an unhealthy or even hostile work environment.4

Prevalence and link to safety In 2003, ISMP conducted a national survey of nurses, pharmacists, physi- cians, and other health professionals re- garding intimidation in the workplace. Results showed that disruptive (disre- spectful) behaviors were not isolated events, they were not limited to just a few difficult practitioners, they involved both lateral (peer-to-peer) and intradis- ciplinary staff (and not just physicians), and they involved both genders equally.9 Back then, 88% of respondents reported that, in the year prior to the survey, they encountered condescending language or voice intonation; 87% encountered impatience with questions; and 79% encountered a reluctance or refusal to answer questions or phone calls. Almost half of the respondents reported more explicit forms of intimidation, such as being subjected to strong verbal abuse

(48%) or threatening body language (43%). Incredibly, 4% even reported physical abuse.

Almost everyone who works in health- care has a story to tell about disrespect- ful behavior. Unfortunately, patients have paid a high price–even with their lives–for our inability to be respectful to each other, as there is a clear link to ad- verse patient outcomes and disrespect- ful behaviors. Almost half of our 2003 survey respondents told us their past ex- periences with disrespectful behavior had altered the way they handled order clarifications or questions about medi- cation orders.9 At least once during the prior year, about 40% of respondents who had concerns about a medication order assumed it was correct or asked another professional to talk to the pre- scriber, rather than interact with the in- timidating prescriber. Almost half felt pressure to accept the order, dispense a product, or administer a medication despite their concerns. As a result, 7% of respondents reported they had been in- volved in a medication error during the prior year in which intimidation clearly played a role.

In 2008, a survey of more than 4,500 nurses, physicians, and other healthcare professionals from 102 hospitals was conducted to assess the significance of disrespectful behavior and its impact on patient safety.5 More than two-thirds (70%) reported a link between these behaviors, medical errors, and poor qual- ity patient care; more than 65% linked the behaviors to an adverse event; more than 50% reported patient safety had been compromised; and more than 25% linked the behavior to patient mortality!

In 2009, the American College of Physi- cian Executives conducted a survey of more than 2,100 physicians and nurses

continued on page 2—Disrespectful

NurseAdvise-ERR Medication Safety Alert!

Educating the healthcare community about safe medication practices July 2013 Volume 11 Issue 7

â

â A federally certified

Patient Safety Organization

Disrespectful behavior in healthcare... Have we made any progress in the last decade?

National Alert Network (NAN ALERT). ISMP and the American

Society of Health-System Pharmacists (ASHP), in cooperation with the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), distributed an alert in June about an important labeling change for heparin products. The alert (www.ismp.org/NAN/ default.asp) was sent via the National Alert Network (NAN). As of May 1, 2013, labeling of heparin vials must express the total amount of units in the container as well as the units per mL, rather than just the units per mL as formerly required. We are very much in support of this move as it will help to eliminate con- fusion about how much heparin is in each container. All too often, the per mL quantity has been misinterpreted as the amount per container, which has led to overdoses, including fatalities. Earlier in June, we learned of a fatal heparin error for this very reason. There will be a peri- od of transition during which vials with the old label and vials with the new label will both be available. To minimize the risk of confusion, hospitals should con- sider transitioning fully to the newly labeled heparin, even if it means discard- ing some older vials. (Don’t forget vials stored in less obvious places.) Otherwise, separate heparin vials with the old label- ing from those with the new labeling,

safetywires

continued on page 2—safetywires

In addition to a full array of medication safety consulting activities, ISMP offers a 1-day, onsite, customized risk assess- ment that can help your organization quickly address specific medication safety challenges. It’s cost effective; it’s time effective; and you will receive input from some of the nation’s leading safety experts. Check out our Medication Safety Checkup at: www.ismp.org/ Consult/oneDayRiskAssessment.pdf.

Medication Safety Checkup...

Supported by educational grants from Baxter and BD

Page 2 July 2013 Volume 11 Issue 7

NurseAdvise-ERR

that showed a fundamental lack of re- spect between the groups.6 Nearly 85% of the participants indicated that de- grading comments and insults were the most common form of disrespectful be- havior, followed by yelling (73%), curs- ing (49%), and inappropriate joking (46%). “The worst behavior problem is not the most egregious,” added one par- ticipant. “It’s the everyday lack of re- spect and communication that most ad- versely affects patient care and staff morale.”6(p.6) In this study, respondents also reported that disrespectful behavior led to patient harm. For example, a nurse called a patient’s physician several times to ask him to come into the inten- sive care unit (ICU) to see a patient whose condition was declining. Each time, the physician became verbally ab- usive and refused to come in to the hos-

pital. After two attempts, the nurse hes- itated to call again. By the time she called, the patient was hemorrhaging internally, was rushed to the operating room, and then died.

In the same year, the Pennsylvania Pat- ient Safety Authority reported receiving 177 error reports that detailed disre- spectful behaviors, many of which neg- atively affected patient care, during a 2- year period.7 In one case, a physician refused to wait 30 minutes (as required for effectiveness) after applying a topi- cal anesthetic to a newborn’s penis be- fore performing a circumcision, despite ongoing protests by staff. In numerous other cases, prescribers had hung up the phone when they were called with a critical laboratory result or when asked to clarify medication orders.

Disrespectful continued from page 1

â

Take our survey on disrespectful behavior on page 4 (www.surveymonkey.com/s/disrespect)

Table 1. Scope of Disrespectful Behavior

Behavior Category Description Examples Disruptive Behavior Egregious conduct clearly evi-

dent in the behavior and/or speech

Angry outbursts Verbal threats Swearing Throwing objects Bullying Threat/infliction of physical force

Demeaning Treatment Patterns of debasing behav- iors that exploit the weakness of another

Shaming, humiliation Demeaning comments Ignoring behavior Constant distorted or misrepresented

nitpicking/faultfinding Passive-Aggressive Behavior

Negativistic attitudes and passive resistance to demands for adequate performance

Unreasonably critical of authority Negative comments about colleagues Refusal to do tasks Deliberate delay in responding to calls Go out of the way to make others look

bad while acting innocent Undermine another’s status or value

Passive Disrespect Uncooperative behaviors that are not malevolent

Chronic lateness to meeting/rounds Sluggish response to requests Resistance to follow safety practices Non-participative in improvement

efforts

Dismissive Treatment Behavior that makes patients or staff feel unimportant and uninformed

Condescending comments Patronizing comments/attitude Resistance to working collaboratively Constant refusal to value, acknowledge,

praise the contributions of others Exclusionary and over-ruling behavior

Systemic Disrespect Disruptive behaviors so en- trenched in the culture that the element of disrespect may be overlooked

Making patients/staff wait for services Requiring long work hours Excessive workloads

Adapted from: Leape LL, et al.1

continued on page 3—Disrespectful

and use all vials with the old labeling first before dispensing vials with the new lab- eling. As space permits, pharmacy and nursing databases should express drug amounts the same way as the vial label (i.e., 10,000 units/10 mL [1,000 units/mL]).

Another heparin label issue? Unfortunately, with the new

heparin label as described in the NAN Alert above, another issue has come to light. The US Pharmacopeial Convention (USP) also requires companies to express the concentration in terms of “USP Heparin Units.” Figure 1 shows how the words “USP Heparin Units” forces the volume statement “/10 mL” to the far right of the drug description. A reader recently wrote to complain about this Hospira product after finding the vial in a storage bin that was always used for heparin 1,000 units per mL. Although this was correctly stored, she

thought they had stocked the vial incorrectly because the first thing her eyes saw on the label was 10,000 units. The 1,000 units per mL is in much smaller and unbolded text. She showed the vial to other pharmacy tech- nicians, pharma-

cists, and nurses, and they all thought the vial contained 10,000 units/mL. The “USP Heparin Units” text seems extra- neous to us, and we fear it could lead to medication errors. Given the circum- ference of the vial, just a slight turn of the vial to the right might confuse some- one into believing that 10,000 units are in 1 mL, leading to subtherapeutic doses. We have called this to the atten- tion of Hospira and USP in the hope that the new label will be further improved by dropping this wording, USP Heparin Units, in favor of just units, or at least rearranging the label text.

safetywires cont’d from page 1

continued on page 3—safetywires

Figure 1. It would be easy to miss “/10 mL” with a slight turn of the vial label to the right.

Page 3 July 2013 Volume 11 Issue 7

NurseAdvise-ERR

ISMP continues to receive reports of adverse events related to disrespectful behaviors. A recent case involved a can- cer patient who sustained serious tissue injury and thrombophlebitis after recei- ving IV promethazine via a peripheral vein in the hand. Several years before the event, the Pharmacy and Thera- peutics Committee attempted to re- move promethazine from the formulary. However, given his status and loud in- sistence, this surgeon “overruled” the action to remove the drug. At the time of the event, he was the only physician still prescribing promethazine.

Why the behaviors persist Sadly, healthcare has a history of toler- ance and indifference to disrespectful behavior. These behaviors are clearly learned, tolerated, and reinforced in both the healthcare culture and the soc- ietal culture, where a certain degree of disrespect is considered a normal style of communication, particularly given the increasing opportunity for “aggres- sive crudity” that has taken hold in the social media.1 Nevertheless, the stress- ful healthcare environment, in the pres- ence of productivity demands, cost con- tainment, and embedded hierarchies that nurture a sense of status and auto- nomy, have likely been the most influ- ential factors,1-4 along with an unfortu- nate progression of victims who, in turn, become perpetrators, feeling they have no choice but to join in the practice. Thus, disrespectful behavior has be- come a survival strategy for some—they have to be aggressive enough to discour- age anyone from coming after them.3

Organizational leaders may fail to ad- dress disrespectful behaviors for many reasons. Some individuals who engage in disrespectful behaviors may be pow- erful in the organization,7 which may discourage reporting of the behavior due to fear of retaliation and a general reluctance to confront the individual.4 Organizations may also be wary of offending high-revenue producers.

Where we are today In our 2004 ISMP Medication Safety Self Assessment for Hospitals, just 34% of

participating hospitals felt hospital lead- ers dealt effectively with disrespectful behaviors; another 22% suggested no action had been taken to lessen this behavior. Perhaps spurred by a 2009 leadership standard from The Joint Commission (TJC) requiring hospitals to manage disruptive behaviors,4 im- provement was seen in our most recent 2011 Assessment, with 48% of hospi- tals fully addressing disrespectful be- haviors. However, still more than half of the hospitals dealt with the behaviors inconsistently (43%) or not at all (9%).

ISMP would like to measure the progress (or lack thereof) during the past decade via a readership survey on managing disrespectful behaviors, which is very similar to the survey we conducted 10 years ago. We strongly encourage nurses, pharmacists, physi- cians, and other healthcare profession- als to participate in the survey that appears on page 4 and at: www.survey- monkey.com/s/disrespect. Responses must be submitted by August 30, 2013. We will present the results in a future newsletter along with suggestions for managing disrespectful behaviors.

References 1) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012; 87(7):845-52. 2)Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-8. 3) Johnston J. Those who can, do. Those who can’t, bully. Health and Safety for Beginners. 2004. www.ismp.org/sc?id=200 4) The Joint Commission. Behaviors that undermine a culture of safety. Sent Event Alert. Jul 9, 2008;40:1-5. 5) 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(8):464-71. 6) Johnson C. Bad blood: doctor-nurse behavior prob- lems impact patient care. Phys Exec. 2009; 35(6): 6-11. 7)Pennsylvania Patient Safety Authority. Chain of com- mand: when disruptive behavior affects communication and teamwork. PA Patient Saf Advis. 2010;7(Suppl 2): 4-13. 8) O’Daniel M, Rosenstein AH. Professional commu- nication and team collaboration. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Rockville (MD): Agency for Healthcare Re- search and Quality; 2008 Apr. Chapter 33:1-14. 9) ISMP. Intimidation: practitioners speak up about this unresolved problem-part 1. ISMP Medication Safety Alert! 2004;9(5):1-3.

Disrespectful continued from page 2

â

Take our survey on disrespectful behavior on page 4 (www.surveymonkey.com/s/disrespect)

Don’t forget to filter Cathflo Activase. CATHFLO ACTIVASE

(alteplase) is available again, but the US Food and Drug Administration (FDA) asked us to remind healthcare practitioners that the final reconsti- tuted solution must be filtered with a 5-micron filter needle upon with- drawal from the container. This is necessary to remove potential rubber stopper particulates found in some vials after reconstitution. A letter was sent out earlier this year by the prod- uct manufacturer, Genentech, and is available for your review at: www.ismp.org/sc?id=199.

safetywires cont’d from page 2

Special Announcements

ISMP Cheers Awards! Nominations for this year’s Cheers Awardswill be accepted through September 14, 2013. The prestigious Cheers Awards honor individuals, organi- zations, companies, and agencies that have set a standard of excellence in preventing medication errors during the previous year. For information or to submit a nomination, please visit: www.ismp.org/Cheers.

ISMP webinar. Join us July 18 for Measuring Medica- tion Safety: Using the Right Data for the Best Results. This webinar will look at ways to measure medication safety, identify problems, and determine if improvement efforts have been successful. For details, go to: www.ismp.org/educational/webinars.asp.

ISMP Medication Safety Alert! Nurse Advise- ERR (ISSN 1550-6304) ©2013 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal newsletters or communications. Other reproduction is prohibited without writ- ten permission. Unless noted, published errors were received through the ISMP National Medication Errors Reporting Program (ISMP MERP). Editors:Ann Shastay, RN, MSN, AOCN; Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044-2321. Tel.: 215-947-7797; Fax: 215-914-1492; EMAIL: [email protected]. Report medication errors to ISMP by going to: www.ismp.org/MERP.

Page 4 July 2013 Volume 11 Issue 7

NurseAdvise-ERRâ

Please take a few minutes to tell us about your experiences with disrespectful behavior in your workplace. For the purposes of this survey, disrespectful behav- iors are defined as: any overt or covert interaction (or lack of interaction) between healthcare professionals that may result in either an intended or unintended reluctance to speak up about concerns, question patient care, or share an opinion on a subject. Examples can be found in Table 1 in the July 2013 article on the subject. Please submit your responses to ISMP by August 30, 2013, by visiting: www.surveymonkey.com/s/disrespect.

Please tell us how frequently in the past year you’ve encountered disrespectful behaviors. In the last three columns, please select the three most frequent behaviors encountered in the past year.

Key: Often = more than 10 times this year; Sometimes = 3-10 times this year; Rarely = 1-2 times this year; Never = no occurrences.

1

ISMP Survey on Disrespectful Behavior in Healthcare

Disrespectful Behaviors By Physicians/Prescribers By Others

(e.g., pharmacist, nurse, supervisor) Three Most

Frequent Behaviors Often Sometimes Rarely Never Often Sometimes Rarely Never #1 #2 #3

a. Reluctance/refusal to answer questions, return calls

b. Impatience with questions, hanging up the phone

c. Yelling, cursing, outbursts, verbal threats

d. Report you to your manager (actual or threat)

e. Physical abuse/assault

f. Condescending or demeaning comments, insults

g. Constant nitpicking/faultfinding

h. Inappropriate joking

i. Shaming, humiliation, or spreading malicious rumors

j. Throwing objects

k. Insulted/slighted due to race/religion/gender/appearance

l. Negative comments about colleagues/leaders

m. Reluctance to follow safety practices/work collaboratively

n. Other: (describe)

If you answered “Sometimes” or “Often” to any item in Question 1, how many different individuals committed the disrespectful behaviors? 1-2 3-5 More than 5

Please tell us how frequently in the past year you’ve experienced the following potential effects of disrespectful behavior. Key: Often = more than 10 times this year; Sometimes = 3-10 times this year; Rarely = 1-2 times this year; Never = no occurrences.

2

3

Potential Effects of Disrespectful Behavior Often Sometimes Rarely Never a. Despite concern (even vague), I’ve assumed that a medication order is safe rather than interact with a particular prescriber.

b. Despite concern (even vague), I’ve assumed that a medication order is safe because of the stellar reputation of the prescriber.

c. I’ve asked colleagues to help interpret an order or validate its safety so that I did not have to interact with a particular prescriber.

d. I’ve asked another professional to talk to a particularly disrespectful prescriber about the safety of an order.

e. I’ve asked/suggested/allowed a physician to give a medication himself despite concerns (even if vague) about its safety.

f I’ve felt pressured to accept an order, dispense a product, or administer a drug despite concerns (even vague) about its safety.

Please respond “Yes” or “No” (or “Don’t Know”) to the following statements related to disrespectful behavior in the workplace.4

Please select the categories that best describes you. a. Practitioner type: Physician Pharmacist Pharmacy Technician Registered Nurse Practical Nurse Quality/Risk Other b. Position type: Staff Level Manager/Director Administration Attending Resident/Fellow Student Other c. Total years of experience: Less than 2 years 2-5 years 6-10 years More than 10 years d. Gender: Female Male

5

Statements Yes No Don’t Know a. Past experiences with disrespectful behavior have altered the way I handle order clarification or questions about medication orders.

b. My organization has clearly defined an effective process for handling disagreements with the safety of an order.

c. The process for handling clinical disagreements allows me to bypass a typical chain of command.

d. My organization has held educational programs in the past year to help address and reduce disrespectful behaviors.

e. My organization deals effectively with disrespectful behavior.

f. My organization/manager would support me if I reported disrespectful behavior by another professional. g. I am aware of a medication error in the past year where disrespectful behavior played a role (briefly describe).