Sorry about that. I am a member to this site, didn't realize. Long article, but here you go!
Publication: ADVANCE for Nurses Online
Issue Date: 12/9/2002
Search String: mutual respect
Vol. 4 *Issue 25 * Page 33
By Jane L. Willig
In a survey of 1,200 nurses, physicians and hospital administrators at 84 hospitals, published recently in the American Journal of Nursing, 30.7 percent of all respondents knew of nurses who had left a hospital as a result of a physician's disruptive behavior.
"I know of some who left because of poor treatment from peers and physicians," reported Mary Ann Whitcomb, RN, CNOR, clinical educator at an Atlanta-area hospital. "It's a tough thing to have to face put-downs when you are trying your best to follow policy and guidelines. Most physicians do a fine job and have great manners, but those few who make our lives miserable? There's no need for it."
Although less than 5 percent of physicians were reported to demonstrate disruptive behavior, all respondents agreed that it influences nurses' and other staff members' attitudes toward patient care and inhibits teamwork, affecting the efficiency, accuracy, safety and outcomes of care. The impact was enough to cause nurses to leave their hospital positions for this reason. Survey respondents said, on average, 2.4 nurses left their facility each year as a result of disruptive behavior. Such behavior also caused nurses to make other changes - such as switching shifts, revising schedules or changing departments - to avoid confrontation.
Designed to assess the views of nurses, physicians, and hospital executives, the AJN survey "examined nurse-physician relationships, disruptive physician behavior, institutional responses to such behavior, and its impact on nurses' job satisfaction, morale and retention." "Disruptive physician behavior" was defined in the study as "any inappropriate behavior, confrontation or conflict, ranging from verbal abuse to physical and sexual harassment."
Instances reported include yelling, cursing, abusive language, throwing a chart, pouting, sarcasm, racist remarks, crude gestures, harsh looks, nasty put-downs, public berating, abruptly hanging up a phone call, an accumulation of insults, and general condescension and disrespect. These behaviors generally result in humiliation and erosion of an individual's self-worth and dignity, and are sometimes called intraprofessional abuse or horizontal abuse.
Although almost all respondents reported disruptive behavior in their institutions, respondents viewed this behavior and its consequences differently. Generally, physicians rated the nurse/physician relationship more positively than did nurses and executives, and nurses rated physician awareness of the importance of that relationship much lower than did physicians and executives.
Nurses were more likely than physicians to believe that doctors do not value their input and collaboration as much as they should. Nurses were also more likely than doctors and executives to feel that nurses do not have enough administrative support to deal with conflicts with physicians.
About 92.5 percent of all respondents had witnessed disruptive behavior by a physician, but doctors were significantly less likely than nurses and executives to believe that such incidents have an important influence on nurses' morale. All respondents, however, saw a direct link between disruptive physician behavior and nurse satisfaction and retention.
Some hospitals have put "zero abuse tolerance" policies into effect as this problem has come to light, and as a result, have seen nurse dissatisfaction and turnover rates drop, as well as medical complications. A code-of-conduct policy for handling disputes is one solution; 65.4 percent of survey respondents said their institutions had such a policy.
At the Moses Cone Healthcare System in Greensboro, NC, the problem has been addressed by a formal policy and procedure process. According to Susan Hamilton, MSN, RN, director of nursing, this is a process for complaints of disruptive behavior and conflict between staff members. Instances may range from abusive language to angry confrontations.
Paperwork is filed outlining the grievances and the matter is forwarded for peer review. All parties receive counseling by a peer member.
"We see this as a tool," Hamilton stated. "Everything is done in a professional and confidential manner. It has to work from the top down, and our administration is supportive. We have seen positive results, but it will take some time for everyone to feel comfortable with the system."
On the other hand, the AJN survey reports that fewer than 50 percent of respondents whose organizations used a code-of-conduct policy felt that it was effective, commenting that the policy was not enforced, the staff was unaware of it, or outcomes were not reported. Few were satisfied with the results of physician counseling.
Barriers to Reporting
Nearly 50 percent of the survey respondents mentioned barriers or resistance to the reporting of abusive behavior. The most common barriers mentioned were fear of retribution, intimidation, lack of confidentiality, the belief that "nothing ever changes," peer pressure, potential legal ramifications and lack of administrative support. Disruptive behavior often leads to confrontation and unease, and it can cause widespread frustration among staff members who question why their facility tolerates such behavior. The report states that institutions that develop, implement and enforce appropriate policies must be aware of such barriers to effective communication, remove them and provide feedback on the outcomes of reporting.
Whitcomb reported an incident in which a neurosurgeon chose to work with extremely loud music in the operating room. Not only could Whitcomb not hear his instructions, she had to step out of the room to answer his pager, which was from a nurse who was caring for another of his patients. When she did this, the physician screamed and cursed at her, causing many staff members to run to the scene. The anesthesiologist suggested she report the incident, and she followed procedures to do so. However, the physician received no discipline from his peers, and she was advised not to take the matter further because she would get no support from the medical staff.
"It was as if I didn't count, while everything he did, without question, was correct," she said. "Physicians must take seriously what we report about their peers, discipline their peers, refuse to make referrals, and say, 'Stop-that's not acceptable here.' If they could just do that, things would be better." Whitcomb's solution to the problem would be zero tolerance for continued disruptive behavior with a loss of privileges for a certain number of days. "[Then] maybe, just maybe, we may see a change for the better."
A survey published in the August 2001 issue of Clinical Issues, a journal of the American Association of Critical-Care Nurses, states that almost 50 percent of nurses who experienced verbal abuse were reluctant to seek help because of concern about their jobs, and more than 40 percent felt that the reporting process was not confidential. If disruptive behavior is discussed in secret, the article states, abusive situations cannot be improved. The behavior and its negative impact must be acknowledged by all involved.
What Can Be Done?
Respondents to the AJN survey offered many suggestions for improving abusive situations. They include:
* Create more opportunities for collaboration and communication through open forums, group discussions and workshops.
* Increase availability of training and educational programs for nurses and physicians that focus on improving teamwork and working relationships (sensitivity training, assertiveness training, conflict management, collaboration skills, stress management, time management and phone etiquette, with emphasis on courtesy, respect, promptness and preparation).
* Improve organizational processes by requiring administrators to take a more proactive approach to avoiding potential confrontations related to staffing, scheduling and equipment.
* Establish a zero-tolerance policy for disruptive behavior, holding nurses and physicians more accountable for their actions.
* Disseminate code-of-conduct policies and reporting guidelines to both nurses and physicians, and apply policies consistently and quickly, providing feedback to all involved.
* Ensure appropriate nurse competencies.
* Have physicians sign a code-of-conduct policy when they are credentialed or recredentialed.
* Appoint a physician leader who will take charge of training and educational programs.
* Provide an ongoing forum to increase physician awareness of disruptive behavior issues and raise awareness of other factors that increase nurses' stress levels.
* Place physicians on nurse recruitment teams, enabling them to gain a better understanding and appreciation of the factors that are important to nurses as they consider employment opportunities.
* Provide a case study or conduct role-play exercises that give physicians a firsthand understanding of nurses' responsibilities and workflow.
Respondents also emphasized the need to emphasize the connection between communication, collaboration and teamwork, and improved quality, safety and patient outcomes, since nurses are concerned that patients may be receiving a lower quality of care. Other studies have shown a link between team collaboration and patient safety, error rates, and patient outcomes.
Important Stress Factor
Working daily in a profession that is largely focused toward others, nurses may routinely experience unpleasantness and unfairness and become insensitized to it, eventually coming to accept some behaviors that could be termed abusive. Even if they do recognize abuse in some situations, nurses may often feel powerless and helpless to change the situation, turning their frustrations inward as self-criticism, or outward as actions toward innocent patients and co-workers.
In any case, mistreatment and abuse can be destructive to all involved-the frustrated abuser, the hesitant victim and the blameless patient. It defeats teamwork and robs the staff of precious time and energy that may better be used to care for the needs of patients who depend on these professionals for their welfare.
Disruptive behavior by physicians is only one cause of burnout and stress in the nursing profession. Nurses have many causes for stress-heavier patient loads, more overtime, cutbacks, concerns for their safety and job security-all of which must be dealt with. Although the United States is in the midst of nursing shortage, some physicians apparently are not aware that their own behavior may be driving some nurses from the field. As the AJN survey reports, losing nurses one by one due to lack of respect can profoundly affect a hospital's ability to operate and can add to the already high costs of recruitment and retention.
Barnsteiner, J.H., Madigan, C., & Spray, T.L. (2001). Instituting a disruptive-conduct policy for medical staff. Clinical Issues, 12(3), 378-382.
Rosenstein, A.H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102(6), 26-34.
Jane L. Willig is a freelance writer for ADVANCE.
ADVANCE for Nurses Online 12/9/2002