The New Age of Bullying and Violence in Health Care: Ethics and … · 2017-08-30 · Workplace...

The New Age of Bullying and Violence in Health Care:

Ethics and Practice Impact

Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP

EFS Supervision Strategies, LLC

[email protected]

BULLYING & VIOLENCE

mailto:[email protected]

Once Upon a Time…

EFS Supervision Strategies, LLC 2015 2

Disclaimer

There are no potential conflicts of interest contained in the information provided in this

presentation. All material is the opinion of this presenter or cited to source and/or authority

Any products referred to during this presentation are for the sole purpose of example only and should not be taken as

product endorsement.


Objectives

• Explore the incidence, scope, and organizational impact of bullying and violence in the health care workplace.

• Identify implications for the industry’s emerging interprofessional practice culture.

• Discuss the new dimension of trauma for health care sector victims.

• Review current initiatives and strategies to empower professionals on their own journey to overturn this dangerous new culture. EFS Supervision Strategies, LLC 2015 4

Bullying: Data, Definitions & Demographics

Workplace bullying: the repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators, marked by abusive conduct that is:

• Threatening, humiliating, or intimidating, or

• Work interference — sabotage — which prevents work from getting done, or

• Verbal abuse

(Workplace Bullying Institute, 2015)EFS Supervision Strategies, LLC 2015 5

Consider this…• A physician screams obscenities at the

case manager who approaches him to clarify a patient’s code status. The physician threatens to have the case manager fired if she ever ‘second guesses’ him again.

• When the case manager discusses the situation with colleagues, she is told, “Oh, his bark is worse than his bite. Ignore him like everyone else does.”.

• The behavior is dismissed and the physician enabled to engage in further antagonistic interactions with other staff.

• The end result? EFS Supervision Strategies, LLC 2015 6


• Lateral Violence: when people who are both victims of a situation of dominance, turn on each other rather than confront the system which oppressed them both.

• Whether individuals and/or groups, those involved internalize feelings such as anger and rage, and manifest those feelings through behaviors as gossip, jealousy, putdowns and blaming (US Legal TM, 2014).

• More than 72% of employers deny, discount, encourage, rationalize, or defend it (Workplace Bullying Institute,

2014).


How Often Has This Happened To You?

• A fellow case manager throws a tantrum during a care conference, cursing out team members and stomping out of the room yelling, “You’re all incompetent. These meetings are a waste of my time since I know better than all of you.”

• A patient and family in attendance are shocked by the interchange.



Workplace Bullying is 4X more common than sexual harassment or racial discrimination on the job, though not yet illegal (Drexler, 2013)

35% of workers have been bullied in the workplace, with actions of:• verbal abuse• job sabotage • misuse of authority• intimidation and humiliation, and • deliberate destroying of relationships.

(Workplace Bullying Institute, 2015)


• The health care profession has one of the highest levels of workplace bullying (Farouque and Burgio, 2013)

• In a survey of >4,500 health care workers:

– 77% reported disruptive behaviors by doctors, and

– 65% reported the same presentation among nurses.

– 99 % indicated these behaviors led to impaired nurse-physician relationships (Rosenstein and O’Daniel, 2008).




C-Suite

Physicians

Clinical Professionals

Para-professionals

Non-clinical/support

staff


•Some view the bullying dynamic as a reflection of

the hierarchical stratification that exists in health care

(Neckar in Nesbitt, 2012).

• The Joint Commission identified that intimidating and disruptive behaviors fuel medical errors and lead to preventable adverse outcomes (TJC, 2008).

• Studies have yielded that more than 75% of those surveyed identified how disruptive behaviors led to medical errors with nearly 30% contributing to patient deaths (Painter, 2013).

• Other reports cite the number at potentially as high as 200,000 deaths a year (Brown, 2011).



The Ethical Effect


• Stephanie is the case manager for a spinal cord injury program in an acute rehabilitation hospital.

• The rehab team is working with Michael, a 23 year old involved in a motor vehicle accident. He has suffered a C-2 injury with Tetraplegia and is wheelchair dependent. The team recommend Michael be discharged with a specialized wheelchair. Having the wheelchair will mean less energy consumption and increased independence. Michael wants to live on his own post-discharge, and the specialized wheelchair would promote his self-sufficiency.

• The PT mentions Michael to a durable medical equipment vendor, who agrees to bring a demo of the wheelchair to the unit for Michael to trial.

• Stephanie is enraged when she hears the plan and throws her mobile phone across the nursing station, with team members ducking for safety.

• She yells, “Seriously? Why should I request a motorized wheelchair for this guy? If he wasn’t texting his friends, the accident never would have happened. He must understand there are consequences to his actions. Michael will see the chair as a reward, and this won’t happen on my watch, ” The team is horrified by what they hear.

Ethical Tenets and Codes: Application to Bullying

• Beneficence

– Stephanie is not acting in Michael’s best interests

• Non-Malfeasance

– Stephanie is potentially harming Michael’s recovery

• Autonomy

– What do Michael and/or his family want in this situation?

• Justice

– Michael is not being treated fairly by Stephanie

• Fidelity

– Do you see Stephanie’s actions as a violation or not?

(CMSA, 2010)

Commission for Case Manager Certification (2015)

Principle 2: Board-Certified Case Managers (CCMs) will respect the rights and inherent dignity of all of their clients.

Principle 3: Board-Certified Case Managers (CCMs) will always maintain objectivity in their relationships with clients.

Principle 4: Board-Certified Case Managers (CCMs) will act with integrity and fidelity with clients and others.


Commission on Rehabilitation Counselor Certification (CRCC, 2010)

Section D: Professional Competence

• D.5. RESPONSIBILITY TO THE PUBLIC AND OTHER PROFESSIONALS

Section E: Relationships with other professionals

• E.1. RELATIONSHIPS WITH COLLEAGUES, EMPLOYERS, AND EMPLOYEES

• E.3. AGENCY AND TEAM RELATIONSHIPS

Certification of Disability Management Specialists Commission (CDMS, 2010)

• Principle 4: Certificants shall act with integrity in dealing with other professionals.


Ethical Tenets and Codes: Application to Bullying

You Can’t Make This Stuff Up• A doctor often slapped anesthetized patients on the buttocks and called

them derogatory names before surgery.

• He slapped them so hard he left red marks or hand prints, per a report by the Center for Medicare & Medicaid Services(CMS).

• The slapping and other inappropriate behavior by the surgeon went on for at least a year and the hospital did nothing until a complaint was filed with hospital administrators in December 2013.

• One staffer told investigators the hospital did nothing after the staffer reported the doctor's behavior to OR administrators early last year. Others said they did not report it because they doubted anything would be done, feared their jobs could be jeopardized or did not want to confront the doctor.

• The hospital is facing serious sanctions, including possible termination from CMS, which pays for the majority of patients treated in hospitals.

EFS Supervision Strategies, LLC 2015

http://www.syracuse.com/news/index.ssf/2014/04/feds_say_syracuse_doctor_slapped_sedated_patients_on_butts.html

16

http://www.syracuse.com/news/index.ssf/2014/04/feds_say_syracuse_doctor_slapped_sedated_patients_on_butts.html

Workplace Violence: Data, Demographics & Dynamics

• Workplace Violence: Refers to any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site.

– It ranges from threats and verbal abuse

– to physical assaults and even homicide

(United States Department of Labor, 2015)


The FBI’s Four Types of WPV (2002)

• All involve aggression, where the offender:

– Type I: has no relationship with the victim

– Type II: is receiving services from the victim

– Type III: is either a current or former employee acting out against other coworkers

– Type IV: has a personal relationship with an employee and acts out at the employee’s workplace.

(Blando, 2014)



• OSHA Reports a single hospital had 40 instances of violence from patients & visitors against employees from February-April 2014 (Herman, 2014)

• More than 50% of nurses have been threatened or verbally abused at work (LaGrossa, 2013)

• The ANA Health and Safety Survey (2015): Concerns about ‘on the job assault’ now at 34%



“ the manifestation of violence against the professional workforce is viewed as just part of

the job and is not being treated seriously.

70% of attacks and threats toward social workers and other agency staff members were

never investigated.” (Schraer, 2014)



The Common Thread: The Impact of Trauma on the Workforce

20% of bullying & WPV victims meet the DSM-5 criteria for Post Traumatic Stress Disorder

Suffering:

• Debilitating Anxiety—80%

• Panic Attacks— 52%

• Clinical Depression—either new to the person or exacerbated condition, 49%

• Post Traumatic Stress—30%(Workplace Bullying Institute, 2015)


• Diagnostic criteria includes history of exposure to a traumatic event (Criterion A) that meets specific stipulations and symptoms from each of four symptom clusters:

– Criterion B: intrusion,

– Criterion C: avoidance,

– Criterion D: negative alterations in cognitions and mood, and

– Criterion E: alterations in arousal and reactivity.

• Criterion F: duration of symptoms (>month);

• Criterion G: assesses functioning (e.g., social, occupational); and

• Criterion H: clarifies symptoms as not attributable to a substance or co-occurring medical condition.

(APA, 2013)


The Common Thread: The Impact of Trauma on the Workforce

“The negative consequences of this behavior on the mental health and well-being of employees are a growing focus in the literature, as it directly impacts organizational

performance” (Fink-Samnick, 2015)

• Workforce retention: – 21% of turnover related to incivility in the workplace, and– Costs to replace one nurse in the US: $88,000 (RWJF, 2015)

• Cost of care: – Loss of productivity of $5-$6 Billion annually due to bullying

alone (US Bureau of National Affairs in RWJF, 2015)

• Patient safety: 200,000 lives and rising…


There’s Light at the End of the Tunnel


Advocacy, Accountability & Awareness Toward Action

There is no federal standard to require workplace violence protections

1. Model “State” Bill: The Violence Prevention in Health Care Facilities Act-Requires health care entities to establish programs to protect health care workers from acts of violence.

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/ModelWorkplaceViolenceBill.pdf

2. The Healthy Workplace Bill (HWB)-Template of a bill that:– Defines an "abusive work environment”

– Requires proof of health harm by licensed health or mental health professionals

– Protects employers from vicarious liability risk when internal correction and prevention mechanisms are in effect

– Gives employers the reason to terminate or sanction offenders

– Requires plaintiffs to use private attorneys

– Plugs the gaps in current state and federal civil rights protections

http://healthyworkplacebill.org/bill/EFS Supervision Strategies, LLC 2015 25

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/ModelWorkplaceViolenceBill.pdf

http://healthyworkplacebill.org/bill/


SC

VA

NM

CO

TX

OK

WA

OR

CA

ID

NV UT

MT

WY

ND MN

KS

NE

MO

IA

AR

MS

IL IN OH

KY

TN

wv

WI MI

PA NJ

NY

HI

MD DE

MA

NH VT

RI

NC

GA AL

FL

LA

(21 states) Enacted/ adopted: AL, AZ, CA , CO, CT, IL, ME, MN, NE, NV, NJ, NM, NY,

NC, OH, OK, OR, TN, VT, VA, WA and WV. HI passed a resolution.

* laws vary – generally, approaches are either comprehensive programs or establish /

increase penalties for assaults on nurses/healthcare personnel. Laws excluding nurses

are not reflected .

M

E

September 2015

American Nurses Association

WORKPLACE VIOLENCE

SD

AZ

CT

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-

Nurse/bullyingworkplaceviolence/WorkplaceViolenceMap.pdf

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/WorkplaceViolenceMap.pdf

• Effective January 1, 2009 The Joint Commission (TJC) created a new standard in the Leadership chapter, LD.03.01.01. It calls for organizational leaders to create and maintain a culture of safety and quality throughout the (organization):

– A4: Leaders develop a code of conduct that defines acceptable and disruptive and inappropriate behaviors, and

– A5: Leaders create and implement a process for managing disruptive and inappropriate behaviors that undermine a culture of safety.

(TJC, 2008)




• Effective, April 20, 2015, The U.S. Department of Veterans Affairs rolled out the Equal Employment Opportunity, Diversity and Inclusion, No FEAR, and Whistleblower Rights and Protection Policy Statement– commitment and obligation to proactively prevent unlawful

discrimination, harassment, and reprisal, and

– reaffirms VA commitment to their Mission and Core Values-Integrity, Commitment, Advocacy, Respect, and Excellence.

– prohibits workplace violence and bullying, harassment, as well as prohibited personnel practices of discrimination, coercion, intimidation, preferential treatment, et. al.

– reaffirms whistleblower rights and protection(Official memorandum, The Secretary of Veterans Affairs, Washington DC, 4/2015)



National Association of Social Workers-Guidelines for Social Work Safety in the Workplace (2013)

1. Organization Culture of Safety and Security

2. Prevention3. Office Safety4. Use of Safety Technology5. Use of Mobile Phones6. Risk Assessment for Field Visits7. Transporting Clients8. Comprehensive Reporting Practices9. Post-Incident Reporting and

Responsibility10. Safety Training11. Student Safety



Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA, 2015)

• Risk Factors

• Violence Prevention Program Elements

– Management Commitment and Worker Participation

– Worksite Analysis and Hazard Identification

– Hazard Prevention and Control

– Safety and Health Training

– Recordkeeping and Program Evaluation

• Workplace Violence Program Checklist


https://www.osha.gov/Publications/osha3148.pdf

https://www.osha.gov/Publications/osha3148.pdf

Advocacy, Accountability & Awareness Toward ActionThe Emergency Nurses Association (ENA) & the American Organization of Nurse Executives 8 guiding principles for mitigating workplace violence include recognizing that:• Violence can and does happen anywhere.• Healthy work environments promote positive patient outcomes.• All aspects of violence, including those involving patients, families and

colleagues, must be addressed.• A multidisciplinary team is needed to address workplace violence.• Everyone in the organization is accountable for upholding behavior

standards.• When members of a healthcare team identify an issue that contributes to

workplace violence, they have an obligation to address it.• A culture shift requires intention, commitment and collaboration of nurses

with other healthcare professionals at all levels.• Addressing workplace violence may increase the effectiveness of nursing

practice and patient care.


Incivility, Bullying & Workplace Violence: Position Statement (2015)

“ the nursing profession will no longer tolerate violence of any kind from any source. All registered nurses and

employers in all settings, including practice, academia, and research must collaborate to create a culture of respect, free

of incivility, bullying, and workplace violence.

This position statement, although written specifically for registered nurses and employers, is also relevant to other

health care professionals and stakeholders who collaborate to create and sustain a safe and healthy interprofessional

work environment.”



http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-

Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Incivility-Bullying-and-

Workplace-Violence.html

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Incivility-Bullying-and-Workplace-Violence.html

We must shift from traditional professional education models

• National average of bullying & mistreatment in medical education: 50%

• Transition from a ‘transgenerational legacy’ of mistreatment, cynicism, and abuse in medicine that hinders interpersonal communication and negatively impacts care.

• Advance from the ‘nurses eat their young’ approach to one of empowering and mentoring

http://journalofethics.ama-assn.org/2014/03/fred1-1403.html

• Teach newer Interprofessional Education models which promote work in teams.



http://journalofethics.ama-assn.org/2014/03/fred1-1403.html


• Organizational leaders must take a strong stance to promote a culture where advocacy to address bullying is the norm.

• Hospitals and organizations rendering care have a primary responsibility to protect stakeholders from the impact of this issue, employees and patients alike.

• Standards of professional behavior must be developed and implemented with uniform application across all departments, and consistent monitoring to assure adherence.

• All employees need to know they can report incidents confidentially (Brown, 2011).

• There should be intervention to address the emotional and psychological injuries of affected staff (Trossman, 2015)



Health care teams which lack the ability to trust, respect, and collaborate with one another are

more likely to make a mistake that could negatively impact the safety of patients

(Rosenstein and O’Daniel, 2008)


(Adapted from Rosenstein and O’Daniel, 2008)



When events occur:

• Step 1: direct discussion between involved parties to confront the actual behavior

• Step 2: seek all available resolution routes through the employer.

• Step 3: Potentially file a complaint against a colleague with the requisite credentialing body.

• By engaging in a gradient action plan to directly address and report bullying, professionals are empowered to be accountable for their own practice. (Fink-Samnick, 2014)


References• American Psychiatric Association. (APA) (2013) Diagnostic and

statistical manual of mental disorders (5th ed.). Washington, DC: Author

• American Nurses Association . ( 2015). 2011 ANA health and safety survey . Retrieved February 3, 2015, from http://www.nursingworld.org MainMenuCategories/Workplace

• Ariza-Montes, A., Muniz N., Montero-Simo M. and Araque-Padilla R, (2013) Workplace Bullying Among Healthcare Workers, International Journal of Environmental Research and Public Health , 10, 3121-3139

• Blando , J. ( 2014 ). Violent patients, abusive staff: A summary of unpublished study findings . N21: Nursing in the Twenty-First Century: A Mobile Journal , 3 .


http://www.nursingworld.org

References• Brown, Theresa (2011) Physician Heel Thyself, NY Times The Opinion

Pageshttp://www.nytimes.com/2011/05/08/opinion/08Brown.html?partner=rss&emc=rss&_r=0

• Case Management Society of America (2010). CMSA Standards of Practice for case management Revised 2010.Retrieved from http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf

• CDMS (2010). Code of Professional Conduct, Certification of Disability Management Commission, Retrieved March 26, 2015, http://www.cdms.org/For-Employers/Content/code-of-conduct.html

• Cipriani, P (2015) Workplace Violence a Growing Problem for Health Care Workers, Huffington Post, http://www.huffingtonpost.com/pamela-f-cipriano-phd-rn-neabc-faan/workplace-violence-a-grow_b_8089938.html


http://www.nytimes.com/2011/05/08/opinion/08Brown.html?partner=rss&emc=rss&_r=0

http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf

http://www.cdms.org/For-Employers/Content/code-of-conduct.html

http://www.huffingtonpost.com/pamela-f-cipriano-phd-rn-neabc-faan/workplace-violence-a-grow_b_8089938.html

References• CRCC (2010). Code of Ethics, Commission on Rehabilitation Counselor

Certification, Retrieved March 26, 2015, http://www.crccertification.com/pages/crc_ccrc_code_of_ethics/10.php

• Farouque, K. and Burgio, E (2013) The Impact of Bullying in Health Care, The Quarterly, The Royal Australasian College of Medical Administrators, Retrieved March 8, 2015 from http://racma.edu.au/index.php?option=com_content&view=article&id=634&Itemid=362

• LaGrossa , J. ( 2013 ). Confronting workplace violence innursing. Advance Healthcare Network for Nurses .Retrieved February 4, 2015, from http://nursing. advanceweb.com/Features/Articles/Confronting-

• Laposa , J. M. , & Alden , L. E. ( 2003 ). Posttraumatic stress disorder in the emergency room: Exploration of a cognitive model . Behaviour Research and Therapy , 41 ( 1 ), 49 – 65 .

• National Association of Social Workers (2013) Guidelines for Social Work Safety in the Workplace, National Association of Social Workers, Washington, DC


http://www.crccertification.com/pages/crc_ccrc_code_of_ethics/10.php

http://racma.edu.au/index.php?option=com_content&view=article&id=634&Itemid=362

http://nursing

References• National Center for PTSD (2015) DSM-5 Criteria for PTSD, U.S Department of

Veterans Affairs, Retrieved March 8, 2015 from http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

• Nesbitt, W (2012) Workplace Bullying in the Healthcare Setting, SMSI Online Newsletter: The Hospital Reporter, Friday, December 12, 2014, Security Management Services International and The Hospital Reporter

• Nurse.com (2015) ENA, AONE address workplace violence, Nurse.com , September 11, 2015, Retrieved September 16, 2015 from https://news.nurse.com/2015/09/11/ena-aone-address-workplace-violence/

• OSHA (2015) Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, OSHA, ,U.S. Department of Labor, www.osha.gov.

• Rice , S. ( 2014 ). States increasingly trying to protect healthcare workers from violence, modern healthcare Retrieved February 19, 2015, from http://www.modernhealthcare.com/article/20140214/NEWS/302149971

• RWJF Executive Nurse Fellows Program (n.d.) Stop the Bullying Toolkit, funded by the RWJF

• Rosenstein, A and O’Daniel, M in Hughes, RG (Ed.)(2008) Patient Safety and Quality: An Evidenced-Based Handbook for Nurses, Chapter 33 Professional Communication and Team Collaboration, Agency for Healthcare Research and Quality, US


http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

https://news.nurse.com/2015/09/11/ena-aone-address-workplace-violence/

http://www.osha.gov

http://www.modernhealthcare.com/article/20140214/NEWS/302149971

References• Schraer , R. ( 2014 ). 85% of social workers assaulted, harassed or

verbally abused in the past year, community cares: Inspiring excellence in social case . Retrieved March 3, 2015, from http://www.communitycareco.uk/2014/09/16/violence-social-workers-just-partjob-70-incidents-investigated /

• The Commission for Case Manager Certification (2014), The Code of Ethics and Professional Conduct for Case Managers, Retrieved March 8, 2015 from http://ccmcertification.org/content/ccm-exam-portal/code-professional-conduct-case-managers

• The Joint Commission [TJC], (2008). Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety, Retrieved May 17, 2014 fromhttp://www.jointcommission.org/assets/1/18/SEA_40.PDF

• Trossman, S (2015) It can make you sick, The American Nurse, http://www.theamericannurse.org/index.php/2015/07/01/it-can-make-nurses-sick/

• US LegalTM (2014) Definition of Lateral Violence, Retrieved August 11, 2014 from http://definitions.uslegal.com/l/lateral-violence/

• Workplace Bullying Institute (WBI) (2015) The WBI Definition of Workplace Bullying, Retrieved February 17, 2015 from http://www.workplacebullying.org/individuals/problem/definition/


http://www.communitycareco.uk/2014/09/16/violence-social-workers-just-partjob-70-incidents-investigated /

http://ccmcertification.org/content/ccm-exam-portal/code-professional-conduct-case-managers

http://www.jointcommission.org/assets/1/18/SEA_40.PDF

http://www.theamericannurse.org/index.php/2015/07/01/it-can-make-nurses-sick/

http://definitions.uslegal.com/l/lateral-violence/

http://www.workplacebullying.org/individuals/problem/definition/

The New Age of Bullying and Violence in Health Care: Ethics and … · 2017-08-30 · Workplace...

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