RCMA News & Information | Workplace Bullying and Its Effect on Patient Safety and Liability Risk Exposure (2024)

Workplace Bullying and Its Effect on Patient Safety and Liability Risk Exposure

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Introduction

Bullying can decrease patient safety and increase liability risk. The stress, anger and frustration resulting from even mild incivility can interfere with working memory, which, in turn, adversely affects cognitive functions necessary for medical decision-making and procedural performance.¹ Bullying undermines coordination, collaboration, teamwork, and communication, which are also essential to delivering safe patient care.^1,2

Bullying not only can increase patient injuries2 (which increase the chance of being sued), but it can complicate the defense of a malpractice claim. When a plaintiff files a lawsuit, he or she generally names everyone on the patient’s healthcare team as defendants. Consequently, while the bullies, victims, and witnesses find themselves with the common goal of defeating the patient’s negligence allegations; victims and bullies tend to blame each other for the patient’s injury. This kind of “finger-pointing” diminishes the probability of a defense verdict and increases potential plaintiff’s verdict and settlement values.

Physician-nurse incivility is well documented in medical journals and the popular media. It is also apparent in many closed claims. In the following case, the nurses and physicians seemed more focused on antagonizing each other than they were on safely delivering the patient’s baby.

Case Study

Allegation: Physician-nurse conflict prolonged labor, which resulted in the infant’s brain injuries.

At the beginning of a labor and delivery (L&D) nurse’s shift, a high-risk prima gravida patient was admitted because her membranes spontaneously ruptured at home. She was at full-term, but not in active labor. The patient’s obstetrician (OB) ordered oxytocin. The L&D nurse believed the patient needed a C-section, not augmentation; therefore, she delayed starting the oxytocin and did not increase it as ordered. Her plan was to get the OB into the hospital to examine the patient, so that she would realize herself that the patient needed a C-section. Throughout the nurse’s shift, she called the OB, who continued to refuse to come in until the patient was in active labor. After the patient developed a fever, and the OB still refused to come in, the nurse instituted the chain of command all the way up to the chief of OB surgery. At each level she was told to follow the OB’s orders. At the end of the nurse’s shift, the OB examined the patient and found the fetal heartrate patterns reassuring and the fever appropriately addressed by the antibiotics she ordered. The OB reprimanded the nurse in front of the family for not having the oxytocin at the level she ordered and blamed her for the lack of progress. The OB then left to see other patients, and the nurse went off shift. Within the next hour, the patient was complaining of chest pain and shortness of breath. The next L&D nurse on duty called the OB stating she was concerned with the well-being of the mother and fetus. Shortly thereafter, the OB delivered a blue, hypotonic infant via C-section. Cord blood gases indicated the infant was severely acidotic. He survived, but with significant brain injuries.

The child’s parents filed a malpractice lawsuit against the OB, nurses, and hospital, alleging the delay in performing the C-section caused the infant’s brain injuries. The OB’s privileges were also suspended because the medical executive committee (MEC) determined the OB’s failure to respond to nurse requests to examine patients was causing patient injuries.

Discussion

The standoff between the nurses and the OB became a contest of wills in which the well-being of the patient was overlooked. The litigation and the investigation associated with the removal of the OB’s privileges revealed an underlying environment of incivility and disrespect.

The OB, in defense of her failure to present to the hospital when requested, cited her unusually high volume of cases with no back-up. Although the OB should have treated the L&D nurse more respectfully, the administration had created an environment that was more likely to trigger incivility. The OB did not receive the sort of support that might have led her to employ positive and productive coping strategies rather than resort to bullying.

Hospital administration also failed to provide the nursing staff with the support they needed to safely manage patients. Administration was aware of the conflict between the defendant OB and L&D nursing staff. Labor and delivery nurses had lodged multiple complaints, and there were multiple adverse events involving patient outcomes associated with the OB’s failure to respond appropriately to nurses’ concerns about patient well-being. However, there were no policies and procedures in place that addressed bullying behavior, and the chain of command protocols were not effective. With no administrative support, the nurses had resorted to bullying behavior of their own.

Bullying not only contributed to the patient’s injuries in this case, but it also complicated the defense of malpractice allegations against the defendants. Each of the defendants blamed the other for the infant’s injuries. The unsupportive work environment had fostered antagonistic feelings between the L&D nurses and the OB. They were extremely critical of each other during depositions and were expected to testify against each other if the matter went to trial. This benefitted the plaintiffs and had little effect on the attribution of liability among the defendants. As it did in this case, finger-pointing in malpractice cases generally increases settlement and verdict amounts; makes dismissal of parties more complicated; and prolongs litigation.

The experts who reviewed this case could not support the care and treatment of the patient. They believed the OB should have delivered the infant by C-section hours earlier because of the developing infection and lack of progress. They faulted the hospital for an ineffective chain of command. Experts did not believe the nurse’s failure to increase the oxytocin was below the standard of care. Unfortunately for the nurse, the OB had said so many unflattering things about her that the plaintiffs’ attorney was unwilling to dismiss her from the case.

Risk Reduction Strategies

Managing bullying requires a multi-modal approach. Although holding bullies appropriately accountable for their behavior is paramount to the success of an anti-bullying policy, many more processes must be in place to create an environment in which bullying is less likely to occur and, when it does occur, is remedied prior to causing patient injury.

Operations

Medical practice administrators have a vital role in managing bullying. Consider the following recommendations:^1,3

• Establish anti-bullying policies and procedures that include:
  • A definition of bullying behavior that provides enough clarity for individuals to know what behavior is prohibited or reportable and includes examples of bullying behavior.
  • Administrator, clinician, and staff roles and responsibilities.
  • Strategies for responding to bullying.
  • Clear and confidential grievance, investigation, and disciplinary procedures.
  • Requirements for documenting the process.
  • Protections for individuals who report bullying or cooperate in investigatory processes (i.e., non-retaliation clauses).
  • Training requirements.
• Enforce a “zero tolerance” bullying policy, without exemptions for well-connected or powerful members of the workforce.
• Focus on bullying prevention and a culture change instead of relying on reactionary processes.
• Have a plan for managing bullies. For example, in some cases mentoring and coaching might be appropriate; however, probation and termination may be necessary in other cases.
  • Document counseling, coaching, mentoring, and other management of individuals who have been reported for bullying, including recommendations or requirements for behavior change.
• Provide training for physicians and staff in recognizing bullying and complying with the bullying policy.
• Stress the risks of bullying and the specific detrimental effects bullying has on victims, bystanders, and patients.

• Establish a confidential bullying reporting system.
• When bullying is observed or reported, intervene promptly.
• Appropriately investigate every report of bullying.
• Ensure victims of bullying are adequately supported.

Clinicians and Staff

Administrators, physician leaders, and managers can and should put policies and processes in place to create a healthcare environment in which bullying does not thrive; however, the onus is really on the bully to stop behaving poorly. Consider the following recommendations:

• Honestly assess your own behavior. If you are bullying someone, stop doing it, or ask for help to stop.
• Promote and exemplify respectful behavior.
  • o When under stress, do not let your emotions escalate the situation.
• Reject and report bullying.
• Stand up for people who are being bullied.
• Encourage an environment in which anyone who needs help can ask for it, as well as ask questions about patient care.
  • Do not penalize someone for asking questions or requesting help.
  • Look for opportunities for improvement that can be used as teaching moments.

Conclusion

Bullying is a serious problem. Not only does it affect the mental health and well-being of victims and bystanders, but it also creates a culture of disrespect in which patient injury is more likely.² Ridding medical practice of bullying will require a coordinated effort on various fronts. Bullies must stop their harmful behavior. Physician leadership must promote and exemplify respectful behavior. Victims and witnesses must report bullying. Administrators must establish and enforce anti-bullying policies and procedures to create an environment in which bullying is less likely to occur; where the response to bullying is swift and effective; and where the workforce has the resilience to withstand the damaging effects of bullying before patients suffer harm.⁴

End Notes

1. Riskin A, Erez A, Foulk TA, Kugelman A. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015; 136(3): 487-495. https://www.researchgate.net/publication/280967683_The_Impact_of_Rudeness_on_Medical_Team_Performance_A_Randomized_Trial.
2. Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, et al. Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians. Acad Med. 2012; 87(7): 845-852. http://journals.lww.com/academicmedicine/Fulltext/2012/07000/Perspective___A_Culture_of_Respect,_Part_1___The.10.aspx; Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, et al. Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect. Acad Med. 2012; 87(7): 853-858. http://journals.lww.com/academicmedicine/Fulltext/2012/07000/Perspective___A_Culture_of_Respect,_Part_2__.11.aspx.
3. Bullying in the Health Care Workplace: A guide to prevention and mitigation. AMA website. https://www.ama-assn.org/system/files/2021-02/workplace-aggression-report.pdf. Created January 27, 2021.
4. Ofri D. In a Culture of Disrespect, Patients Lose Out. New York Times Website. http://well.blogs.nytimes.com/2013/07/18/in-a-culture-of-disrespect-patients-lose-out/?_r=0. Published July 18, 2013.

The information provided in this article offers risk management strategies and resource links. Guidance and recommendations contained in this article are not intended to determine the standard of care, but are provided as risk management advice only. The ultimate judgment regarding the propriety of any method of care must be made by the healthcare professional. The information does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about this topic should be directed to an attorney.