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Inside Medical Liability

First Quarter 2020



Recognizing and Addressing Workplace Bullying in Ambulatory Care

Despite the obligation of ambulatory care practices to provide a safe workplace environment, bullying is prevalent, endangering patient safety, increasing risk, and compromising the ability of healthcare workers to collaborate and deliver patient care.



Safety and security training often focus on steps healthcare workers can take to de-escalate situations in which patients are exhibiting anger or hostility. However, this training frequently fails to address the issue of workplace bullying.

Bullying behavior seems to be especially prevalent in the healthcare setting. In its 2019 report, Deep Dive: Safe Ambulatory Care, ECRI Institute PSO analyzed 208 reports of safety and security issues in the ambulatory care settings. Although only 8% (15) of these reported incidents involved disruptive or threatening staff, ECRI Institute has received enough anecdotal reports of bullying to know that it is likely an under-reported concern.

The Joint Commission defines workplace bullying as “repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators,” noting that “workplace incivility that is expressed as bullying behavior is at epidemic levels.”1

Bullying exerts a major toll on the health of ambulatory care workers and also has an impact on patient safety.While most bullying is never reported by the victims, incidents that are reported almost always remain unaddressed by the ambulatory care organization in which they occur.

Individuals with a history of disruptive behavior also pose a high risk of litigation—for example, a 2018 survey found that the highest odds of facing at least one malpractice claim were for surgeons who co-workers indicated “snap at others when frustrated” and “talk down to others.”2

To address this important workplace issue, ambulatory care organizations should undergo efforts to raise awareness about the negative impact of bullying and to stop such behaviors. These efforts may include engaging leadership, developing a code of conduct, implementing a zero-tolerance policy, encouraging staff to speak up, and watching out for microaggressions.

When ambulatory organizations make the elimination of bullying a major workplace priority, it can be recognized, reduced, and eventually eliminated. The result is a major reduction of risk, a safer patient care environment, and a more collaborative, pleasant workplace culture.

What is bullying?

Bullying may include verbal abuse; threatening, intimidating, or humiliating behaviors; and sabotage, according to the Workplace Bullying Institute. Verbal abuse includes microaggressions, which are subtle or nonverbal behaviors that arise from unconscious bias, stereotyping, covert prejudice, or hostility. Bullying behaviors can be nonverbal, and sabotage prevents work from getting done.

Bullying can occur when an imbalance in power exists between the perpetrator and the victim, such as when a physician bullies a nurse or resident. However, it can also occur when the bully and the victim are on the same level—this is known as lateral violence or horizontal hostility.

As a subset of workplace violence, bullying is not the same thing as creating a hostile work environment, and it does not include illegal harassment and discrimination. However, bullying does not facilitate setting a high work standard, sharing differences of opinion, or providing feedback.3

For workers, being the subject of bullying can create emotional anxiety and depression, which can lead to increased absenteeism, burnout, job dissatisfaction, low morale, and decreased productivity, all of which can compromise patient safety. Organizations also suffer consequences as a result of workplace violence, including liability risk, costs associated with hiring temporary staff and with supporting affected staff, potential staff turnover if safety concerns are not directly addressed, and reputational damage.

Impact of bullying in healthcare

Bullying in the workplace can have a devastating effect on healthcare workers and patients alike. Such behavior can result in more than hurt feelings: When a provider creates an environment in which others find it difficult to safely do their work, it must be treated as a critical patient safety issue.

One study found that 44% of nursing staff members reported being bullied by other staff members,4 and another found that 38% of U.S. healthcare workers feel psychologically harassed at work.5

In 2018, ECRI Institute asked a sample of its members to share just how prevalent bullying is in their workplaces. More than 90% of respondents said they had experienced bullying at work. Responses also revealed that all workers, regardless of title, can engage in disrespectful behavior.

Consider the following responses:

  • “Attending physicians have no restraint in screaming at residents and students in front of staff, patients, and visitors.”
  • “As a young nurse, I had no support from seasoned nurses.”
  • “I was bullied by a clinical instructor when I was a student. The university dismissed my complaints. She bullied students until she retired.”
  • “When I expressed my concerns about a rude doctor, our [chief executive officer] put his hand to my face, told me to ‘shut the [expletive] up,’ and told my staff to ‘quit their whining.’”7

Although workplace bullying is common in healthcare and presents a significant patient safety issue, it often goes unreported. When it is reported, the reaction is often indifference, as seen in the ECRI Institute study. When asked what happened after they reported the bullying, one answer turned up more often than any other: “Nothing.”

Mitigation strategies

Ambulatory care organizations have a duty to provide a safe work environment for employees and there are a number of strategies that can help organizations identify, address, and prevent workplace bullying.

Engage leadership—Leadership plays a vital role in eliminating bullying in the healthcare workplace. The Joint Commission recommends the following actions to consider:

  • Establishing a safety system and culture that does not tolerate bullying behavior, embedded in the core values of the organization n Addressing bullying behavior with the perpetrators and supporting people targeted by bullying
  • Educating all team members on appropriate professional behavior
  • Holding all team members accountable for bullying
  • Ensuring that policies address bullying, the response to bullying, and how and when discipline will be meted out.8

Develop a code of conduct—A code of conduct that includes definitions for “bullying” and “disruptive behavior” should be included in the medical staff bylaws, as well as in human resource policies. Definitions should clearly delineate what behavior is expected and what behavior is considered a hindrance to delivering high-quality care.

Copies of the organization's code of conduct and other policies should be given to each employee upon hiring as well as during each evaluation and reappointment, and all employees and credentialed practitioners should confirm in writing their understanding of the code of conduct.

Show zero tolerance for bullying—Adhering strictly to your organization’s code of conduct around bullying is the key to reducing and eliminating bullying. When top executives, leadership “favorites” and major revenue producers fail to be held accountable for bullying behavior, employees get the implicit message that bullying is tolerated and that stated policies are ineffective and unenforced. Consistent enforcement of policies over time demonstrates the organization’s support for such policies.

Facilitate reporting—In November 2018, ECRI Institute's clinical risk management program hosted a webinar with more than 400 participants. In real time, participants were asked why they would not report disruptive behavior. The most common answers, by an overwhelming majority, were “fear” and “retaliation.”9

The Joint Commission has also listed fear of retaliation as well as “stigma associated with ‘blowing the whistle’” as primary reasons someone might not report. Other reasons include a general reluctance to con-front an intimidator and a feeling that a revenue-generating physician might be "let off the hook" for his or her behavior.10 The fear of retaliation can be diminished by instituting a policy of zero tolerance for bullying, and by encouraging staff to speak up when they encounter bullying.

Break down group silence—Bullying is frequently the result of a larger group issue, and it often persists because even those who do not support it look the other way. Sometimes addressing the problem with those who passively support bullying, or ignore bullying when it occurs, is the key to stopping the bullying cycle. Staff should be educated on the importance of reporting incidents of workplace bullying and on the protection from retaliation offered to those who report a co-worker's bullying behavior.

Deter microaggressions—Microaggressions are often based on assumptions about a person’s race, ethnicity, gender, sexual orientation, or age. A recent study found that when watching video representations of microaggressions, female participants more frequently identified microaggressive behavior than male participants. The authors concluded, “Privilege is often invisible to those who have it, whereas bias and discrimination are readily apparent to those who experience it. Knowledge of common microaggressions will allow for targeted individual, interpersonal, and institutional solutions to mitigate disparities in medicine.”11

Race-based microaggressions, which are often connected to physiological distress, typically fall into one of the following themes:

  • Alien in one’s own land (i.e., may feel like perpetual foreigners)
  • Assumption of criminality
  • Second-class citizen
  • Ascription of inferior intelligence (e.g., are assumed to be less intellectual or uneducated)
  • Assumption of inferior social and/or wealth status
  • Colorblindness (e.g., when someone claims that they “don’t see race”)
  • Denial of racial reality (e.g., when someone defensively denies that they are engaged in racist behaviors).12

Leadership should evaluate the prevalence of microaggressive behavior in their organizations, provide education to all staff about recognizing and stopping microaggressive behavior, and engage in sup- portive and validating conversations with staff to help them process their experience with microaggressions and to determine which coping strategies are helpful to them.13

1. The Joint Commission. Bullying has no place in healthcare. Quick Safety, 24, June 2016. unorganized/imported-assets/tjc/system-folders/joint-commission- online/quick_safety_issue_24_june_2016pdf.pdf?db=web&hash= 84E4112AB428AD3CA1D5B9F868A1AD10.
2. J. Lagoo, et al. Multisource evaluation of surgeon behavior is associated with malpractice claims. Ann Surg, Mar 2019. https://www.ncbi.nlm.nih. gov/pubmed/29578910.
3. The Joint Commission. Bullying has no place in healthcare. Quick Safety, 24, June 2016. unorganized/imported-assets/tjc/system-folders/joint-commission-online/quick_ safety_issue_24_june_2016pdf.pdf?db=web&hash=84E4112AB428AD3CA1D5B 9F868A1AD10.
4. Judith E. Meissner. Nurses: Are we eating our young? Nursing 16:3, Mar 1986. our_young_.14.aspx.
5. AntonioAriza-Montes,etal.Workplacebullyingamonghealthcareworkers. Int J Env Res Pub Health 10:8, Aug. 2013. articles/PMC3774428.
6. ECRI Institute. PSO Deep Dive: Safe Ambulatory Care. Oct. 14, 2019.
7. ECRI Institute. PSO Deep Dive: Safe Ambulatory Care. Oct. 14, 2019.
8. The Joint Commission. Bullying has no place in healthcare. Quick Safety, 24, June 2016. unorganized/imported-assets/tjc/system-folders/joint-commission-online/quick_ safety_issue_24_june_2016pdf.pdf?db=web&hash=84E4112AB428AD3CA1D5B 9F868A1AD10.
9. ECRI Institute. Healthcare risk control: Executive summary. June 4, 2019. behavior.pdf.
10. The Joint Commission. Sentinel event alert 40: Behaviors that undermine a culture of safety. July 9, 2008. ments/resources/patient-safety-topics/sentinel-event/sea_40.pdf
11. Vyjyeyanthi S. Periyakoli, et al. Common types of gender-based microaggres- sions in medicine. Ac Med, Oct. 19, 2019. cine/Abstract/publishahead/Common_Types_of_Gender_Based_Microaggressio ns_in.97398.aspx.
12. DeraldW.Sue,etal.Racialmicroaggressionsineverydaylife:Implicationsfor clinical practice. Am Psych, May-June 2007. 07130-001.
13. D. Sanchez, et al. Racial-ethnic microaggressions, coping strategies and mental health in Asian American and Latinx college students: A mediation model. J Couns Psych 65:2, March 2018.

Jacqueline M.
Ferenschak, MA,

is a Risk Management Analyst at ECRI Institute.

Deborah E.
Ballantyne, JD,

is a Legal Editor at ECRI Institute.

Mark Macyk
is a Risk Management Analyst at ECRI Institute.