By Debra Wood, RN, contributor
August 12, 2013 - Nurses working in negative environments suffer from more verbal abuse from physicians and harbor less favorable work attitudes than their peers, according to a recent study by the RN Work Project. But the investigators could not determine causality and ask whether poor working conditions create an environment in which physicians are more likely to be abusive, or does verbal abuse by physicians create an unfavorable work environment.
Carol Brewer, PhD, RN, FAAN, said higher levels of verbal abuse by physicians are correlated with poorer perceptions of the work environment across the board.
“I think in places where staffing is poor, supervisory support is poor, leadership is poor and culture doesn’t support respect for colleagues, abuse is more likely to happen, but we cannot answer that,” said Carol Brewer, PhD, RN, FAAN, professor at the University at Buffalo School of Nursing in New York.
The RN Work Project, a program of the Robert Wood Johnson Foundation (RWJF), focuses on new nurses’ career changes and work attitudes. Brewer and Christine T. Kovner, PhD, RN, FAAN, professor at the New York University College of Nursing, direct the project. They first surveyed newly licensed nurses in 2006 and will continue to study them until 2015. The study draws on data from nurses in 34 states, covering 51 metropolitan areas and nine rural areas.
The project’s prior research indicated verbal abuse was a problem. For this study, reported in Nursing Outlook, they and colleagues surveyed 1,328 RNs in the cohort about how often they experienced verbal abuse from physicians and the nature of the abuse.
They found nurses on the receiving end of one or more episodes of verbal abuse by a physician in the last three months had less favorable perceptions of their work environments, lower intent to stay in their jobs and lower commitment to their organizations. The nurses experiencing the most abuse from physicians--five or more episodes over the last three months--also reported poor collegial relations between nurses and physicians, more verbal abuse among nurse colleagues, poor workgroup cohesion and more work–family conflict.
“Verbal abuse sets a tone that impacts satisfaction,” Brewer said. “The whole environment makes a difference.”
Other factors that contribute to the work environment include workforce aggression, workflow and institutional constraints, workload and staffing.
Younger nurses, those working in hospital settings, working day shifts and working on units that were short-staffed were most likely to report experiencing verbal abuse by physicians.
Working in Magnet hospitals was associated with lower levels of verbal abuse by physicians, something Brewer expects could be related to the more positive nurse work environment in Magnet facilities.
“The hallmark of the Magnet hospital is the work environment is healthier,” Brewer said. “They are paying more attention to the things that impact the nurses’ work environment. But you don’t have to be a Magnet hospital to have a good work environment.”
The Joint Commission has recognized that intimidating and disruptive behavior, including verbal outbursts, can undermine a culture of safety. Its 2008 Sentinel Event Alert maintains that “safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.”
The RN Work Project study did not assess how verbal abuse may affect patient care, but Brewer agreed that is a concern.
“The implication is always, ‘What effect does it have on patient care?’” Brewer said. “We already know nurse–physician communication matters.”
Many health care organizations, recognizing the risks, have worked to improve communication skills but verbal abuse remains a persistent pattern.
Christine T. Kovner, PhD, RN, FAAN, urges health care organizations to do more to create positive, healthy environments.
“Physicians’ verbal abuse of nurses is a long-standing problem and one we need to do much more to address,” said Kovner, in a statement. “It hurts morale, breeds further verbal abuse, and is associated with nurse intention to leave, particularly among younger nurses. All of these things ultimately reduce the quality of patient care. Health care organizations need to do much more to create positive, healthy work environments.”
In a toxic environment, nurses often become stressed and lack important resources; this may cause them to become snippy with physicians, leading to an escalation in tensions.
“When people are under stress, they don’t behave as they should,” Brewer said. “If leadership doesn’t say ‘I don’t care how stressed you are, you still have to be polite,’ you have the situation where the behavior can flourish.”
The authors suggest policies to prevent verbal abuse should be developed in cooperation with nursing leaders, key physicians and administrators.
“If leadership tolerates abuse from physicians, who are already in a higher-power position than nurses, it sets a tone,” Brewer said. “If nurses don’t get support from their higher-ups, the message is ‘Shut up and take it,’ which is not what you want to have happen. There is a power dynamic. The only structured way to approach it is to get support throughout the organization.”
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