Nurse manhandled by doctor

CountyRat · Oct 1, 2008

scrubby: get. a. lawyer!

you are one brave woman. you are doing a great job handling this, and you have my admiration and respect. in your first two posts, you were a weak victim, but not any more. you have rejected that role, and become a strong, active player. it is great that you are talking with your assaulted coworker, supporting her, and encouraging her to report the crime to the police. bravo!

how does that feel? do you feel different today than you did two days ago? i really want to know. please respond.

but first, get. a. lawyer!!!

rph3664 · Oct 1, 2008

I let the nurse know that if she wanted to call the police then I would be more than happy to be a witness.
The nurse involved is new to our department and country and her English isn't 100%. Today she seemed really confused on what to do because everyone was telling her different things. I thought the best thing for her was to go home and have a think about it because the last thing she needs is pressure put on her.
If it were me I would definitely be calling the police. I don't care what management or the CNC would have to say about it because what he did was illegal.

I haven't read the rest of the thread, so I definitely have a question. Is the doctor foreign too?

rph3664 · Oct 1, 2008

I've heard of this happening back in the day, but thankfully, have never seen it or had it happen to me.
The nurse who was victimized should have pressed charges(after the crisis was over of course). You can bet I would have.

When my mom was a hospital volunteer in the early 1970s, she saw a very prominent OB backhand a nurse in the nurse's station because she didn't get him something soon enough.

Why he was prominent was a complete mystery because he was abusive to his patients too. His favorite thing was doing episiotomies, whether they were necessary or not, and then sewing up the women so tight they couldn't have sex with their husbands. :eek: I knew his son when we were teenagers, and the son was a pompous jerk himself.

lindarn · Oct 2, 2008

I couldn't have handled it better myself, and it's amazing the way the facts get twisted- but so predictable.
Has anyone involved thought about putting in a complaint with the medical board?

You should definately write a letter to the State Medical Board. I have called the medical board concering physicians, and I was told that they wish more nurses would write letters to them concerning abusive and/or negligent phsyicians. This way they can start a "paper trail" on them, in case there comes a time when the you know what hits the fan.

Too often, there is a really bad situation, somone finally calls the medical board, and then the doctor's defense attorney states, "Well, as you can see, my client's record is immaculate. Not one complaint against his license". And you know, he is probably right. At that point, there is minimal what the board can do. With no other complaints on their record, they are going to walk with no more than on a slap on the wrist. Remember that when you decide not to make a formal complaint against a physician. It really does make a difference.

Lindarn, RN, BSN, CCRN

Spokane, Washington

finn11707 · Oct 2, 2008

This falls under workplace safety/violence---there are definitely regulatory bodies, laws and guidelines for healthcare organizations---OSHA might direct, Board of Registered Nursing, American Nurses Association, The Surgical Nurses professional organization---check them all out. Does your employeer have an EAP program which supports staff? If not, definitely make an appointment with an MD and be sure he documents all details along with stress, insomnia, lack of concentration, anxiety results---you definitely have concerns and injury as wittness to this abuse. We all have an ethical responsibility to report abuse and safety risks in the workplace---this was dangerous to the patient safety and others and an assult to your coworker. This cannot slide, you are right to stand up AND brave.

Scrubby · Oct 2, 2008

This falls under workplace safety/violence---there are definitely regulatory bodies, laws and guidelines for healthcare organizations---OSHA might direct, Board of Registered Nursing, American Nurses Association, The Surgical Nurses professional organization---check them all out. Does your employeer have an EAP program which supports staff? If not, definitely make an appointment with an MD and be sure he documents all details along with stress, insomnia, lack of concentration, anxiety results---you definitely have concerns and injury as wittness to this abuse. We all have an ethical responsibility to report abuse and safety risks in the workplace---this was dangerous to the patient safety and others and an assult to your coworker. This cannot slide, you are right to stand up AND brave.

I don't work in the US so we have different laws and regulatory bodies. I'm going to be making further enquiries to ensure that we are doing all we can at this point. It's not as easy here to actually sue a person, though it can be done here down under it's a lot harder.

The way I see it me and the other nurse have taken the first step by making the incident known to management. Today the nurse who was treated in this disgusting manner also handed in a formal complaint. She described how this has affected her psychologically. She said that she no longer wishes to remain in this country (she recently came from overseas), does not feel safe at work and that she is reconsidering her nursing career.

Hopefully this will throw a spanner in managements little plan because it's clear from my interview they are just trying to manipulate her into saying that it's all ok, she understands, happens in a crisis.

I have spoken with a relative of mine who is a human resources manager and used to be a professional mediator with my state government. What she has told me that unfortunately in my state we tend to 'educate' these people rather than giving out 'punishment'.

If I believe that this matter is going to just end with it being treated like something trivial I'm leaving my workplace. I refuse to work where violence is condoned in ANY circumstance. I did not put myself into debt and study hard for three years to work for an organisation where my coworkers are going to get away with violence.

I want to thank you all for your support through this. I will update and let you know what happens. Unfortunately I'm sure it won't be positive. .

finn11707 · Oct 2, 2008

Scrubby--It does sound like you are starting from scratch - so the goal might have to be one of making a loud point out of this as best you can. But just because the protections aren't in place now, doesn't mean it can't change. In the 30+ years of my nursing here in the USA I have witnessed lots of improvements around dealing with MD workplace verbal abuse, sexual harrassment and MD hissy-fits on the job. I recall several brutally disrespectful MDs at the beginning of my career and it just is not there now. It did not happen over night. It took many nurses speaking up to demand respect in the workplace and a safe work environment. Just speaking up loudly can have great healing power. I know what you mean about moving on if your employer does not give enough support to you and your co worker in this issue. Chin up!

Scrubby · Oct 11, 2008

Update:

There will be a meeting on Monday with myself, the nurse and the doctor. I'm dreading it because I fear me and this nurse will be made to feel like we're being drama queens and that we will be criticisd for not doing the right thing during this crisis.

I am going to remain silent so this nurse can do the talking. I don't want to 'take over' because I'm just the witness. The last thing I want to do is give anyone the impression that I'm being melodramatic.

I think this doctor will probably say he did the right thing at the time, was trying to help the patient and that we are dramatising the whole thing. If this happens then I am going to disagree with this and say that what I saw was unprofessional and not safe for the staff or the patient. I will say that I don't believe there is any justification for yanking a nurses arm in this way to stop bleeding.

If the management take his side and say it was all for the good of the patient, a first time offence for this doctor, and understandable given the stressful situation, well theres not really a lot I can do about their attitude is there? I will request then that if this is considered as acceptable behavior then I will refuse to work with him I fear standing next to him if a similar situation was to happen. I will say I have worked with other doctors in similar circumstances who have always remained calm and rational in emergencies and would prefer to work with them.

Wish me luck!

Will update Monday night.

morte, LPN, LVN · Oct 11, 2008

Update:
There will be a meeting on Monday with myself, the nurse and the doctor. I'm dreading it because I fear me and this nurse will be made to feel like we're being drama queens and that we will be criticisd for not doing the right thing during this crisis.
I am going to remain silent so this nurse can do the talking. I don't want to 'take over' because I'm just the witness. The last thing I want to do is give anyone the impression that I'm being melodramatic.
I think this doctor will probably say he did the right thing at the time, was trying to help the patient and that we are dramatising the whole thing. If this happens then I am going to disagree with this and say that what I saw was unprofessional and not safe for the staff or the patient. I will say that I don't believe there is any justification for yanking a nurses arm in this way to stop bleeding.
If the management take his side and say it was all for the good of the patient, a first time offence for this doctor, and understandable given the stressful situation, well theres not really a lot I can do about their attitude is there? I will request then that if this is considered as acceptable behavior then I will refuse to work with him I fear standing next to him if a similar situation was to happen. I will say I have worked with other doctors in similar circumstances who have always remained calm and rational in emergencies and would prefer to work with them.
Wish me luck!
Will update Monday night.

i think this is another "wait till monday" let them stew over the w/e, set up

are you uinion? even a local nurses organization? other than that, i would bring some disinterested third party, and insist that there be physical distance between you and the doc, and that you are between the door and he, not the other way around.....have all other witnesses provided statements??

finn11707 · Oct 11, 2008

UMAN RESOURCE MANAGEMENT

Highlight, copy & paste to cite:

Martin, A., Gray, C. & Adam, A. (2007). Nurses’ Responses to Workplace Verbal Abuse: A Scenario Study of the Impact of Situational and Individual Factor, Research and Practice in Human Resource Management, 15(2), 41-61.

Nurses’ Responses to Workplace Verbal Abuse: A Scenario Study of the Impact of Situational and Individual Factor

Angela Martin, Cynthia Gray & Andrea Adam

Abstract

Verbal abuse in the workplace represents a costly problem for human resource management, with implications for staff productivity and retention. Nurses are a profession exposed to extremely high levels of verbal abuse, particularly from patients, but also from colleagues, making these abusive behaviours, and reactions to them, of vital significance to hospital personnel management professionals. The present study investigated the extent to which responses to verbal abuse scenarios varied as a function of the role and gender of the perpetrator, the situation in which the verbal abuse occurred, and the participant’s level of assertiveness, with a view to establishing key contributors for management attention. Participants were 62 female registered nurses. Results showed evidence of variation in cognitive, affective and behavioural attitudes toward the verbal abuse described, particularly as a function of situation. In particular, verbal abuse was reported to be more frequent, considered less acceptable and elicited more affective arousal in non emergency than in emergency situations. These findings were consistent with predictions that were based on attribution theory. Responses to verbal abuse also varied in relation to the nurse’s assertiveness, which is a finding suggesting that assertiveness training is a potential strategy for protecting employees against the effects of verbal abuse. This study has important implications for managers in hospitals, and indeed, other organisational settings in that dealing with verbal abuse requires cognisance of the need for the implementation of both organisational and individual levels of intervention, within a framework that acknowledges the complexity of responses to verbal abuse in the workplace.

Introduction

Workplace violence is an issue of global concern (Gill, Fisher & Bowie 2002), with potential negative ramifications for organisations including reduced productivity and morale, and increased absenteeism and turnover rates. It has been suggested that nurses are subjected to up to three times as much violence in the workplace than any other profession (Paterson, McCornish & Bradley 1999, Perrone 1999). Verbal abuse is an insidious form of workplace violence that is a major contributor to dissatisfaction and high rates of attrition in nurses (Vogt, Cox, Velthouse & Thames 1983, Bush & Gilliland 1995, Smith 1997, Sofield & Salmond 2003). Although patients are a major source of workplace violence for nurses, it is noticeable nurses have also reported workplace violence from colleagues, with incidences of up to 36 per cent reported in private hospitals (Hegney, Plank & Parker 2003). This high rate of workplace violence towards nurses makes verbal abuse a significant concern for human resource management within hospital settings.

In order to understand the specifics of the nurses’ experiences of workplace verbal abuse, conceptualisations need to incorporate analysis of the hospital context. It has been hypothesised that the hierarchical nature of the hospital environment may contribute to high rates of verbal abuse through its hierarchical organisation and exposure to suffering and grief (Simms 2000). In addition, it is possible that workplace violence towards nurses is exacerbated by the traditional gender inequalities across roles of differing status that exist within hospital settings, where the lower status role of nurses has been compounded with a gender that has also traditionally accorded lower status. However, there is limited understanding of how gender interacts with the status differences between doctors and nurses to influence the frequency of, and reactions to, verbal abuse. In turn, this lack of information constrains understanding of the way changing gender distributions within nursing and doctoring professions might affect the experienced verbal abuse of nurses.

Empirical research into workplace violence, which might aid the development of strategies to deal effectively with abuse, has had practical difficulties (Douglas & Martinko 2001). This condition has resulted in the majority of literature being atheoretical and anecdotal in nature (Cusack 2000). In contrast, the current study was underpinned by several theoretical approaches that provide insight into the verbal abuse behaviour of doctors and nurses, including: Social Role, Social Identity, and Attribution theories. Furthermore, while the prevalence of verbal abuse may be relatively well known, the scenario methodology, that was adapted for this investigation, provides a format to examine workplace violence, in this case verbal abuse, in an empirical and replicable manner. This method also allowed systematic rather than incidental investigation into the impact that situational variables have on incidents of verbal abuse.

The aim of this study was to investigate how nurses’ reactions to verbal abuse are influenced by the role and gender of the abuser, and the situation in which abuse occurs. Because assertiveness training is a popular strategy currently promoted to deal with workplace violence (e.g., Milstead 1996, Mimura & Griffiths 2003), the ways in which the nurses’ assertiveness affects their experience of, and their likely reactions to, verbal abuse, was also examined. Several theoretically based predictions about nurses’ likely responses to verbal abuse enacted in a range of scenarios are developed in the following literature review. The remainder of the paper is structured in a scientific report format, culminating in a discussion of the findings in relation to the theoretical predictions that were made, and the implications for human resource management.

Literature Review

The Problem of Verbal Abuse

Verbal abuse in organisations is a central feature of the conceptualisations of counter productive work behaviour, workplace incivility, aggressive interpersonal behaviour, overt bullying and workplace violence (Arway 2002, Barron 2002, Fox & Spector 2005). Verbal abusers use aggressive communication tactics such as humiliation, sarcasm, insults, labelling, and blaming in an attempt to discredit the victim. It has been argued that verbal abuse is a less extreme, but more widespread form of workplace violence that has been empirically neglected in comparison with the study of physical attacks (Gill, et al. 2002).

The occurrence of verbal abuse has serious implications not only for the recipients of such communication, but also for the organisations in which the abuse occurs. An incident of verbal abuse can potentially reduce productivity, efficiency, and morale and could lead to increased absenteeism, higher turnover rates, greater recruitment costs, elevated workers’ compensation premiums, and possible legal defence costs (Queensland Government 2001). Affective responses to verbal abuse can vary from neutral, or unperturbed, to very distressed, potentially resulting in severe emotional impairment and reduced self esteem (Elgin 1980). Durkin and Wilson (1999) argued that verbal abuse could be as distressing as a physical attack. Antai-Otong (2001) found that the accumulated stress related to repeated experiences of verbal aggression was not only associated with psychological complaints such as depression, panic disorder, and posttraumatic stress disorder, but also could be related to physical ailments such as hypertension. Of particular importance for human resource managers, in healthcare settings, is the research has demonstrated that verbal abuse is one of the strongest factors that contributes to dissatisfaction and high rates of attrition in nurses (Vogt, et al. 1983, Bush & Gilliland 1995, Smith 1997, Sofield & Salmond 2003).

Role and Gender Influences on Responses to Verbal Abuse

Nurses have frequently described their work environment as a hostile climate where scapegoating, disrespectful treatment, and lack of support are commonplace (Smith, Droppleman & Thomas 1996). Healthcare settings are thought to be predisposed to verbal abuse behaviours by the frequent occurrence of high level stressors such as failure to cure, suffering, and death. It has been theorised that unexpressed grief in staff may surface as aggressive behaviours such as verbal abuse (Simms 2000). It has also been argued that the potential for verbal abuse rises when collaboration and communication are overridden by hierarchical structures, such as those observed within hospitals (Simms 2000). Organisational culture within hospitals is deeply entrenched in a hierarchical structure, which recognises doctors as the pinnacle of the organisation and the sole possessors of power (Numerof 1978, McCall 1996, Smith, et al. 1996). This power is derived from a number of sources such as expert and legitimate power invested by the organisation, as well as power drawn from gender inequality, reflecting the fact that historically the majority of doctors have been male and the majority of nurses have been female (Pokalo 1991, Woodward & House 1997, Worchel, Cooper, Goethals & Olsen 2000). Thus, a feminist analysis links hospital culture to the broader patriarchal structure that operates to subordinate women in society. It is argued that verbal abuse is one strategy used by men as a method of asserting and maintaining this dominance (Bruder 2001).

Another important concept in theorising aggressive behaviours such as verbal abuse is that of gender roles. This notion advances the socially determined classifications of ‘appropriate’ behaviour as prescribed by gender. According to Social Role theory, gender roles are evident in social expectations that women should be communally oriented and primarily concerned with the welfare of others, whilst men should display more ‘agentic’ characteristics such as independence and assertiveness (Eagly 1987). The social role of the nurse aligns with traditional female roles through caring for the sick, whilst functioning as a supportive labour force for doctors. This role is described by Muff (1982) as involving and following the orders of doctors, running their errands, and tolerating their abuse and rudeness.

It could be argued that the power gradient between men and women is fading. Recent social changes have reflected an increasing convergence of gender roles and an increase in women’s access to previously male dominated roles, such as medicine, and the power associated with those roles (Diekman & Eagly 2000). However, Inglehart and Norris (2003) noted that women continue to predominately hold jobs of lower status and rewards, and recent literature shows that very little has changed in the area of gender roles for doctors and nurses (Simms 2000, Bruder 2001, Cook, Green & Topp 2001, Dunn 2003, Sofield & Salmond 2003).

An analysis of verbal abuse informed by issues of power, status and social roles support the expectation that this behaviour is more likely to occur with doctors as perpetrators and nurses as victims (known as vertical violence). Substantial literature has documented that doctors are a frequent source of verbal abuse attacks on nurses (Lopez 1993, Begany 1995, Farrell 1999, Simms 2000, Bruder 2001, Cook, et al. 2001, Sofield & Salmond 2003, Buback 2004). For example, one study reported that two thirds of nurses acknowledged they had experienced verbal abuse from a doctor in the previous twelve months (Begany 1995). However, it is important to note that the verbal abuse of nurses is not restricted to doctors alone. Hegney, et al. (2003) also reported that apart from patients and doctors, other nurses are a frequent source of verbal abuse. The phenomenon where employees in similar roles become the instigators of aggression and violence towards each other was first investigated amongst nurses, and became known as horizontal violence (Taylor 2001, Bowie 2002). Horizontal violence between nurses has long been acknowledged as a negative adaptation of oppressed group behaviour related to the subordination of women within the health care system (Duffy 1995, McCall 1996, Smith, et al. 1996, Roberts 1997, Dunn 2003). Freire’s (1970) model of oppression argued that subordinate groups learn to value the norms of the dominant group whilst simultaneously learning to abhor their own attributes. As evidence of this, when nursing leaders emerge, they inevitably adopt the values of the dominant group (doctors) which results in internal domination of nurses by members of their own group (Roberts 1983, Duffy 1995). Further, Cox (1994) suggested that verbal abuse by nurses that is directed at other nurses and perceived subordinates, could be seen as a coping mechanism related to frustration and negative self esteem as a consequence of being treated as inferior members of the healthcare team.

Another theoretical perspective relevant to exploring the reactions to verbal abuse amongst doctors and nurses is Social Identity theory, which has made an important contribution to understanding the phenomena of social group behaviour (Tajfel & Turner 1979). In this framework it is argued that individuals see themselves as members of groups and they self categorise as a means of constructing and maintaining identity. Perceived membership of a group, the ingroup, is defined in relation to an outgroup. Ingroup members tend to be characterised with positive qualities and outgroup members are characterised with negative qualities (Worchel, et al. 2000). The purpose of this discrimination is to maintain or realise supremacy over an outgroup (Tajfel & Turner 2001). Social Identity Theory may offer an explanation of reactions to vertical and horizontal verbal abuse. It could be suggested that ingroup members (nurses or females — horizontal perpetrators) tend to perceive that outgroup members (doctors or males — vertical perpetrators) have negative qualities. Thus, verbal abuse from an outgroup member may fit the concept of negative qualities of the outgroup, and although offensive, it would not be an unexpected outcome. On the other hand, verbal abuse instigated by a member of one’s own ingroup (other nurses, or other women) would be considered more offensive, as ingroup members have higher expectations of positive characteristics amongst members and may include beliefs that members should respect one another and demonstrate ‘solidarity’. In accord with this theoretical rationale, and in particular Social Identity theory, several predictions were made in relation to female nurses’ responses to verbal abuse as a function of the gender of the actor. Although traditionally there is some overlap between gender and status (operationalised here as role), an increasing number of women are entering the medical profession changing the distribution of genders. Therefore, role and gender were treated as separate variables. From this theoretical underpinning the hypotheses H1 and H2 were conjectured.

H1: If the actor of verbal abuse was also a female (i.e., the same gender), it would be considered less acceptable and more upsetting, but the participant would be more likely to report an intention to deal with it assertively as status issues are less relevant.

H2: If the actor of verbal abuse was also a nurse (i.e., the same role) it would be considered less acceptable and more upsetting than if the actor was a doctor, but the participant would be more likely to report an intention to deal with it assertively as status issues are less relevant.

Other Situational Influences on Responses to Verbal Abuse

Another important contribution to developing an understanding of responses to verbal abuse is offered by Attribution theory (Heider 1958), which is increasingly utilised to explain behaviour in the workplace (Ashkanasy & Gallois 1994, Douglas & Martinko 2001). A pivotal notion of this theory is that people ascribe a particular behaviour a person exhibits as either a function of personal disposition (an internal attribution) or induced by the situation in which the behaviour occurs (external attribution). Research has shown that in conflict situations individuals demonstrate a strong propensity to analyse the cause of other people’s behaviour (Fiske & Taylor 1984). If the recipient perceives that there are mitigating circumstances for an attack, an external attribution will be made, the actor is ascribed less malevolent intent (Fiske & Taylor 1984), and lower levels of arousal, such as anger, or retaliation are observed (Baron 1985). Thus, it would be reasonable to anticipate that common situational variables, such as emergencies within the hospital environment, may induce an external attribution to be assigned to the actor of verbal abuse. In this case, the perceived acceptability of the behaviour, level of emotional reaction and likely behavioural response to the behaviour would differ from an internally attributed act of verbal abuse, a more likely attribution in a non emergency situation.

Attribution theory provides theoretical underpinning for the hypothesis H3 which combines several predictions regarding respondents’ attributions about the verbal abuse scenarios. Emergency situations could be expected to induce an external attribution to be assigned to the actor of verbal abuse and influence the perceived acceptability of the behaviour, level of emotional reaction and likely behavioural response.

H3: In a non emergency situation verbal abuse would be considered less acceptable, affective arousal to verbal abuse would be greater and the intended behavioural response would be more assertive than in an emergency situation.

Individual Influences on Responses to Verbal Abuse - Assertiveness

Regardless of the situation and attributions made, verbal abuse can have a negative impact on employees and organisations. Many organisations use education and individual empowerment strategies to manage the problem. Assertiveness training programmes for nurses are seen as an effective means of enabling them to cope with verbal abuse (Numerof 1978, McIntyre, Jeffrey & McIntyre 1984). For example, Cox (1991: 33) found “…the higher the [nurse’s] rating of assertiveness in the work setting, the more likely the nurse was to rate her handling of verbal abuse as good.”. However, it should be noted that many researchers have rejected general assertiveness training on the grounds that it often fails to deal with issues of culture, status and complex social rules (Alberti & Emmons 1982, Rakos 1997, Wilson, Lizzio & Zauner 2001). In addition, although it has been considered that assertiveness training may augment an individual’s motivation, satisfaction, and self esteem (Spreitzer 1997), the effectiveness of these strategies within the organisational context has been questioned. It has been argued that evidence for the efficacy of developing individual coping strategies within organisational settings is weak (Burke 1993) and only serves to heighten the employee’s tolerance of unacceptable behaviour (De Frank & Cooper 1987). It is often suggested that the most effective means of addressing the problem of verbal abuse within the workplace is to target the organisational culture (Burke 1993).

Despite these claims, assertiveness training for nurses remains a central part of stress management and conflict resolution as it enables them to express themselves more effectively during challenging situations and to use coping strategies (i.e., see the abuse as an indicator of a problem with the communication of the other party and not ‘take it on’ or let it be of detriment to their self esteem). Although concerns that assertiveness training fails to prevent verbal abuse from occurring have been raised, it is included in the present study due to its ubiquitous nature as a strategy for dealing with the problem of verbal abuse. Further, individuals vary in the extent to which they possess assertiveness skills and accordingly, their responses to verbal abuse could be expected to vary. Hence, it is an important individual difference variable in attempting to explain responses to the scenarios in the present research. The assertiveness literature provided the foundation for the hypotheses H4, H5 and H6 which predicted that participants’ cognitive, affective and behavioural responses to the verbal abuse will vary as a function of their level of assertiveness.

H4 Assertive participants would consider verbal abuse less acceptable and experience lower affective arousal in response.

H5: Assertive participants would be more likely to report the intention to respond actively than non assertive participants.

H6: Non assertive participants would be more likely to report the intention to respond passively than assertive participants.

These testable propositions were evaluated by simulating verbal abuse in the form of scenarios and gauging the participant’s likely responses to such events. Gender, role, and situational variables were manipulated in the scenarios and the effect of individual differences in assertiveness among participants on responses to verbal abuse was also examined. In terms of descriptive empirical evidence, the study also assessed the prevalence of verbal abuse episodes levelled at nurses (participants) by doctors (vertical violence) and by other nurses (horizontal violence) in the sample that was studied. The range of responses to the scenarios included how frequently participants had experienced behaviour similar to that described in the scenario, how acceptable they thought the behaviour was, what sort of emotional response they would be likely to have, and their intended behavioural strategy for dealing with the behaviour.

Method

Participants and Site

The participants for this study were a convenience sample of volunteers recruited from registered nurses working at an Australian private hospital. At this research site all the potential participants were all female nurses. As nursing remains a predominantly female profession (Smith, et al. 1996) it is argued that the all female sample was not problematic in terms of generalisability. Two hundred questionnaires were distributed to registered nurses via Nurse Unit Managers in six units of an Australian private hospital including the women’s and children’s unit, the surgical unit, the medical and orthopaedic unit, the operating theatre, the cardio thoracic unit, and the intensive care unit. A total of 70 questionnaires were returned, and this yielded a response rate of 32.5 per cent. The sample of female registered nurses were aged 20 to 60 years, (M = 38.87, SD = 10.67), with years of experience as a registered nurse being 0.5 to 43 years (M = 16.91, SD = 11.01), but eight participants were excluded from the study due to incomplete data on the Rathus Assertiveness Schedule, which reduced the sample size to 62.

Procedure

The completion time for the questionnaire was approximately 20 to 30 minutes. It was emphasised to the potential participants that participation was entirely voluntary and that they could withdraw from the project at any time. Confidentiality was assured as neither the questionnaires nor the envelopes contained any identifiers and each questionnaire was provided with a self sealing envelope. The participants were asked to place their completed questionnaires into the boxes provided in the staff room of each of the six units.

Measures

The pen and paper questionnaire distributed to the participants included an information sheet and a set of demographic questions such as age, and length of time working as a nurse. Also included were a series of eight scenarios, with ten questions relating to each scenario and the 30 item Rathus Assertiveness Schedule (Rathus 1973). The eight verbal abuse scenarios were adapted from vignettes used by Buback (2004), which depicted verbal abuse within a hospital operating theatre. The scenarios were confirmed as realistic and believable by a small group of experienced registered nurses who worked at the hospital that was sampled, and these nurses had skills in several specialities. These nurses were asked not to discuss the scenarios with other staff members and were excluded from the study.

Participants assessed each of the eight scenarios using ten, seven point scales. The first item assessed the frequency of experience or witness of the communication depicted in the scenarios (1 = Not at all frequently to 7 = Very frequently). The second item assessed the respondent’s view of acceptability of the communication (‘If I were [the nurse in this scenario], I would consider the perpetrator’s [perpetrator of the verbal abuse] verbal communication to be acceptable’) with a seven point Likert scale (1 = Strongly Disagree to 7 = Strongly Agree). The next four items assessed the participant’s emotional response to the communication (e.g., ‘If I were [the nurse in this scenario], I would feel. 1 = Not at all depressed to 7 = Extremely depressed). In an effort to establish an overall measure of affective response to verbal abuse, a composite variable was computed based on the total score of the four affective responses (angry, depressed, upset, and bothered). Correlations among the four affective responses (across all scenarios) were all significant (p <.01 and ranged from to indicating moderate high levels of common variance. a cronbach alpha coefficient was calculated using the four items as part scale across scenarios provide some evidence that composite measure tapping general level emotional arousal.>

The final four items of the ten item scale assessed the participant’s intended behavioural response to communication in terms of verbal abuse. The four behavioural intentions, identified within the study, could be positioned on a continuum from passive through to active. An entirely passive intended behavioural response to verbal abuse would be to ‘ignore the verbal abuser’ (Ignore). A slightly more active, but indirect option would be to ‘report the incident to your supervisor’. Rakos (1991) argued that assertive behaviour reflects the expression of one’s opinions and wishes directly, and for this reason Report was seen as an indirect response and next on the continuum from passive to active. A more active and direct responses to the verbal abuse would be to ‘tell the verbal abuser that the communication was not acceptable’ (Tell Them). This reflects the classic assertive response taught in social skills training. Finally, at the more active end of the continuum is an aggressive response ‘shout back at the verbal abuser’ (Shout Back). Although this response would be classified as aggressive rather than assertive, given the widespread culture of verbal abuse in the hospital setting, it was considered a likely, but active behavioural intention. Hence, it should be noted that behavioural intentions are operationalised as including both assertive and aggressive responses as the participant’s level of assertiveness may also predispose them to aggressive behaviour given the strong influence of hospital norms supporting such behaviour. Participants rated how likely they would be to use each of these responses in relation to the behaviour described in the scenario (1 = Not at all likely to 7 = Extremely likely). Participants were also given the opportunity to write their preferred response to the communication scenarios in case the seven point interval scales had not fully captured their response. These responses did not capture any different responses to verbal abuse. However, some of the comments supported the results, and these responses are referred to in the discussion section.

In an endeavour to circumvent priming effects, the Rathus Assertiveness Schedule (RAS) was placed at the end of the questionnaire, on a separate sheet of paper, so that the scenarios would be answered first. It was anticipated that this sequencing would also reduce the incidence of the participants guessing the hypotheses of the study and inadvertently affecting the results. The RAS has been shown to have moderate to high test-retest reliability (r = .78; p

Analysis

Responses on each of the first three dependent variables (1. frequency of similar episodes, 2. acceptability of the episode, and 3. affective response to the episode) were analysed in separate 2 (Role: doctor, nurse) x 2 (Gender: male, female) x 2 (Situation: emergency, non emergency) x 2 (Assertiveness: assertive, non assertive) mixed within and between subjects ANOVAs. Role, Gender and Situation were within subjects factors, and Assertiveness was a between subjects factor. Dependent variables were the level of perceived acceptability of the verbal abuse, the composite affective reactions score, and each of the separate behavioural intentions.

Results

Data Screening

Data analysis was conducted using the SPSS 11 .0 for Windows software programme. Prior to analysis, all dependent measures were examined through the SPSS programme to assess accuracy of data entry, the fit between variable distributions, and the assumptions of analysis of variance (ANOVA). For this study, there were a total of 89 variables. Data screening revealed that the assumption of normality had been violated for a proportion of these variables. Indeed 23 (25.84%) of the variables were found to have a positive skewness statistic greater than ±1. As both positive and negative violations of normality were represented, data transformation was not considered a viable option. In view of this violation of the normality assumption of analysis of variance (ANOVA), the more stringent epsilon adjusted values were used to interpret within subjects effects. The Greenhouse- Geisser estimation was chosen as it produces a stronger adjustment, and thus, offers a more conservative result (Tabachnick & Fidell 2001). Significance levels were set at .05 for all statistical analysis. However, more conservative p values are reported.

Frequency of Verbal Abuse

Across all scenarios 61.43 per cent of the nurses indicated that verbal abuse was not frequent (scores 1.00-2.99), whereas 37.14 per cent reported moderately frequent verbal abuse (scores 3.00-5.00), and a further 1.43 per cent described the abuse as very frequent (scores 5.01-7.00). An analysis of the reported frequency of the participant’s experience of similar verbal abuse scenarios revealed a significant interaction between Role and Gender, F (1, 60) = 26.29, p

Table 1

Means of Frequency of Abuse Non Emergency Situation Emergency Situation MD FD MN FM MD FD MN FM 3.512.872.422.552.992.482.282.34 (1.39)(1.33)(1.28)(1.31)(1.50)(1.23)(1.26)(1.28) Notes:

a. MD = Male doctor, FD = Female doctor, MN = Male nurse, and FN = Female nurse.

b. Values in parentheses are the standard deviations of the means.

Additional analyses also revealed significant main effects for Role, F (1, 60) = 15.01, p

Acceptability of Verbal Abuse

A significant interaction between Role and Situation, F (1, 60) = 5.51, p

finn11707 · Oct 11, 2008

Go prepared with examples of what other studies/focuses are doing to fight workplace violence--including specific noted verbal abuse of MDs towards nurses! I found the above study when I googled--and there are lots of others--reflects it as a real concern which is being focused on. Employers HEAR words like staff retention, harm to reputation, public awareness, ethical issues....as it will impact on their stand in the community and incoming profit. Again, I commend you for stepping forward. You are a credit to your profession--

finn11707 · Oct 11, 2008

raging bullies

a disturbing number of nurses face verbal abuse, mostly from physicians, and some hospitals are taking steps to improve relations

by heather stringer

february 12, 2001

illustration: young kim

[color=#666633]studies have shown that more than 90 percent of nurses have experienced verbal abuse.

you've read the article.

now tell us what you think.

mary, rn, began to feel uneasy the day she started her job at a hospital in california’s central valley. seasoned nurses in the unit warned her to avoid a particular surgeon and to make sure she had a more senior nurse with her whenever she worked with him. mary (not her real name) quickly discovered why.

she was shocked to see the physician yell at nurses, often using profanity. at first, other rns protected mary, but that lasted only a couple of months. sometimes, he’d point a finger 1 inch from her face as he shouted. she was constantly looking over her shoulder to see if he’d entered the unit.

"during a code situation, he would become out of control," mary said. "i was incapable of thinking. we’d freeze, and then he’d become more angry."

she began to have nightmares and felt anxious even outside of work. twice, he was so angry he threatened to kill someone.

"it terrified me," mary said.

research suggests that mary’s experience is not uncommon for nurses throughout the country. helen cox, ed.d., msn, rn, and laura sofield, msn, rn, each surveyed hundreds of nurses about their experiences with verbal abuse. cox conducted her study in 1991, sofield in 1999. both researchers found that more than 90 percent of nurses experienced verbal abuse, and most encountered an average of five incidents per month.

cox and sofield agreed that the most disturbing finding was that their results were remarkably similar, which led them to believe that verbal abuse is not on the decline. the majority of respondents named physicians as the most common perpetrators.

the surveys also revealed that verbal abuse has consequences. the majority of nurses in both surveys said the abuse increased turnover rates and contributed to the nursing shortage. most participants also reported that poor interactions with physicians caused an increase in the number of errors on the job.

although the statistics may be discouraging, some hospitals are pioneering strategies to improve physician-nurse relations. one facility encourages nurses to speak up by allowing anonymity for those who report incidents. el camino hospital in mountain view, calif., has physician-nurse counseling teams that act as liaisons between employees on each unit.

other nurses are battling the issue with a change of demeanor. several rns said verbal abuse incidents dropped when they learned to speak firmly to physicians who had a habit of yelling.

cox and sofield would like to see their studies encourage more hospitals to acknowledge that verbal abuse is a problem. cox, executive associate dean of nursing administration at texas tech university, surveyed 1,168 nurses nationwide in 1991, and 97 percent said they’d experienced verbal abuse in their careers an average of five times a month.

eight years later, sofield, who worked on the study with susan araujo, msn, rn, sent out a variation of cox’s survey to nurses nationwide and received 461 responses. about 94 percent said they encountered verbal abuse with an average of five to six incidents per month.

"the most shocking thing was that the data stayed the same," said sofield, practice manager at the meridian institute for aging in lakehurst, n.j. "what it shows is that the problem hasn’t gone away, and it needs to be addressed more thoroughly."

cox said tense interactions are prevalent in nursing in part because medical work is stressful. she found that more than two-thirds of her respondents said the abuse followed a stressful situation. another key ingredient in the recipe for verbal abuse is the hierarchy in hospitals.

"physicians realize they report to no one, and they can’t blame a patient when something goes wrong, so they sometimes blame it on a nurse," she said.

but sofield suggested in an advance for nurses article in july that nurses also may have a role in perpetuating the cycle of abuse.

"nurses continue to accept verbal abuse because they feel that they do not have the power to change it. they view physician power as higher than that of nursing … nursing, a predominantly female profession, has been conditioned to accept behavior from those they view as powerful. women have been socialized to be passive in communication and relinquish power."

john bondi, md, a physician for more than 20 years at valley medical center in kent, wash., said he’s not surprised that verbal abuse plagues hospitals. physicians have become more frustrated in general as insurance companies increasingly limit what physicians can do to treat patients, bondi said. physicians commonly have to slog through an insurance company’s phone system only to talk to an agent who does not have the medical training needed to answer a question, he said.

"i think physicians are disillusioned as insurance companies fail to treat us as professionals and with respect," he said.

although he believes there is no excuse for verbal abuse, bondi said physicians’ frustration can leak out and be directed toward nurses. he suggested that the nursing shortage also contributes to the risk of negative interactions between physicians and nurses. physicians more frequently are working with new nurses who are not rns.

"if you take charged communication and get rid of the personal aspect, it’s a setup for trouble," bondi said.

the causes of verbal abuse may be complex, but sofield said hospitals lose out by ignoring the issue. it’s expensive for facilities to replace nurses and train new hires, but she found that 35 percent of the nurse respondents left their jobs because of verbal abuse.

poor physician-nurse interaction also compromises patient care, according to survey respondents in both studies. at least 70 percent said a blowup with a physician increases errors, and nearly as many said it decreases productivity on the job.

mary said she, too, struggled to make sound decisions when she worked with the abusive surgeon.

"you couldn’t think the way you normally would because you were so worried about him blowing up," said joyce (not her real name), another rn who worked in mary’s unit.

mary reported incidents to the hospital several times, but the surgeon’s behavior didn’t change. she considered resigning, but she enjoyed everything about her job – except the interactions with the abusive physician.

then, one day, he threw something. mary and the majority of the floor’s staff decided to report the incident to the hospital as a group. mary, who had worked at the hospital for 12 years, said the administration seemed to do nothing to discipline the physician. the yelling continued.

finally, mary and four other nurses quit. all five have stayed in nursing but transferred to other hospitals.

although mary’s hospital had procedures to report workplace violence, she said this was not enough to change the surgeon’s behavior. she believes these systems are not effective unless administrators are willing to discipline physicians who are abusive and protect nurses who report the incidents. in sofield’s study, only about half of the nurses who had experienced verbal abuse reported it.

debbie, an rn in florida who did not want to give her last name, admits that she didn’t report incidents for fear that it would jeopardize her job. one of the most painful interactions happened when she asked the charge nurse for a change of schedule. the nurse responded with, "most women can’t hack things anyway. most of you are bi-polar."

debbie took the problem to her manager, who also was abusive and known for using profanity. he responded by telling debbie that most people in the unit didn’t like her anyway. rather than file a report, she simply left after six months.

cox said nurses such as debbie are at risk of resigning because verbal abuse is particularly discouraging when it comes from a nursing supervisor. staff nurses lose hope of promotions and raises when their managers yell and criticize employees, so they leave to cut their losses, cox said.

linda, an rn at twin falls clinic and hospital in idaho, quit when she worked for a volatile nursing manager.

"i just didn’t like the way things were handled," she said. "there was a lot of favoritism."

yet now that she is a nurse manager, she finds herself yelling occasionally.

"sadly, i do [yell] sometimes, but i go back and apologize," she said. "i try hard not to."

even though many nurses may have horror stories to tell, hospitals are working to find new ways to tackle temper problems among physicians.

usc university hospital has discovered a method that encourages nurses to report physicians who exhibit destructive behavior. the facility has an ethics hotline where employees can anonymously call with concerns, and the issues are taken to hospital administrators. a spokeswoman for the hospital said the hotline has been successful.

a franciscan hospital in new york took a different approach. when a physician continued to be verbally abusive, nurses suggested installing a system in which an employee could page a certain code number over the intercom when the yelling began. then other nearby staff members could fill the room to diffuse the situation. the physicians opposed this idea, according to a former employee who did not want to give her name or the name of the hospital.

then the physician went too far, she explained. he shook a nurse. the idea of a policy was revisited. the hospital decided that a nursing supervisor would follow the physician throughout his day until the problem subsided. his behavior improved, except for flare-ups in the operating room.

at el camino hospital, physicians become directly involved when a fellow physician needs to be reprimanded. in the early 1990s, the facility started a program in which a physician and nurse work together as a counseling team for each unit. when nurses need to report verbal abuse, they can approach their unit’s nurse manager, who then discusses the incident with the unit’s physician counselor.

saul eisenstat, md, a general surgeon at el camino hospital, is the counselor for his unit. he has no qualms about talking to physicians who have been reported.

"usually it only takes a phone call from me to solve the problem," he said.

twin falls clinic and hospital has dealt with the issue by imposing fines against physicians who continue their outbursts even after warnings. last year, one physician was fined $10,000 and was required to attend anger management classes for one week, said wendy somerset, human resources manager for the hospital. physicians own the facility, and they subtracted the fine from the physician’s salary and redirected the money back to the hospital.

"but $10,000 is hardly a punishment for a physician who makes $400,000," somerset admitted.

yet the physician has changed his ways and no longer is abusive, she said.

linda, an rn at the same hospital who did not want to give her last name, said the best antidote she’s found for verbal abuse is learning to defend her actions with confidence.

"earlier in my career, it was more common for me to get yelled at because i was timid and didn’t stand up to physicians," she said.

linda said she reached a turning point one day when a physician criticized her. "i was fed up," she said. instead of cowering, though, she firmly explained why she had made the decision and the result of her action. she was surprised when the physician was satisfied with her explanation and never again spoke condescendingly to her. now that linda is a nurse manager, she encourages her nurses to stand up to physicians when they believe they are right.

jimmie harris, ms, fnp, rn, an associate chief nurse at the dallas veterans administration medical center, has experienced a similar transformation. when she was a budding nurse manager, a physician told her in front of her staff that she wasn’t doing her job.

"i was crushed," harris said. "it made me question if i wanted to be a nurse manager. the problem was that i was new and lacked confidence."

to convey self-assurance, she now introduces herself to new physicians as soon as she begins working with them. she explains that they can come to her whenever they have problems.

joyce and mary chose another route to take a stand against verbal abuse. they and three other nurses filed a lawsuit against the abusive surgeon. they also filed a grievance with the hospital. both cases still are unresolved, but mary is confident that it has been well worth the effort.

"i can look at myself in the mirror and know i did the right thing," mary said. "nurses have to stand up for each other, and i want to make a difference in nursing culture."

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