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Stop Bullying and Promote Unity

By Don Sadler

Bullying has long been a problem in the OR that is too often swept under the rug. In fact, The Joint Commission has identified bullying as a Sentinel Event that “fosters medical errors and contributes to poor patient satisfaction and preventable adverse outcomes.”

A Significant, Persistent Issue

A study conducted by the Association of periOperative Registered Nurses (AORN) reveals just how prevalent OR bullying is. Approximately 6 out of 10 (59 percent) perioperative nurses and surgical technicians who responded said they had witnessed coworker bullying on a weekly basis.

In addition, more than three out of 10 (34 percent) respondents said they had witnessed at least two bullying acts per week.

“Statistics like this indicate to me that bullying is a significant issue in operating rooms all across the country,” says Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and Executive Director of AORN.

“These statistics tell us that bullying or intimidating behaviors continue as a persistent issue in health care, and in the operating room environment in particular,” adds Coleen A. Smith, RN, MBA, CPHQ, CPPS, Certified RPI Black Belt, Director, High Reliability Initiatives, Joint Commission Center for Transforming Healthcare.

Groah defines bullying as “threatening behavior based on intimidation that stems from the bully’s issue with personal power over a colleague. Bullying interferes with effective health care communication and thus threatens a culture of patient safety.”

Examples of common OR bullying tactics cited by Groah are withholding information, sabotage, scapegoating and backstabbing. Smith adds intimidation, harassment, victimization, aggression, emotional abuse and psychological harassment to the list.

Incivility is another source of negative and dangerous behavior in the OR.

“This includes rude or disruptive behaviors such as eye-rolling and making disparaging remarks when a team member insists on following protocol, such as the surgical time out,” says Groah.

“In this situation one practitioner is not respectful of the other person’s contribution to the team and demonstrates this either verbally or non-verbally during an encounter,” adds Groah.

Safety Put at Risk

According to Smith, any time a health care worker in any setting is intimidated or bullied, this puts the safety of the health care worker and patients at risk.

She lumps disrespectful behaviors in with bullying. These are described by the Institute for Safe Medication Practices as ranging from “overt acts of abuse and bad behavior to insidious actions so embedded in our culture that they seem normal, such as gossip.”

Smith describes a “punitive and disrespectful culture” as one where “there is little trust, teamwork is difficult, reports are inhibited, and the communication and collaboration that are essential for excellent patient care are compromised.”

“Organizations with such cultures are not likely to learn from their mistakes, which makes harm more likely,” adds Smith.

Downward vs. Lateral Bullying

Bullying in the OR is usually thought of as surgeons being threatening, intimidating or verbally abusive toward other perioperative team members. This is known as downward bullying. However, lateral bullying – or bullying between colleagues – is just as common.

Younger OR nurses, in particular, are susceptible to being bullied by older and more experienced colleagues, according to a study conducted by the Robert Wood Johnson Foundation. So are nurses working the day shift and those working in an understaffed unit.

Groah believes that downward bulling can be more damaging than lateral bullying to perioperative team members’ self-esteem and may have a longer-term impact on their career.

“Supervisors should have a positive, nurturing attitude toward team members, not a negative, ‘out to get you’ attitude,” says Groah. “Most OR personnel see their managers as role models and want to please them by performing well. They need positive recognition and feedback to reach professional fulfillment.”

Cindy Mask, CST, FAST, AA, BAAS, Program Director of Surgical Technology at Tarrant County College in Ft. Worth, Texas, stresses the importance of teamwork and collaboration in the OR.

“It’s critical that the surgeon, nurses, anesthetists, surgical technologist and all other OR team members work together collaboratively,” says Mask.

She cites a recent study that found there were teamwork issues underlying up to 75 percent of completed malpractice claims. In another study, less than half of the staff in a majority of the hospitals surveyed said that they experienced good teamwork.

Not only do bullying and incivility in the OR have the potential to threaten patient safety, but they can also be costly to health care organizations. Mask points to a 2011 court decision (Tuli v. Brigham & Women’s Hospital) in which a jury ordered a hospital to pay a total of $1.6 million in damages for failing to reign in a disruptive physician.

“This underscores the need for hospitals to promptly address and respond to complaints of disruptive behavior,” says Mask. “This includes discriminatory or retaliatory conduct.”

Shifting the OR environment away from one of bullying toward one of cooperation and teamwork starts with creating a code of conduct with “a zero tolerance toward bullying and other toxic behaviors,” says Groah. “This should be communicated during the orientation of all new OR personnel hires.”

Groah also stresses the importance of implementing what she calls a “just culture” in the OR.

“This creates an environment of trust in which all perioperative team members are acutely aware of the distinction between acceptable and unacceptable behavior,” she says.

“In a just culture, individual accountability is established and appropriate actions are taken when disruptive behavior is reported,” Groah adds. “Leaders have a responsibility to create an open and supportive environment where team members’ concerns and questions are responded to without retaliation.”

If any kind of bullying or incivility does occur, it should be investigated as soon as possible after the incident and the findings reported to HR or the appropriate person or department.

“And prompt feedback needs to be provided to all the individuals who were involved in the incident, as well as the final results of the investigation,” says Groah.

5 Cs of Eliminating Bullying

Mask has identified what she calls the “5 Cs” of eliminating bullying and promoting teamwork in the OR:

  1. Improve Communication
  2. Focus on Culture
  3. Stress Collaboration
  4. Build Camaraderie
  5. Practice Conflict resolution

“I strongly believe that every patient deserves a surgical experience in which he or she is the sole focus of the entire surgical team,” says Mask. “Denying any patient of this is deplorable, in my opinion.”

Smith points to The Joint Commission’s recently released Sentinel Event Alert 57 that stresses the essential role of leadership in developing a safety culture in health care organizations.

“This Alert stresses the fact that to advance trust within the organization, health care leaders must adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors, including behaviors in the OR,” says Smith.

“Physician and nursing leaders should both model appropriate behaviors,” adds Smith. “In addition, there should also be a structure in place to allow for non-punitive reporting of issues related to bullying and an effective governance structure to respond to such instances.”

Visit to download an infographic created by The Joint Commission discussing the 11 tenets of a safety culture in health care organizations.

A Tough Question

So is bullying a problem in your healthcare organization? Mask says you should ask yourself whether or not you would have surgery in your own hospital. “If the answer is ‘no,’ then you’ve got some work to do,” she says.



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