February 25, 2010 -- Recent news reports reveal that many nurses around the world confront high levels of abuse from patients and colleagues. On February 4, the OneIndia web site posted an unsigned item from ANI, the South Asian news agency, about an Australian study published in the U.K.-based Journal of Clinical Nursing that found not only that most nurses had been physically assaulted at work, but that many nurses considered violence to be "just part of the job." That short piece does a good job of conveying the magnitude of the problem and of highlighting nursing research, though it might have dug a little deeper about why nurses may view abuse that way, and it might have clarified that lead study author "Dr. Rose Chapman" is a nurse with a PhD, not a physician. Today, the News Chief (Winter Haven, FL) ran a longer Scripps Howard News Service report by Lee Bowman discussing recent studies suggesting that conflict among nurses and physicians is "rampant." The piece provides valuable information about the nature of such conflict and the growing awareness that it undermines patient care. But the report also implies that all concerned are more or less equally responsible, making no real effort to explore the power disparity between the two professions, which professions are more likely to suffer which forms of abuse, or whether aggression among nurses might be rooted in nursing's disempowered status. So readers are likely to come away thinking nurses and physicians confront a similar situation with regard to workplace abuse, an idea that is false and unhelpful, as problems are hard to solve if some of the root causes are ignored. Still, we thank those responsible for both of these important articles.
The ANI report is headlined "Nurses consider workplace violence part of their job, finds Oz study." The piece explains the key findings of the study:
The study showed that three-quarters of nurses who provide private and public care have experienced workplace violence, with 92 percent saying they have been verbally abused, 69 percent saying they have been physically threatened and 52 percent saying they had been physically assaulted. A total of 2,354 incidents were reported to the research team, with nurses facing an average of two to 46 incidents a year. ... The 113 nurses who took part in the study were mainly female, in their early 40s and had been in the profession for between six months and 40 years, with an average service of just under 18 years.
The piece says that the study's "lead author" was "Dr Rose Chapman, from Curtin University of Technology in Perth, Western Australia," and it gives her several quotes. She explains:
The nurses in our study were reluctant to report episodes of workplace violence unless they considered the event to be serious. ... 30% did not report incidents because they felt workplace violence was part of the job and 50% said that when they had reported an event, senior managers had failed to take action. This finding was supported by a retrospective audit of the hospital's formal incident reports, which showed that 96 percent of the reporting nurses had received one or more injuries as the result of a violent incident in the workplace.
Chapman concludes that reducing workplace violence requires better understanding of why nurses may fail to report it, and that more research about how people adapt to violence is needed. The piece does not pursue this, but it might have done more to suggest why the nurses might feel that suffering violence was part of their jobs. Could it relate in part to the gender makeup of the profession? To its relative lack of power? In addition, many nurses say that their reports of such incidents are often not taken seriously by hospital managers, and that they are expected to just "get over it" as if it was indeed "just part of the job."
The OneIndia report presents Chapman as an authoritative health expert. But without any indication that she is a nurse with a PhD, or that she teaches in the nursing program at Curtin, many readers may assume she is a physician. That would not only result in others getting credit for nursing research, but might also suggest that physicians direct nursing research, and perhaps nursing generally, a common misimpression that is very damaging.
The report says that the study was published in the February issue of the Journal of Clinical Nursing, and it also quotes this UK-based journal's editor Roger Watson, "from the University of Sheffield." Identifying this journal is very helpful, showing readers that there is such a thing as nursing research, which seems pretty basic but is far from universally understood. Watson says:
Workplace violence is never acceptable and it is a very sad indictment of society today that so many of the nurses in this study saw these incidents as part of their job. ... It is vital that workplace violence is tackled to ensure that healthcare systems are able to retain good quality, trained staff.
Watson also echoes Chapman's comments about the importance of research that addresses what affects reporting of such incidents. Here again, these are helpful quotes, particularly in drawing the link between reducing violence and retaining staff, but it would also have been valuable for the report to note that Watson himself is a prominent nursing scholar.
The News Chief headlines the Scripps Howard report, "There's a lot of bad blood between docs, nurses." Its main theme is that "surveys and studies in the past decade suggest that bad blood - and bad behavior - between and among doctors and nurses is rampant." It's not clear that any particular recent study led to the article, as if Bowman and his editors simply decided that a piece on the overall state of these relations might make a good story. The piece's initial hook is that some of the difficult health care characters on television "reflect a troubling reality," that health workers may not always be so nice (the piece cites "churlish" physicians Greg House and Perry Cox from Scrubs, as well as "rule-defying" nurse Jackie Peyton).
Then the report weaves together descriptions of the statistical and anecdotal findings of several studies. It begins with a reference to several anecdotes, though it's not clear if these are drawn from one or more of the studies:
Some behavior is so extreme that it could result in assault charges -- the surgeon who hurls a scalpel across an operating room in a fit of anger, the internist who attempts to stuff a nurse into a trash can or the nurse who squirts a used syringe in a co-worker's face or amends a chart to sabotage a doctor.
We're not so sure amending a chart could result in assault charges. Anyway, the piece describes the 2009 American College of Physician Executives survey of more than 2,100 nurses and physicians that found "98 percent of both professions had witnessed behavior problems between physicians and nurses in the past year," and 10% see it every day. The piece quotes one nurse respondent:
The worst behavior problem is not the most egregious. It's the everyday lack of respect and communication that most adversely affects patient care and staff morale.
The piece notes that 85% of survey respondents cited "degrading comments" and 73% "yelling between colleagues"; other "common problems" included "cursing, inappropriate jokes and refusing to work with one another." The article mentions that more than two thirds of those who responded were nurses, but does not discuss what that might mean. Does that percentage reflect who was asked to respond? If so, does it skew the results? If not, does it suggest that nurses are far more likely to experience serious abuse?
The piece goes on to note that a 2002 survey of nurses at 50 hospitals found that 94% had seen a physician acting in a
disruptive manner,...but a 2004 survey that included hospital pharmacists found that while doctors were most likely to engage in intimidating behaviors such as threatening to complain to a worker's boss, nurses were nearly as likely to make threats or refuse to answer phone messages about pharmacy orders.
The article rightly notes that the wider clinical setting, which of course includes patients and families, involves a great deal of stress. It cites a survey of emergency nurses that found half had experienced violence on the job, including being "hit, kicked, scratched or spit on." And it notes that surveys covering "more hospital departments" found rates of violence of "more than 13 percent" and "30 percent to 50 percent reporting verbal abuse from patients," though the article does not make clear whether those surveyed were only nurses.
To its credit, the report explains that the problems can threaten patient care, noting that any job can include conflict, but "relatively few workplace dustups endanger lives and long-term health." The 2002 "nurses-only survey" found that 60 percent knew of "adverse medical events" that may have stemmed from the disruptive behavior, and the 2004 survey, by the Institute for Safe Medication Practice, "found that 40 percent of clinicians have remained silent or passive rather than question possibly dangerous orders issued by a doctor or nurse who has a reputation for intimidation."
This is all valuable information, but overall, the way it is presented suggests that nurses and physicians are more or less equally responsible, and that they confront similar situations in the workplace. Note how the piece quickly counters the findings of the 2002 nurse survey with the description of the 2004 survey that suggests nurses were "nearly as likely" to make threats or "refuse" to answer phone messages about pharmacy orders. The great majority of the descriptions here suggest simply that "bad conduct happens," and everyone is at fault. That's true, to some extent, but did these studies really find that nurses, statistically or anecdotally, tended to throw dangerous objects at physicians? Scream at physicians? Threaten or insult physicians? Is there really a lot of evidence that physicians are too intimidated by the power disparities to challenge dangerous care plans by nurses? Are surgeons commonly too scared of powerful, revenue-generating OR nurses to stop them from making mistakes that endanger patients' lives? Do physicians generally have to suggest alternative care options to nurses in the most indirect and coded ways, to persuade nurses that in fact the nurses have thought of ideas the physicians really came up with, all in order to protect fragile nursing egos and avoid scary nursing tantrums? Are physicians as likely to be hit or kicked or scratched?
Physicians have more, often far more, power than nurses do in most clinical settings. And research has shown that disruptive physician conduct and abuse of nurses by patients are major factors in nursing burnout and poor care. We are aware of nothing to suggest that nurses or patients present a comparable problem for physicians, though it would hardly be surprising if some nurses tried to strike back at physicians with whatever weapons they felt they had, such as (as the piece suggests) sabotaging charts, nor if some nurses transferred the aggression they felt powerless to return onto their fellow nurses. Horizontal aggression, captured in the phrase "nurses eat their young," is a significant problem in nursing.
The Scripps Howard report does, to its credit, discuss measures to resolve the problems. The piece notes that this workplace "crossfire" makes it "hard to focus on quality," and that because the evidence is mounting that the "lack of a team approach" is hurting care, the Joint Commission on Healthcare Accreditation and others are starting to address the problems.
The commission early last year set a new standard that hospitals must have in place -- a code of conduct that defines acceptable and inappropriate behavior and sets up a process for dealing with disruptive behavior. Many hospitals already have codes or policies for staff conduct, but may have left enforcement to supervisors or peer committees. By putting complaints in the framework of patient safety, the commission envisions disruptive behavior being taken more seriously. At the same time, many medical educators are trying to make doctors, nurses and other professionals better team players by setting up "shadow days" and seminars to help them understand one another's responsibilities and treat each other with greater respect.
These are all promising measures, and we commend this article for including them. Still, we have to note that pretending everyone is similarly situated is not helpful. Of course everyone should be held to the same standards of conduct, but it would be absurd to suggest that nurses have as much to learn about what physicians do as physicians have to learn about nursing. Nurses spend a lot of time focusing on what physicians are doing and what they want, because physicians have a lot of power and influence over what happens to nurses' patients, and because nurses do carry out many physician care plans. And of course, given the media's enduring fascination with physician practice, it would be difficult for anyone who spends time awake not to have some understanding of what physicians do. Certainly nurses could benefit from measures to help them see things from physician perspectives; nurses should have realistic views of what physicians can be expected to know and do, and they should realize that physicians are human beings. But the relative positions of the professions are not really similar. Many physicians enjoy a level of impunity because of their social and economic status. And impunity is often corrupting. Of course, there are promising shadowing programs to help physicians understand nursing, as well as university programs in which those studying to join the two professions learn together, and we have always encouraged such programs.
Despite some flaws, both articles convey helpful information, and we thank those responsible.
See the article "Nurses consider workplace violence part of their job, finds Oz study," posted on OneIndia.com on February 4, 2010.
See the article "There's a lot of bad blood between docs, nurses" by Lee Bowman from Scripps Howard News Service, published February 25, 2010.
See the article "Violence Is Part of the Job, Say Nurses, as Study Shows Only 1 in 6 Incidents Are Reported," published by Science Daily on February 3, 2010.
See the study by Rose Chapman, Irene Styles, Laura Perry & Shane Murdoch (January 12, 2010). "Examining the characteristics of workplace violence in one non-tertiary hospital" Journal of Clinical Nursing, Volume 19 Issue 3-4, Pages 479 - 488.