Published On September 22, 2013
When Lucian Leape, during a recent talk before 7,000 members of the American Association of Critical Care Nurses, asked the crowd how many had witnessed or suffered abusive behavior in their workplace during the past three months, a majority raised their hands. Leape wasn’t surprised. Known as the father of the modern patient safety movement, Leape is now making news for his scrutiny of the “culture of disrespect” in medicine, which he contends is a barrier to patient safety and quality of care. Leape, a former pediatric surgeon who helped write the Institute of Medicine’s two seminal reports, To Err Is Human in 1999 and Crossing the Quality Chasm in 2001, says poor work relationships threaten safety improvement efforts. In a two-part series published last year in Academic Medicine with colleagues at Harvard Medical School, Leape delved into the forms disrespectful behavior can take and its toll on the safety of both patients and health care workers, and he provides recommendations to improve the situation.
Q: You’ve described health care culture as dysfunctional, not only in teaching disrespectful behavior but also in tolerating, even rewarding, it.
A: I’ve found it useful to think about the issue in two very different categories: overt and covert. Overt is when people really hurt other people’s feelings with their intentional behavior: disruptive, demeaning conduct or dismissive treatment of nurses, patients or students. What I mean by covert are individuals who aren’t good followers of protocols or safe practices like disinfecting their hands, are chronically late, don’t get charts done, just aren’t good team players. And then there is the health care workplace itself—the high risk of physical injury and the stressful environment of long hours and heavy workloads. These are all forms of disrespect.
Q: What does disrespect look like from a patient’s perspective?
A: The most obvious form is waiting. Much more serious, though, is not getting a full explanation of what’s going on. Another example is, when something goes wrong, a lack of honesty in admitting what exactly happened. Also, what strikes patients as disrespectful is having to fill out that clipboard every time they go to a physician’s office regardless of how many times they’ve been there.
Q: But what does disrespect have to do with safety?
A: First, there’s the influence of people who are overtly disrespectful, which is often powerful and corrosive. If, as an institution, you tolerate such behavior, you block communication and destroy morale, both threats to safety. Covert disrespect undermines the implementation of safe practices (such as hand hygiene) and the teamwork that is needed for people to work together and develop new, safer practices. Just consider that the prevalence of physical harm—such as needlesticks and back strain—is much higher than in other industries, yet hospital personnel have accepted those risks as a hazard of the trade. And I don’t think most people have thought about long resident duty hours as a form of systemic or institutional disrespect. When we put people in a position in which they’ll be significantly sleep deprived, we are knowingly putting them in a situation where they are more likely to hurt someone else or themselves.
Q: What are the solutions to these problems?
A: Virginia Mason Medical Center in Seattle, to look at one example, has made a huge effort to address behavior issues. Its 5,000 employees are put through a training course about respectful conduct, and the hospital has established best practice methods, such as respecting the confidentiality of employees who report problems. Vanderbilt University Medical Center has created a patient advocacy reporting system that tracks complaints about physicians and then provides physicians with data and feedback, even interventions, to address problems. Two-thirds of physicians showed improvement after such actions were implemented. And there’s a lot of work we can do to improve the patient experience in terms of reducing waiting, how we treat patients and how we deliver information to them.
Q: What’s the biggest challenge in creating a culture of respect?
A: Too many people in leadership positions feel they shouldn’t be telling physicians what to do. But this is about involving them in solving problems, and that fits the role of all health care workers. People work in health care because they want to serve others, do something important and do it right. You couldn’t ask for a better group of people to make these improvements.