Articles: Medical Errors

How Harshness Harms Patients

by Patricia Iyer

(print version [pdf])

Modified from Patricia Iyer, “Roots of Patient Injury”, Iyer and Levin (Editors) Nursing Malpractice, 3rd edition, 2007.

The physician who screams at the nurses’ station may soon be exhibiting a behavior of the past. Increasingly, healthcare facilities and staff are identifying the negative impact of disruptive or abusive behavior on communication, patient safety, employee morale, and turnover. Incidents of verbal abuse of nurses, typically by physicians, are unfortunately well known. According to a VHA (Volunteer Hospitals of America) survey, an estimated 2-3% of physicians behaved badly toward their nurse colleagues. Specific triggers often precipitated abuse, such as:

• nurses calling the physician during evenings or weekends to question or clarify orders
• orders carried out incorrectly or in an untimely manner
• unexpected delays in care
• difficulties with procedures or process flow, and
• changes in patient condition. 1

A study of 50 VHA hospitals culminating in data from more than 1,500 participants, primarily registered nurses or physicians, yielded these conclusions:

• There were 965 respondents to the question “Have you ever witnessed disruptive behavior from a physician at your hospital?” Nearly three quarters said “Yes."
• There were 960 respondents who answered the question “Have you ever witnessed
disruptive behavior from a nurse at your hospital?” Sixty eight percent said “Yes.”
• The majority believed that male physicians were more disruptive than females.
• Overall, between 73 – 95% of the respondents stated that disruptive behavior sometimes, frequently, or constantly resulted in:
   • stress
   • frustration
   • loss of concentration
   • reduced team collaboration
   • reduced information transfer
   • reduced communication
   • impaired nurse-physician relationship
• Effects of disruptive behavior on the patient included
   • adverse events
   • errors
   • (impaired) patient safety
   • (reduced) quality of care
   • patient mortality
    • (decreased) patient satisfaction. 2

A study of 2,095 healthcare providers revealed that intimidating behaviors are far from isolated events. In one year, 88% had encountered condescending language or voice intonation; 87% encountered impatience with questions, and 79% encountered reluctance or refusal to answer questions or return phone calls. Sixty nine percent reported that physicians/prescribers had often (12%) or at some time during the past year (57%) stated: “Just give what I ordered.” Consequently, 49% of the respondents said that intimidation had altered the way they handled order clarification or questions about medication orders. At least once during the past year, about 40% of the respondents who had concerns about a medication order assumed it was correct, or asked another professional to talk to the prescriber, rather than interact with the intimidating prescriber. Another large group of respondents (75%) sought the help of colleagues to help interpret an order rather than contact the prescriber. Seven percent of the respondents had been involved in a medication error in which intimidation clearly played a role. 3

As the above results confirm, some nurses avoid contacting a physician when they are intimidated by the abusive behavior they anticipate will occur. Patient safety is compromised.

In Anonymous Parents and Deceased Five-year-Old Girl v. Anonymous Obstetrician and Anonymous Hospital, the plaintiffs alleged their infant developed cerebral palsy after a difficult labor and delivery. Deposition testimony of the labor and delivery nurses indicated they were concerned about the lack of progress of the mother’s labor, but they were reluctant to voice those concerns to the obstetrician because of the doctor’s well-known tendency to respond negatively to such nursing input. This North Carolina case settled for $1.2 million. 4

The importance of a multidisciplinary approach to patient care is gaining greater recognition. Fostering a systematic and coordinated approach to patient care

• failure to identify an established protocol for patient care or even to develop a treatment plan,
• failure to advocate and assert an alternative plan or corrective course of action when a question arises about the patient’s care,
• failure to prioritize caregiver tasks for the patient,
and
• failure to cross-monitor actions of other team members. 6

The influx of Masters’ prepared nurse practitioners and clinical specialists may disturb the traditional hierarchy of the authoritarian physician. Generally confident and assertive, these nurses are less likely to accept abuse. In one setting, a cardiothoracic surgeon was well-known for his pattern of screaming at nurses as soon as he came on the nursing unit. The staff learned to scatter and hide when they saw him coming. Shortly after a Masters-prepared clinical specialist began work, she encountered the screaming surgeon for the first time. She stopped his screaming by saying, “Excuse me, you must have me confused with someone who will take this abuse.” The surgeon quickly learned to change his communication pattern. He claimed no one had paid attention to him before unless he screamed. 7 As collegial working relationships become more of the norm, such abusive behavior will subside, with a concomitant increase in communication and patient safety.

References
1. Joint Commission on Accreditation of Healthcare Organizations, Health Care at the Crossroads, www.jcaho.org, last accessed 12/10/05.
2. Intimidation: practitioners speak up about this unresolved problem, www.ismp.org, last accessed 9/18/07
3. Rosenstein, A and O’Daniel, M. “Disruptive behavior and clinical outcomes: perceptions of nurses and physicians”, AJN, 105: 1, pgs. 54-63, January 2005.
4. Laska, L. (Editor) “Hypoxic brain damage to infant”, Medical Malpractice Verdicts, Settlements, and Experts, pg. 34 March 2003.
5. Mason, D. “Safe practices and quality health care”, presentation at 3rd Annual Patient Safety Conference: University of Pennsylvania, December 1, 2005.
6. Barrett, J, Gifford, C., Morey, J, Risser, D., and Salisbury, M., “Enhancing patient safety through teamwork training”, Journal of Healthcare Risk Management, pgs. 57-65, Fall, 2001.
7. Crow, G., “Gerontological nursing: looking toward the horizon”, presentation at National
Gerontological Nursing Association, October 21, 2005.

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