Editor’s note: We originally produced the article “Nurses, Doctors Agree on Rx for Improved Work Environment” with anonymous quotes to open a risk-free dialogue on the issues addressed. In keeping with that parameter, we publish this anonymous letter to the editor.
In response to your May article, I would like to specifically address the comments related to surgeons and disruptive behavior. Sadly, very little has changed since 2008, the year this entrenched problem was addressed by the Joint Commission.
According to Becker's Hospital Review, the average operating margin of non-profit hospitals now stands at 2.5 percent – probably less since the statistics were compiled. As a result of a rapid-changing healthcare system and the commercialization of healthcare, rules regarding disruptive behavior, horizontal violence and bullying (a documented recipe for medical error) are not enforced. This is especially true within the closed, non-transparent doors of the operating room (OR), where losing a surgeon means losing money.
Although many healthcare organizations seem to have successfully created a culture of collegiality between hospital and medical staffs, the OR – a major source of income and revenue – seems to be the last holdout. It is also a place where errors made while distracted by aberrant behavior can mean the difference between life and death (or errors leading to life-threatening complications) for an asleep and powerless patient – utterly dependent on the presence of a well-functioning team. Surgeons’ “run-amok” behavior and “captain of the ship” (rather than team) mentality remain the norm – so much so that most surgical team members fail to recognize it as a negative, potentially dangerous situation. This “abnormal normalcy,” best known as the “normalization of deviance,” – a term coined by NASA after the Challenger explosion – is alive and well in operating rooms across the country.
Quality and safety policies touting zero-tolerance for disruptive behavior, lateral violence, bullying and retaliation seem to be written for the sake of regulatory agencies and frequently unenforced by ineffective management teams. Management team members often fear for their own jobs when the mainstay of the OR – productivity – decreases. Hospitals commonly mitigate risk through termination of nurses who internally and/or externally report abusive physicians, rather than risk losing said revenue-producing surgeon. The decision to get rid of a nurse who dares to speak out is as simple as the decision between trying to contain costs and increase business – or the hospital shutting its doors.
When nurses (expense) are denied a voice and physicians (revenue) are allowed to exhibit abusive behavior, the result can be deleterious to patient safety and surgical outcomes. Patients are denied the advocacy of the Registered Nurse; who knows he or she will most likely be fired after speaking up. Thus, the so-called “culture of silence” in the healthcare industry translates to yet another risk for patients in the OR. It coincides with the equally dangerous “culture of fear.” Nurses, when faced with the potential personal cost of reporting risks to patient safety, are caught between the legal, ethical obligations of every state Nurse Practice Act and the Nurses’ Code of Ethics, and the very real personal risk to career, reputation and financial stability.
There is more. According to OSHA, none of the 22 federal laws addressing retaliation against whistleblowers mention the wrongful termination of healthcare workers who report threats to patient safety. Most federal whistleblower legislation concerns fraud, waste and abuse – protecting whistleblowers in the financial industry or financial realm of healthcare, but not healthcare workers who report patient safety issues, and certainly not patients. Although several states have passed bills protecting healthcare whistleblowers, once a lawsuit is filed, these statutes often lack the power wielded by hospital attorneys and state judicial systems.
Once the nurse is wrongfully terminated – potentially losing the ability to make a living in his or her chosen profession – there are two choices available to fight the “system.” First, there is the Equal Employment Opportunity Commission (EEOC), the federal agency that addresses discrimination related to wrongful retaliatory termination. The other choice – IF one lives in a state with patient safety legislation – involves paying an attorney to fight the hospital system and its high-powered legal team. In doing so, the healthcare professional risks bankrupting financial resources, loss of reputation, ability to obtain employment and precious time fighting a legal battle that, statistically, will probably be lost. Thus, the “culture of silence” is reinforced by the legal system.
Sadly, nurses who have seen co-workers terminated for their courage to report a powerful physician are too afraid to speak up within this culture of silence and fear. This begs the question: Who is left to advocate for the patient during “free-for-all” aberrant behavior occurring daily behind the closed doors and windowless, non-transparent walls of the Operating Room?
— Memphis Operating Room Nurse
