Bullying,Moral Courage,Patient Safety,and the Bariatric Nurse

Moral Courage

Moral courage is simply defined as courage of a moral nature; courage emerging from the rightness or wrongness of human behavior. Moral courage is an expression of one's values. In clinical practice, Lachman explains that moral courage is the individual's capacity to overcome barriers and act on his or her core values and ethical obligations. ² Clinical practice offers a multitude of opportunities to speak out and advocate for patients, families, colleagues, organizational health, and the preservation of quality care. ³ In the healthcare setting, the failure to act in a morally courageous manner threatens patient safety. ⁴

Understanding Safety in U.S. Healthcare

The total national annual cost (lost income, lost household production, disability, healthcare costs) related to adverse events are estimated to range between $37.6 billion and $50 billion. Of those, the cost of preventable adverse events is estimated to range between $17 billion and $29 billion. ⁵ Healthcare costs alone account for more than one-half of these total costs. Even when using the lower estimates, the total national costs associated with adverse events and preventable adverse events represented approximately 4% and 2%, respectively, of national health expenditures in 1996. ⁶

Further, a study conducted at two U.S. teaching hospitals suggested that almost 2% of those admitted experienced a preventable adverse medication event, resulting in average increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed hospital. ⁷ Of note, much of this cost is nonreimbursable, and is absorbed directly by the institution. ⁸ In terms of human loss, medication errors were estimated to have accounted for 7,000 deaths.^9,10 Medication errors accounted for one out of 131 outpatient deaths and one out of 854 inpatient deaths. ¹¹ Sadly, one out of 100 pediatric medication orders are likely to result in an adverse drug event. ¹²

Putting This in Perspective

Although the mortal risk of a medical error far surpasses the risk of dying in an airline accident, a good deal more public attention has been focused on improving safety in the airline industry than in the healthcare industry. The risk of death per domestic jet flight is estimated to be one in eight million. ¹³ Statistically, an average passenger would have to fly around the clock for more than 438 years before being involved in a fatal crash. Some believe that public concern about airline safety, in response to the impact of news stories, has played an important role in the dramatic improvement in safety in the airline industry.

The American public is aware that healthcare is not as safe as some other environments, but to date, it has made few demands on the healthcare industry to demonstrate improvement. In a public opinion poll conducted by Louis Harris and Associates for the National Patient Safety Foundation, the healthcare environment was perceived as only moderately safe, being rated 4.9 on a scale of one through seven, where one is not safe at all and seven is very safe. ¹⁴ Respondents viewed the healthcare environment as much safer than nuclear power or food handling but somewhat less safe than airline travel or the work environment.

What is “Bullying” in Nursing Practice?

Experts over the past decade suggest that the lack of moral courage in the occupational setting contributes to workplace bullying. ¹⁵ Bullying, lateral violence, and occupational incivility take many faces. The term workplace incivility has been defined as behavior with ambiguous intent to harm the target. In the healthcare setting, uncivil behavior is characterized by a lack of regard for others. ¹⁶ Incivility is distinct from violence. Examples of workplace incivility include insulting comments, denigration of the target's work, spreading false rumors, or social isolation. Laschinger et al. found that among 612 staff nurses, 67.5% had experienced incivility from their supervisors and 77.6% had experienced incivility from their coworkers. In addition, they found that low levels of incivility along with low levels of burnout were significant predictors of nurses' job satisfaction and organizational commitment. ¹⁷ Incivility was associated with psychological distress and reduced job satisfaction.

Lateral violence refers to behavior between colleagues. Bullying is described as acts perpetrated by one in a higher level of authority and occur over time. ¹⁸ Experts explain that bullying behavior leads to distractions, which lead to issues of patient safety and potential adverse outcomes. Unfortunately, bullying was found to be commonplace in the transition to become a nurse. Students were bullied and also witnessed patients and nurses being bullied by more seasoned nurses or other colleagues. Studies explain that bullying, and its effects, are perpetuated by practices within nursing. The negative effects related to being bullied specifically include sleep disorders, poor self-esteem, eating disorders, nervous conditions, low morale, apathy, disconnectedness, depression, and impaired personal relationships. ¹⁹ Further, Simon, Stark, and DeMarco ²⁰ over the past 10 years have identified evidence that lateral violence and bullying have significant effects on individual's workplace performance and consequently healthcare organizations (see Table 1). What does this mean for the health and safety of an institution? Hutton explains that the financial cost of these workplace distractions is estimated at $4.2 billion a year. ²¹ Mitigating bullying behaviors impact both financial and human capital within the healthcare organization. Bullied nurses threaten safe, confident, quality nursing care, which ultimately drives up economic costs to the institution providing healthcare services.

Call to Action in Bariatric Nursing

For decades, patients of size have experienced bullying in every area of their lives, including when accessing healthcare.^22–26 For example, children as young as 6 years of age have been found to label silhouettes designed to look like obese people as lazy, dirty, stupid, ugly, and cheats. ²⁷ College acceptance and employment advances have been lost as a result of an applicant's size or weight. ²⁸ Healthcare providers themselves may hold bias toward the obese individual for a number of reasons.^29–34 Further, within this context, many bariatric nurses choose this practice because they themselves have been or are individuals of size. Unacceptable behaviors toward the obese individual will change only if nurses and others involved with healthcare transform practices and the context in which bullying occurs. Otherwise, each new generation of nurses and other healthcare workers will continue to be socialized into negative practices that undermine both their own feelings of self-worth and standards of nursing care.

The American Nurses Association (ANA) and others have outlined steps to serve this goal, such as zero tolerance toward violent or abusive behavior, protection from retribution if reported, and creation of unit-specific guidelines to support these goals. Recommendations include establishing a strategic plan to interrupt the cycle of violence, which includes assessing the nursing unit and raising awareness; brainstorming specific solutions; and encouraging meaningful communication. Further, the ANA recognizes the value of employee assistance programs when indicated.^35–37

Although workplace bullying has many sources, it is most stressful when a colleague is the perpetrator. ³⁷ The ANA reports that 40% of clinicians failed to communicate their concern over an impending medication error because of an intimidating colleague. ³⁷ The individual who is bullying in this situation is most likely using a power imbalance. The victim of bullying is emotionally affected, resulting in an inability to use normal problem solving as a coping strategy. Bullying contributes to a failure or fear of communication. For example, bullied individuals may be reluctant to disclose, and potentially avoid opportunities to communicate at all, thus decreasing effective hand off, reporting, and potentially affecting outcomes. This very similar situation was once commonplace in the airline industry. In one study, up to 70% of fatal aviation accidents were attributed to communication errors. ³⁸ Less experienced flight crew members were often bullied until the advent of Crew Resource Management (CRM) training and support. CRM relies on structured team behaviors that have shown to decrease communication-related errors. When applied to the healthcare setting, one study demonstrated a 30% reduction in observed clinical errors when these principles were employed. ³⁹

The ANA and others recognize this threat to nursing practice and explain the ethical obligation to support colleagues. This is described in a section of the ANA Code of Ethical Conduct, which states: “The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of all individuals.” The standard of conduct, as outlined by the ANA, precludes any form of harassment or threatening behavior, or disregard for the effect of one's behavior on others. ⁴⁰

Conclusion

Healthcare is very complicated and not easily understood by those outside the community. Certainly, there is room for systemic change which impacts the ability for nurses to more fully express moral courage. ⁴¹ These changes might include comprehensive policies and procedure that recognize the value of moral courage, or administrative attention to respect, resiliency, and communication skills to support meaningful change among nurses and other caregivers. This affords opportunity to understand the hope for change from an individual and organizational perspective. It best serves patients and nurses when nurses explore the meaning of moral courage in the face of these dangers—dangers such as bullying and other forms of violence and incivility. Obese individuals have likely experienced bullying behaviors from those within and outside the healthcare community throughout their lives. ⁴² The time has come for bariatric nurses to consider the impact of bullying behaviors on patient safety, especially patients of size. Experts explain that nurses should not tolerate verbal or non-verbal abusive behavior, and it should be reported when it occurs. ⁴³ Bariatric nurses are in a unique position to recognize and address such behaviors.