March 6, 2013 Liz Borkowski, MPH 0Comment

In the Washington Post, Sandra G. Boodman writes about anger management problems in healthcare:

At a critical point in a complex abdominal operation, a surgeon was handed a device that didn’t work because it had been loaded incorrectly by a surgical technician. Furious that she couldn’t use it, the surgeon slammed it down, accidentally breaking the technician’s finger. “I felt pushed beyond my limits,” recalled the surgeon, who was suspended for two weeks and told to attend an anger management course for doctors.

The 2011 incident illuminates a long-festering problem that many hospitals have been reluctant to address: disruptive and often angry behavior by doctors. Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren’t moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions.

While it may be a small percentage of doctors (and, sometimes, nurses) who have such extreme problems with anger, disruptive behavior can have far-reaching effects. Boodman reports that attention to the problem is growing, with more hospitals and state medical boards sending doctors with poor behavior to anger management programs. The surgeon who fractured the technician’s finger told Boodman that such a program helped her learn to regulate her emotions and present a more appropriate demeanor.

Some of Boodman’s sources point to “brutal” medical training as a factor in the obnoxious behavior this 3-5% of physicians displays. Such systemic factors are the focus of a new report from the National Patient Safety Foundation, which addresses the physical and emotional harm that drives alarming numbers of healthcare workers from their jobs. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Healthcare is report from NPSF’s Lucian Leape Institute coming out of the SEIU-funded Roundtable on Joy and Meaning in Work and Workforce Safety.

When it comes to occupational health, I tend to prioritze things “free from recognized hazards” rather than squishier factors like “joy” and “meaning,” but it’s important to remember that many healthcare workers enter the field and take on demanding work because they find joy and meaning in doing so. The report sums up the situation this way:

The health care workforce is composed of well- intentioned, well-prepared people in a variety of roles and clinical disciplines who do their best every day to ensure that patients are well cared for. It is from this mission of caring for people in times of their greatest vulnerability and need that health care workers find meaning in their work, as well as their experience of joy.

Yet many health care workers suffer harm— emotional and physical—in the course of providing care. Many are subjected to being bullied, harassed, demeaned, ignored, and in the most extreme cases, physically assaulted. They are also physically injured by working in conditions of known and preventable environmental risk. In addition, production and cost pressures have reduced complex, intimate, caregiving relationships into a series of demanding tasks performed under severe time constraints. Under these conditions, it is difficult for caregivers to find purpose and joy in their work, or to meet the challenge of making health care safe for patients they serve.

Physical hazards facing healthcare workers include unsafe lifting conditions and exposure to bloodborne pathogens. The report cites a recent national study in which nearly one-third of nurses reported experiencing a back or musculoskeletal injury within the past year. This has consequences for patients, the report points out: “A striking 75.9% of nurses surveyed by the American Nurses Association indicated that unsafe working conditions interfere with the delivery of quality care.”

Mocking, bullying, and threatening of healthcare workers can also have consequences for patients. “Repeated experiences of disrespect and humiliation lead to avoidance, communication blocks, and distraction,” the authors explain. “A culture that tolerates disruptive, degrading, and patronizing behavior lacks psychological safety for its workers. In such an environment, workers often do not feel safe about reporting an error—their own or that of another—because of fear of punishment.”

Boodman’s Washington Post article includes the story of a nurse who called a physician at home with worries that a patient might have developed aspirational pneumonia (which can occur when patients inhale food or other substances into their lungs). The physician reportedly told the nurse to “get better training” and refused to address her concern – and the patient died.

Both pieces also point out that healthcare workers who face physical or emotional strain on the job are more likely to burn out and quit than are workers in healthier environments. Recruiting and retaining healthcare workers is crucial for meeting our population’s growing healthcare needs.

The National Patient Safety Foundation report highlights several examples of healthcare organizations “in which the values of respect, teamwork, and transparency are prized, and in which health care providers operate freer from injury and experience their work as more meaningful.” They also recommend seven strategies for developing effective healthcare organizations where workers find joy and meaning and patients are protected from harm:

Strategy 1: Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.

Strategy 2: Adopt the explicit aim to eliminate harm to the workforce and to patients.

Strategy 3: Commit to creating a high-reliability organization (HRO) and demonstrate the discipline to achieve highly reliable performance. This will require creating a learning and improvement system and adopting evidence-based management skills for reliability.

Strategy 4: Create a learning and improvement system.

Strategy 5: Establish data capture, database, and performance metrics for accountability and improvement.

Strategy 6: Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.

Strategy 7: Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and our patients.

You can download the white paper or the entire report here.

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