Is Incivility an Underlying Threat to Safety in Obstetrics?

By Larry Veltman, MD, FACOG, CPHRM

A resident is called stupid and a fool when she makes a minor error during surgery.

An obstetrician says to a newly hired nurse caring for his patient, “Let me talk to a real nurse.”

An anesthesiologist tells a laboring woman’s nurse, “I’m going to bed; it’s now or never for her epidural.”

A nurse on the night shift does not notify a physician about an abnormal fetal heart tracing because she was reprimanded for calling another physician the night before with similar concerns.

A nurse rolls her eyes and walks away from another nurses’ request for help saying, “She’s not my patient.”

Disruptive behavior? Perhaps these examples do not meet everyone’s threshold. However, few would deny that incivility characterizes these anecdotal interactions, which all occurred in labor and delivery. In 2007, a study of disruptive behavior in labor and delivery units on the West Coast of the United States found that 61% of nurse managers felt that disruptive behavior was currently occurring on their unit (Veltman, 2007).

Also in 2007, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion on disruptive behavior, which concluded, “Disruptive physician behavior creates a difficult working environment for all staff and threatens the quality of patient care and, ultimately, patient safety. (ACOG, 2007)”

In 2008, The Joint Commission issued Sentinel Event Alert #40, “Behaviors that Undermine a Culture of Safety.” New standards set by The Joint Commission require organizations to define “acceptable and disruptive and inappropriate behaviors” (EP 4) and to create and implement a process for managing those behaviors (EP 5). In addition, interpersonal skills and professionalism should be addressed in the credentialing process of the medical staff (The Joint Commission, 2008).

Has anything changed since the Sentinel Event Alert or since the ACOG Committee Opinion on disruptive behavior? Does incivility “come with the territory” of perinatal care? Do we still have “behaviors that undermine a culture of safety”? One might answer vaguely, “It depends.” Yes, most organizations have complied with the Joint Commission standard with written policies and a code of conduct that defines the spectrum of disruptive behavior and lists measures to eliminate such behaviors from the organization. And some organizations have attempted to raise the consciousness of medical staff leaders about unprofessional behavior through additional presentations and training. And there have been some successes in removing high-profile practitioners who demonstrate chronic disruptive behaviors. But many would say that, despite some admirable attempts to eliminate these behaviors, incivility, intimidation, and disruption are still significant deterrents to achieving a culture of safety in perinatal care.

In addition to those listed above, examples of disruptive behavior noted in multiple organizations include:

• Residents refusing to cover for colleagues who have family emergencies.
• Attending physicians physically pushing nurses out of the way in the delivery room.
• Refusal by some obstetricians to assist by standing by for deliveries for physicians who are en route to the hospital.
• Nurses refusing to include new nurses on social media sites until they have “proved themselves.”
• Nurses posting disparaging comments about management on social media sites.
• General gossip about physicians’ and nurses’ private lives at the nurses’ station.
• Post-partum nurses paging physicians to labor and delivery to be transferred to labor and delivery because the physicians do not answer calls to the post-partum unit.
• Physicians turning up oxytocin administration pumps without telling nurses because they feel the nurses are advancing the dose too slowly.
• Physicians giving certain nurses the “silent treatment” when things have not gone according to schedule.

What are we up against?

What is incivility? Some definitions include,
…a form of psychological harassment and emotional aggression that violates the ideal workplace norm of mutual respect.
…low-intensity deviant behavior with ambiguous intent to harm the target, in violation of workplace norms for mutual respect.
…rude and discourteous behavior, displaying a lack of regard for others (Felblinger, 2008).

Although this article focuses on the term “incivility,” similar interactions characterized by intimidation, bullying, disruptive behavior, horizontal hostility, and, in some cases, workplace violence also threaten patient safety and people who work on perinatal units.

A Culture of Fear and Intimidation

“Health care has a long history of toleration of disrespectful behavior by physicians, and to some degree by nurses, and evidence indicates that this toleration continues… Emotional abuse, bullying, and even threats of physical assault and learning by humiliation are all often accepted as “normal” conditions of the health care workplace…There are also less overt behaviors of ignoring, isolating, and using nonverbal expressions of judgment, mocking, or exasperation. These behaviors impact safety, the organizational climate, and job satisfaction…Such behaviors create a culture of fear and intimidation, diminish individual and collective pride and morale, impair learning, and sap joy and meaning from work.“ — Lucian Leape Institute at the National Patient Safety Foundation Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care (pg. 8)

Is incivility a national problem?

Some surveys show that incivility is a national issue, of concern in society in general, not just in healthcare. Sixty-three percent of Americans in one survey felt that we have a major civility problem, and 71% believe it has worsened in recent years (Weber Shandwick, Powell Tate, & KRC Research).

Is incivility widespread in healthcare?

In 2013, The Lucian Leape Institute in conjunction with the National Patient Safety Foundation published a white paper, Through the Eyes of the Workforce: Creating Joy,
Meaning, and Safer Health Care. The report discusses the effect of intimidation, bullying, disruptive behavior, and incivility on patient safety, morale, and burnout of healthcare professionals.

By all means, incivility does not pervade every interaction that occurs on a given perinatal unit. However, it happens enough that some (including both physicians and nurses) are deeply affected by a given incident or incidents, and that may provide an underlying threat to safe care.

Is incivility a threat to patient safety?

When “psychological safety” is threatened by incivility or intimidation, there is reluctance, not only to report these behaviors, but there is fear of speaking up when unsafe practices are observed in real time or after near miss or adverse event debriefings (Edmondon, 1999; VitalSmarts, 2005).

Communication in real time can be stifled when incivility occurs. This may be overt, such as nurses being fearful of being assigned to a given physician’s patient because they did not want to have to call the physician. Or it may be subtle in the sense that even the observation of rudeness may lead to a lack of teamwork, cooperation, and cohesion (Porath & Erez, 2009).

Incivility is also at the root of the “hidden curriculum” that is prevalent during aspects of medical and nursing education. This hidden curriculum breeds fear of supervisor’s responses, speaking up with safety concerns as a sign of being an unwilling team player, and asking for assistance is seen as a sign of weakness (Liao, 2014).

What can we do to eliminate incivility from obstetrics?

In its 2007 Committee Opinion on disruptive behavior, the ACOG states, “..it is important that clear standards of behavior are established and all staff are informed of such standards, as well as the consequences of persistent disruptive behavior. Confidential reporting systems, as well as assistance programs for the offending physician, should be established.” (ACOG, 2007)

A suitable infrastructure for eliminating incivility on every perinatal unit should include:

1. Zero tolerance. To set the stage for culture change, leaders must demonstrate respectful behavior and civil discourse in all situations. They may also use announcements, education, and training. This is a critical and initial imperative that is required for the leadership of all disciplines that interface with the perinatal unit.
2. Supportive documentation and policies. To ensure a change in culture, develop an infrastructure of policies, procedures, by laws, reporting mechanisms, and reporting forms.
3. Training. Leadership, including medical staff and nursing leaders, human resources, residency directors, peer review committees, and credentialing bodies, should be trained to deal with incivility, disrespect, and disruptive behavior and to understand the importance of linking this spectrum of behaviors to patient safety. This training should include a spectrum of interventions from dealing with a single, early episode to dealing with chronic offenders who have demonstrated inability to change. Training should also include simulations and debriefings for situations that give rise to incivility. Actual practice should include the use of scripts that have been developed for those who might find themselves on the receiving end of uncivil behaviors (Griffin, 2004).
4. Within departments and institutions, a hierarchy of responsibility for intervention should be established. Behavioral complaints should be subjects for peer-review evaluation and workplace evaluations.
5. Reporting is critical to generate interventions that will change behavior. Many organizations have “normalized” these behaviors. Ease of anonymous reporting, eliminating fear of retribution, and 1continual emphasis on the link between incivility and safety are critical to achieving change.
6. Continued education should be readily accessible, as well as, when necessary, referrals for rehabilitation for healthcare professionals who are chronic offenders.
7. Finally, mechanisms for removal of any healthcare professional from the medical staff or from employment should remain a viable option for those individuals who cannot change their behavior. Theses processes, including disciplinary action, fair hearings, and legal resources, should be fully functional when needed.

In the bigger picture, medical schools and nursing schools should recognize and approach the problem early in professional education. Practice and mentoring of students of all disciplines regarding professional behavior who will eventually work together on the frontline of patient care is critical and should be started early before the “well is poisoned” by a culture where incivility may be common.

In summary, incivility exists in obstetrics. It is a safety threat. It also can sap the joy of work. Leaders need to model civil and respectful discourse and all individuals need to be held accountable for their behavior. Changing culture isn’t easy, and it takes time. Isn’t it about time?

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Larry Veltman practiced obstetrics and gynecology in Portland, Oregon, for over 30 years.  He was chairman of the Department of Obstetrics and Gynecology for nine years at Providence St. Vincent Medical Center in Portland. He served as chair of the Committee on Professional Liability for the American College of Obstetricians and Gynecologists (ACOG) and was on ACOG’s Patient Safety and Quality Improvement Committee.  He has published articles and given presentations on teaching risk management to physicians, vaginal birth after cesarean section, patient safety in obstetrics, and disruptive behavior as a threat to patient safety.  He is currently a consultant with respect to a variety of subjects dealing with medical malpractice, patient safety, and risk management, primarily in the area of perinatal care. Veltman may be contacted at l.veltman@comcast.net.

References

American College of Obstetricians and Gynecologists (ACOG). (2007). Disruptive behavior. ACOG Committee Opinion No. 366. Obstetrics & Gynecology, 109, 1261–1262.

American College of Obstetricians and Gynecologists (ACOG). (2007). Disruptive behavior. ACOG Committee Opinion No. 366. Obstetrics & Gynecology, 109, 1261–1262.

Edmondson, A. (1999, June). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350.

Felblinger, D. M. (2008). Incivility and bullying in the workplace and nurses’ shame responses. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(2), 234-241. doi:10.1111/j.1552-6909.2008.00227.x

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal for Continuing Education of Nurses, 35(6), 257-263.

Liao, J., et. al. (2014). Speaking up about the dangers of the hidden curriculum. Health Affairs, 33(1), 168-171.

Lucian Leape Institute. National Patient Safety Foundation. (2013). Through the eyes of the workforce: Creating joy, meaning, and safer health. Retrieved from http://www.npsf.org/?page=throughtheeyes

Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence kills: The seven crucial conversations for healthcare. VitalSmarts. Retrieved from http://www.aacn.org/WD/Practice/Docs/PublicPolicy/SilenceKills.pdf

Porath, C., & Erez, A. (2009). Overlooked but not untouched: How rudeness reduces onlookers’ performance on routine and creative tasks. Organizational Behavior and Human Decision Processes, 109, 29–44.

The Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety. Sentinel Event Alert #40. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.pdf

Veltman, L. L. (2007). Disruptive behavior in obstetrics: a hidden threat to patient safety. American Journal of Obstetrics and Gynecology, 196, 587.e1-587.e5

Weber Shandwick, Powell Tate, & KRC Research. Civility in America 2013. Retrieved
from http://www.webershandwick.com/uploads/news/files/Civility_in_America_2013_Exec_Summary.pdf