Ethics Newsline®

Are Health-Care Bullies Compromising Our Safety?

Jul 28th, 2008 • Posted in: Commentary

by Rushworth M. Kidder

They shout, threaten, and burst out in inexplicable rage. They won’t return messages. Their language is belittling, their tone of voice condescending. They’re uncooperative during routine activities and impatient with questions. But they’re brilliant, successful in their fields, and key generators of revenue for their organizations.

Sadly, we all know people like that. We’ve even developed names for such behavior: impolite, intimidating, threatening, disruptive, abusive, or just plain rude. But chances are we stopped short of unethical. Why? Because however nasty and unpleasant the behavior, we’re not sure it lacks moral conscience, so we write it off as a fluke of personality rather than a failure of principle. After all, we say, isn’t everyone entitled to a quirk or two? And really, who is it hurting?

Earlier this month, that last question was answered with surprising force from an unexpected source: the Joint Commission, the leading accrediting body for health-care organizations in the United States. Its “Sentinel Event Alert” for July 9, one of a series of brief reports on threats to health-care quality, is titled, “Behaviors that undermine a culture of safety.” Summarizing years of research, it concludes that “intimidating and disruptive behaviors” in the health-care professions can “foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”

Translated into layman’s language, that means that intimidation causes mistakes, offends patients, ups costs, and drives away staff. And that’s not all. Depending on how you read the quiet euphemism of “preventable adverse outcomes,” it appears that intimidation, in a high-stakes medical setting, could actually kill people.

So much, then, for brushing aside intimidation as unfortunate but not unethical. It’s clear that in places like Robert Mugabe’s Zimbabwe, Saddam Hussein’s Iraq, or Omar Hassan al-Bashir’s Sudan, intimidation in the hands of tyrants ends up littering the landscape with bodies. It’s also clear in school settings that unrestrained bullying, a classic form of intimidation, can be a precursor to tragedies like the 1999 shootings at Columbine High School in Colorado. Now it appears that the same impulses may have devastating effects even within otherwise well-run organizations.

On global as well as local stages, then, intimidation, which relies on fear to impose its will, is not only indefensible but unethical. But is it rare? No, says the Joint Commission study, citing research showing that “40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator.” Not limited to physicians and nurses, these behaviors also “occur among other health care professionals, such as pharmacists, therapists, and support staff, as well as among administrators.” Nor is intimidation restricted to gender or to certain disciplines. It is, however, somewhat foreseeable among individuals who “exhibit characteristics such as self-centeredness, immaturity, or defensiveness.” What’s more, the healthcare culture has “a history of tolerance and indifference to intimidating and disruptive behaviors,” which “often go unreported, and therefore unaddressed” from fear of retaliation and reluctance to blow the whistle.

The Joint Commission, of course, focused on the narrow bandwidth of its own profession. But these findings reach far beyond health care. Substitute your favorite professional arena — teaching, business, law, politics, religion, government, the military — and this report still sheds light.

Fortunately, so do the report’s 11 “suggested actions” for addressing intimidation. Some are strictly managerial. They include skills-based training and coaching, surveillance, interprofessional dialogue, and the use of “cultural assessment tools” to “measure whether or not attitudes change over time.” But perhaps the most important message is that ethical values are essential to combating intimidation. The report’s first recommendation insists that an organization’s code of conduct, as well as the training surrounding it, must “emphasize respect.” Peppered throughout the remaining recommendations are other core ethical values, including accountability, empathy, trust, and equity.

The report doesn’t use the word ethics — which in health-care circles still largely refers to medical rather than managerial issues. Yet the report’s message is profoundly ethical. Intimidation may not be illegal, but it’s unquestionably immoral, and the corrective lies in ethical constructs. Other professions need to follow the Joint Commission’s lead. They should recognize intimidation as an issue of morality rather than manners. They should research its prevalence and destructiveness. They should insist that it be treated as a “zero tolerance” issue. And they should address it by building cultures of respect, equity, and integrity. That would put us well on our way to corralling one of society’s most subtle, perverse, and destructive traits.