In our September 9, 2021 newsletter, we discussed the topic of disrespectful behaviors, which have persisted in healthcare for years. Unfortunately, too many remain silent or make excuses in an attempt to minimize the profound devastation caused by disrespectful behaviors. Disrespectful behaviors encompass a broad array of conduct, from aggressive outbursts to subtle patterns of disruptive behavior so embedded in our culture that they seem normal. Any behavior that discourages the willingness of staff or patients to speak up or interact with an individual because they expect the encounter will be unpleasant or uncomfortable, fits the definition of disrespectful behavior. In our 2021 article, we examined the adverse effects of disrespectful behaviors and why they arise and persist in healthcare.

In 2003 and 2013, ISMP conducted national surveys via our newsletters about workplace intimidation and/or disrespectful behaviors in healthcare. More recently, from September through November 2021, ISMP conducted another survey to measure the progress (or lack thereof) with reducing disrespectful behaviors in healthcare. Although the 2021 survey was conducted amid a worldwide pandemic, more than 1,000 practitioners spoke up and clearly exposed the continued tolerance of disrespectful behaviors in healthcare. In Part I of our report, we present what the 2021 respondents had to say about disrespectful behaviors in the workplace and compare these results to our 2003 and 2013 survey results. In Part II of our report, which will appear in a future newsletter, we will explore how to address disrespectful behaviors in healthcare.

Respondent Profile

Our 2021 survey was completed by 1,047 respondents—995 who worked in an acute care setting and 52 who worked in a long-term care (LTC) setting. More than half of the respondents worked facility wide (28%) or in the pharmacy (26%); however, respondents from critical care (9%), general units (9%), perioperative locations (5%), emergency departments (4%), behavioral health (4%), and ambulatory or other special care units (15%) also participated in the survey. The respondents were mostly nurses (42%) and pharmacists (37%); however, we also received survey responses from pharmacy technicians (6%), quality/risk/safety practitioners (5%), physicians (3%), and others (7%, therapists, administrators, nursing assistants, education specialists). Sixty percent of the respondents were staff-level practitioners, and about one-quarter were managers, directors, or administrators (28%). Examples of other types of practitioners (12%) who participated in the survey included medication safety officers, faculty, clinical specialists, residents/fellows, and consultants. The vast majority (96%) of respondents had 2 or more years of experience in healthcare, with 68% reporting more than 10 years of experience; only 4% of respondents had less than 2 years of experience.

Frequency and Types of Disrespectful Behavior

Almost everyone who works in healthcare today has a story to tell about disrespectful behavior, as healthcare organizations have fueled the problem for years by tacitly accepting and/or tolerating disrespectful behaviors. Furthermore, the healthcare culture historically has accepted a certain degree of disrespect and normalized this style of communication. Also, according to three-quarters (75%) of the 2021 respondents, the coronavirus disease 2019 (COVID-19) pandemic has contributed to an increase in disrespectful behaviors among coworkers. Thus, it is no surprise that most of the survey respondents have personally experienced (79%), witnessed (60%), or are otherwise aware of disrespectful behaviors (23%) during the past year. In fact, only 5% of the respondents reported that they have not experienced, witnessed, or are not aware of disrespectful behaviors in the workplace.

The 2021 survey respondents reported a wide variety of disrespectful behaviors that they had personally experienced or witnessed during the past year (Table 1). The offenders who engaged in disrespectful behaviors were of all genders; however, female offenders were reported most frequently for all types of disrespectful behaviors except physical abuse/assault and throwing objects, for which males were the most frequently reported offenders. Forty percent of respondents reported that three to five different individuals had engaged in disrespectful behaviors during the past year, and another 35% reported that such events involved more than five different offenders. Only 25% of respondents reported that repeated occurrences of disrespectful behaviors arose from just one or two individuals. Surprisingly, respondents reported that individuals who engaged in disrespectful behaviors (offenders) were frequently equal or subordinate in position (rank) to the intended target(s) of the behaviors for certain types of disrespectful behaviors:

Physical abuse/assault
Shaming, spreading malicious rumors
No teamwork/reluctant to follow safety practices
Negative comments about colleagues/leaders
Insulted due to race/religion/gender/appearance
Disrespect during virtual meetings, email, online
Throwing objects
Constant nitpicking/faultfinding
Report you to your manager (threat/actual)

Offenders were frequently more senior in position (rank) than the target for these four disrespectful behaviors:

Impatience with questions, interruptions
Reluctant/refuse to answer questions, return calls
Yelling, cursing, outbursts, verbal threats
Condescending/demeaning comments, insults

When respondents were asked to specify the three most frequently encountered disrespectful behaviors during the past year, more than half included the following:

Condescending/demeaning comments, insults (64%)
Impatience with questions, interruptions (53%)
Negative comments about colleagues/leaders (52%)

Although the following three disrespectful behaviors were, overall, among the least frequent behaviors encountered, it is troubling that more than one in 10 respondents told us at least one of these behaviors was among the three most frequently encountered during the year:

Insulted due to race/religion/gender/appearance (8%)
Throwing objects (3%)
Physical abuse/assault (2%)

Impact on Safety

Unsafe practices, medical errors, and adverse patient outcomes can be clearly linked to disrespectful behaviors in healthcare. For example, in the 2021 survey, more than one in three respondents (40%) told us that their past experiences with disrespectful behaviors had altered the way they handled order clarifications or questions about medication orders. At least once during the past year, approximately half (51%) of the respondents had asked colleagues to help interpret an order or validate its safety to avoid interacting with a particular prescriber—11% reported this occurred more than 10 times throughout the past year (Table 2). Forty-one percent of the respondents had asked another professional to speak to a particularly disrespectful prescriber about the safety of an order at least once during the year, and nearly half (47%) admitted to feeling pressured to accept an order, dispense a product, or administer a drug despite concerns about its safety. At least once during the past year, more than one-third (35%) of the respondents had concerns about a medication order but assumed it was correct rather than interact with a particular prescriber. Similar results were reported when the prescriber’s stellar clinical reputation led to a reluctance to question or clarify orders despite having concerns. table 2 disrespectful behavior

table 3 disrespectful behavior Furthermore, more than one-quarter (27%) of the respondents were aware of a medication error in the past year in which disrespectful behaviors played a role. Nearly 200 events were described by the respondents; see Table 3 for a few examples. Many of the described events involved high-alert medications (e.g., neuromuscular blocking agents, anticoagulants, insulin, chemotherapy) and led to significant delays in care and/or serious adverse outcomes.

Organizational Management of Disrespectful Behaviors

It appears that most of the 2021 respondents were not satisfied with organizational efforts to address disrespectful behaviors. Three-quarters (75%) of the respondents reported that their organization does NOT effectively deal with disrespectful behaviors. Nearly half (45%) of the respondents reported that their organization has not clearly defined an effective process for handling disagreements with the safety of an order, and for those who do, only 41% said that the process for handling clinical disagreements allows them to bypass a typical chain of command, if necessary. On the bright side, 65% of the respondents felt that their organization or manager would support them if they reported disrespectful behavior by another professional. However, while disrespectful behaviors typically occur every day, they often go unreported for a variety of reasons, not the least of which is the stigma associated with “whistle blowing.” If disrespectful behaviors are known, leaders may be reluctant to confront individuals if they are powerful or high-revenue producers, or they may not know how to handle a problem with no obvious solution.

Have Disrespectful Behaviors in Healthcare Lessened?

The results of our 2003 and 2013 surveys painted a grim picture of a hostile work environment in which disrespectful behaviors continued to erode professional communication, which is imperative for patient safety. Unfortunately, the 2021 survey results suggest that disrespectful behaviors in healthcare continue to occur at an alarming rate, demonstrating little or no improvement, and in some cases, worsening. In 2021, respondents reported that disrespectful behaviors persist unchecked, they are not isolated events, they are not limited to only one or two offenders of a single gender, and they occur in both lateral (peer-to-peer) and hierarchical working relationships.

The 2021 respondent profile is similar to the respondent profiles for our 2003 and 2013 surveys. However:

More respondents participated in the 2003 (N=2,095) and the 2013 (N=4,884) surveys than the 2021 survey (N=1,047).
A higher percentage of pharmacists participated in the 2021 survey (37%) compared to the 2003 (17%) and the 2013 (14%) surveys.
More physicians participated in the 2013 survey (more than 200) compared to the 2021 survey (32).

When comparing the 2021 results to our 2003 and 2013 survey results, the prevalence of most disrespectful behaviors included in the surveys generally stayed the same or increased (Table 4), with the most noteworthy increase between 2013 and 2021 in making negative comments about colleagues and leaders. Responses from the 2013 survey participants suggested that some types of disrespectful behaviors lessened between 2003 and 2013, particularly impatience with questions and the use of condescending or demeaning comments and insults. However, 2021 respondents reported that both of these disrespectful behaviors rose in prevalence since 2013 to nearly or above the 2003 reported prevalence levels. table 4 disrespectful behavior

In the 2003, 2013, and 2021 surveys, repeated occurrences of disrespectful behaviors were not reported to arise from a single gender or from a single individual; 38% of the respondents in 2003, 36% in 2013, and 40% in 2021 reported that 3 to 5 individuals were involved; and 19%, 21%, and 35%, respectively, reported that more than 5 individuals were involved in occurrences during the past year. We saw a small reduction in the percentage of respondents who told us their past experiences with disrespectful behaviors had altered the way they handled order clarifications or questions about orders (2003: 49%; 2013: 44%; 2021: 40%). However, the percentage of respondents aware of medication errors in which disrespectful behaviors played a role during the past year more than doubled between 2013 (11%) and 2021 (27%). In the 2003 survey, 7% of the respondents told us they were personally involved in a medication error during the past year where intimidation played a role. Additionally, most respondents since 2003 have not been satisfied with organizational efforts to address disrespectful behaviors. While 70% of the respondents in 2003, 52% in 2013, and 65% in 2021 reported that their organization or manager would support them if they reported disrespectful behavior, only about one-quarter of all respondents (39%, 25%, 25% respectively) felt that their organization had effectively dealt with disrespectful behaviors.

Summary

Our 2003, 2013, and 2021 surveys suggest that healthcare has a long history of tolerance and indifference to disrespectful behaviors. Our results showed little or no improvement, and, in some cases, an increase in the prevalence of disrespectful behaviors between 2003, 2013, and 2021. Some respondents also commented that disrespectful behaviors have increased in patients, too! These behaviors are clearly learned, tolerated, and reinforced in the healthcare culture. In the hundreds of comments from respondents to the 2021 survey, you can feel the despair that disrespectful behaviors still cause as well as see their devastating impact on patient safety. Many 2021 respondents pointed out that the stressful healthcare environment, poor staffing levels, excessive workloads, power imbalances, and the ever-changing science and data associated with COVID-19 treatments were all influential factors contributing to the ongoing prevalence of disrespectful behaviors in healthcare. In many of the 2021 respondents’ comments, the frustration associated with the lack of dealing effectively with disrespectful behaviors was evident, with many respondents claiming that the rank of the offender and professional staffing shortage have contributed to the problem. As one survey respondent noted, healthcare workers “are the most vulnerable, unappreciated, and bullied individuals,” making healthcare facilities a hazardous place to work. Another respondent noted, “We need leaders and providers to display the best example of behaviors in order for others to be influenced by kindness and civility.”

The 2021 survey results and the deep sense of frustration threaded through many of the comments from the survey suggest that now is the time for action. In Part II of our report, we will provide recommendations to help address this longstanding problem. In preparation, we would love to hear from organizations that have been working towards a culture of respect and learn more about what strategies have worked. Please send a message to: ismpinfo@ismp.org, if you would like to contribute to the dialogue on this important issue.