Abstract
Healthcare professionals are in the business of providing care and compassion. It is ironic that healthcare has the highest rate of workplace harassment. Although harassment comes from people of various positions, its existence in healthcare fractures the intention and values that guide its mission. When mental health is compromised, mistakes happen. Healthcare professionals take the health/life of others into their care; distractions and fear from being bullied compromise that care. Health leaders are in a strategic position to address workplace harassment and bullying. Failing to do so results in complacency, jeopardizes our patients, tarnishes the organization, and damages society as a whole. It is a cost that all will pay dearly to remedy, unless it is addressed, enforced with standards, and taken to task for the better health of all.
Introduction
The prevalence of workplace harassment has grown exponentially. In every corner of the world, it surfaces its unwanted presence to demean and condescend employees: the pillars and backbone of any organization. Harassment prevalence is evidenced by the escalating events of the “Me Too” movement. 1 From the corners of Australia, 2 Iran, 3 United States, 4,5 Canada, 6 France, 7 and the United Kingdom, 8 workplace harassment in healthcare flourishes. In fact, healthcare has the highest rate. 9 –11 Workplace harassment is costly, resulting in declining work performance, 12 poor quality service, 13 poor career satisfaction, 14 and increased sick leave/absenteeism. 15 It causes undue stress, threatening the health/safety of patients, for whom healthcare professionals care. It is imminent that health leaders take steps to eliminate harassment and minimize its impact on employees/productivity. This article highlights the costs of workplace harassment/bullying, challenges faced, and how a leader can actively address and eliminate harassment/bullying.
Background
Workplace harassment is “improper conduct by an individual, that is directed at and offensive to another individual in the workplace, including any event/location related to work, and that the individual knew or ought reasonably to have known would cause offence or harm.” It includes objectionable act(s), comment(s), or display(s) that demean, belittle, or cause personal humiliation or embarrassment and any act of intimidation or threat. It includes harassment within the meaning of the Canadian Human Rights Act (ie, based on race, national or ethnic origin, colour, religion, age, sex, sexual orientation, marital status, family status, disability, and pardoned conviction). 16
The terms bullying and harassment have similar meanings. Both are “acts or verbal comments that could ‘mentally’ hurt or isolate a person in the workplace, possibly including negative physical contact as well”. Bullying involves repeated incidents/pattern of behaviour intended to intimidate, offend, degrade, or humiliate a particular person/group of people and/or the “assertion of power through aggression. 17 It is engaging in a course of vexatious comment or conduct against a worker in a workplace that is known or ought reasonably to be known to be unwelcome and the repeated, unreasonable, or inappropriate behaviour directed toward a worker, or group of workers, that creates a risk to health and safety. 18
The value of work
Work provides many benefits, and healthcare professionals tend to give their all. The high prevalence of workplace harassment/bullying not only destroys the quality and safety of healthcare but exponentially escalates budgets. Work provides a sense of identity, 19 love and belongingness, 20 and a social outlet. 19,20 Psychologically, work serves many dimensions of psychological and mental health/well-being. It increases self-esteem, 19 confidence, sense of purpose, self-worth, autonomy, competence, independence, achievement, and an overall increased quality of life, satisfaction, and accomplishment 21 to strengthen one’s sense of self-integrity. Further, workplace social relations help to control and buffer the stress people experience in life.
A leader in today’s healthcare environment
Leaders ensure the organization’s mission, vision, and values are fulfilled. Throughout history, descriptors such as excellence, respect, transparency, partnership, honesty, and integrity take centre stage as values that healthcare organizations pride themselves, the very foundation upon which a business grows and succeeds. Albeit in a setting of healthcare delivery, hospitals boast about the care they provide in terms of quality, availability, respect, and dignity and that professionals and multidisciplinary teams make a reality. Ironically, a workplace that promotes healing, compassion, caring, ethics, and standards of practice has the highest rate of harassment, 22 representation that defies all values of any healthcare facility.
The high prevalence rate of bullying/harassment among healthcare professionals is concerning. From a LEAN Six Sigma model perspective, a bully, threat, and/or complacent leader reflect the waste/defects that jeopardize the caring, respectful, and productive workplace. Healthcare workers represent almost 23% of harassment, much higher than areas of education/law/social (15.3%), business/finance (12.4%), sales/service (17.8%), and trades (16.7%). 10 Furthermore, 94% of health leaders “had to deal with a toxic person at work”, 11 over 50% of Canadians have been/know someone who is been bullied at work, 23 and 98% witnessed such behaviors. 24
The challenges faced
Organizations face many operational challenges in today’s economic climate, particularly with the current COVID-19 pandemic. Hospital resources are stretched to the limit, stretchers line Emergency Room (ER) corridors, operating suites are turned into isolation rooms, and staff are getting infected, and sadly, in some cases, dying. 25 Financial budgets, acuity levels, and scorecards are bursting at the seams, 26 costing governments almost 26 billion/year. 27 As epidemics, endemics, and pandemics come and go throughout the years, workplace harassment and its subsequent damage stay forever, if left unchallenged.
Leaders are well positioned to enforce a respectful workplace. Although they have an agenda to fulfill, workplace harassment destroys the environment and creates havoc for leaders, so any efforts directed toward its elimination are worth it. From the leadership model of LEAN Six Sigma, harassment is the “waste” that needs to be reduced, so that overall efficiency, productivity, performance, and output are achieved. 28
The infrastructure/model of healthcare delivery
The model of healthcare delivery plays a critical role for how a leader functions with personnel. For example, a regional health authority using a program-based structure enables one hospital to specialize in obstetrics, mental health, and gerontology, while another offers medicine and surgery programs. A program manager who is covering mental health and medicine is split due to his/her sites of responsibility. A manager’s lack of visible presence causes staff relationships to fail, interactions to become minimized, and the committed efforts/outcomes of staff to go unrecognized.
Out of sight, out of mind
The presence of a leader in the workplace remains a challenge. Literally and figuratively, being “present” is most supportive for healthcare professionals. Emotionally and spiritually, leaders can show an appreciation to their staff through a demonstration of their artistic endeavours, interactions, and communications. A leader should give staff his/her undivided attention merely by a presence of just “being there” for staff, suggesting, I am here to help. However, growing healthcare costs has forced organizations to consolidate and amalgamate. 29 In an effort to maintain quality, productivity, and a balanced budget, executive/management are often remote from the very programs, divisions, and staff that run them. As leaders grapple with the increasing position expectations, development of executive limitations, patient and organizational acuity, and changing legislation, much of the leader’s time is absorbed, leaving little time/energy for staff recognition nor visitations to the satellite sites they oversee.
Complacency/failing to address workplace harassment
Although workplace bullying is prevalent, most do not report it due to embarrassment, intimidation, and fear. 13 Leaders should create a welcoming environment where workers feel safe coming forward to report harassment. Failure to recognize and address workplace harassment promotes its continuance. 30 The complacent leader, who turns a blind eye and fails to address workplace harassment, interferes with an organization’s successful potential and becomes a liability themselves, as bullying is absorbed, ignored, or rationalized away. Even workplaces with prominently posted policies that mandate respect or decry bullying often fail to address actual complaints. In reality, when policy breaches are followed by inaction, people stop reporting the behaviours. 9 A key reason for this is because dealing with a bully is a lengthy, exhausting, and frightening process for managers, as bullies confront/threaten them too, pushing managers toward the path of least resistance. 9
Failing to address harassment equals an approved continuation of such behaviours, 30 and an informal acceptance that no wrongdoing occurred. Leaving unethical behaviours and declining professional standards of practice unchecked allow mongering gossip to flourish, reputations and careers to be destroyed, and self-confidence and self-esteem to plummet. 22 Eggertson found that nurse-nurse hostility increased because management structure turned nurse leaders into bureaucrats, leaving little time/skills to interact with their staff. 9 Because bullies are often in positions of authority, such as directors, supervisors, and managers, it is even more prudent that complacent leaders be brought to task. 22,31,32
The liability
Workplace bullying/harassment is a significant organizational liability, often manifested as legal, ethical, and professional liability. It causes increased costs, more medical errors, lower quality of work, and jeopardized patient care. 13 Sadly, many leaders do not perceive workplace harassment as a liability.
The stress placed upon frontline healthcare workers, due to prolonged exposure to bullying in the workplace, causes chronic stress that interferes with the practitioner’s capacity and attention to focus on the skills and interventions needed for the patient. 33 Overwhelming stress/duress compromises an employee’s mental health which functions to weaken care and service delivery and hence a hospital’s mission, values, and vision, leaving patient health and safety jeopardized.
Low morale in the workplace as a result of workplace harassment causes poor communication, lack of empowerment, lack of energizing staff, distrust of management, poor interpersonal relations, and inflexible working conditions, 34,35 all required elements of a functioning professional team-oriented environment, directing care for patients. For nurses, in particular, who are with patients 24 hours a day 7 d/wk, increased infection rates of central lines, 33 medical errors, 34 and suboptimal standards of practice resulted. 36 Porath and Pearson found that 66% of workers admitted that their own performance in the workplace had declined significantly, 37 38% intentionally decreased their quality of work, and 48% intentionally decreased their work effort; others just lost interest. 36,38,39 Workplace bullying compromised nurse safety, well-being, and patient-centred safe work practices. 40 Physicians, also compromised patient safety due to their low morale, 41 threw bloody instruments at nurses in the Operating Room (OR), as well as shamed, humiliated, and spread malicious rumours about colleague nurses. 42 As licensed healthcare practitioners are bound by their standards of practice and the mandate to protect the public, any injury to a patient while under the care of a professional practitioner, fully violates this standard.
The monetary costs to an organization because of workplace harassment are significant, particularly, when repeated harassment is ignored. From a budgetary perspective, rising costs of absenteeism, burnout, 43,44 sick leave replacement, and overtime shifts add significantly to rising costs when healthcare professionals miss work because of harassment and deteriorating mental health. For example, compassion fatigue, which healthcare staff endure from “giving,” surpasses the impact on the well-being of individual staff to affect issues of staff turnover and patient satisfaction. 45
A second monetary cost of workplace harassment involves lawsuits resulting from medical errors, substandard practices, and negligence, for failing to address matters of an unsafe workplace. According to the Occupational Health and Safety (OHS) Act, an organization should ensure a safe and healthy workplace. 17,46 In Canada, bullying links to detrimental health outcomes of employees. For example, a healthcare worker who died as a result of a myocardial infarction was proven to be linked to the stress of bullying endured from his supervisor, with his widow receiving a large monetary award. 47 Legal settlements of 2019 included the Ontario Superior Court awarding an employee nearly $200,000 in damages because of abuse/harassment that was ignored/unaddressed repeatedly 43 and a Nova Scotia physician who won her case on grounds of bullying/harassment by the employing Health Authority. 48 Borkowski suggests legal suits are good reason for leaders to pay attention and get workplace harassment/bullying under control to prevent potentially jeopardizing employee and patient health/safety. 49
Actions needed to move forward
Workplace harassment/bullying need to be addressed. As eluded to, there is substantial costs affiliated with failing to provide an occupational healthy and safe workplace. However, health leaders are positioned strategically to ensure interventions and guidelines are in place and enforced to avoid such financial fallout.
In 2013, Canada became the first country to create a professional standard of Psychological Health and Safety in the Workplace. This framework provides guidance so organizations can create/direct policy, interventions, and strategies to address psychological harassment in the workplace. 50 However, it was a voluntary option for organizations, opting for or against its use. Health leaders should mandate such a standard throughout their organization.
Simple gestures such as open, honest, transparent communication go a long way to build rapport with workers. Keeping important issues front and centre on a staff meeting agenda, open lines of communication, and town meetings in the presence of an invited expert keynote speaker are beneficial. Policy development is crucial to build a respectful workplace. Actively addressing all incidents through a consistent process with human resources is vital.
The following comprises a standardized listing on how leaders promote a psychologically safe workplace: Adhere to legal, legislative, and collective agreement requirements to provide a safe workplace. Make the OHS Act of your province/state and OHS Committee of your organization more active in developing violence and bullying prevention strategies, instead of just behind closed door meetings; hold presentations at town halls/staff meetings. Educate to prevent violent situations and de-escalate such situations as they occur. Train employees to be active in reporting bullying immediately when it happens. Create and provide a culture of respect for others, free of violence and bullying. Mandate the adoption of the national standard for Psychological Health and Safety in the Workplace developed by the Mental Health Commission of Canada.
50
Promoting conflict management and effective/professional communication helps. If the harassment is done in the presence of others, the victim needs to clearly say out loud so others can hear, “I really didn’t appreciate what you just said.” Responding to the bully in private only gives the bully more opportunity to harass. Be proactive, not reactive. This encompasses a process that includes human resources personnel, a protective disclosure policy, or some form of Whistle-Blower policy that protects the alleged victim. Discipline employees for not complying with anti-bullying/harassment policies. Promote Employee Assistance Program services so victimized employees can talk to someone confidentially about issues they face. Provide regular educational opportunities about mental health at work. Use performance reviews/evaluations. An effective performance review is an opportunity for honest, open conversation about positive and negative results; it inspires and engages people when focused on plans for the future. It sets expectations and helps employees create achievable targets with coaching and feedback. Performance management becomes part of the culture rather than a dreaded annual event; people support what they help to create, and few are motivated by criticism. Promote a safe and supportive environment to report/follow up on violent and bullying incidents in a timely, consistent manner. Ensuring employees receive encouragement and support in the development of their interpersonal, emotional, and job skills, effective assertive communication, and increasing competence and confidence in all that they do.
Recognizing workplace harassment is a global priority; the International Labour Organization passed a convention making workplace harassment equivalent to a violation or abuse of human rights. 51 Such behaviours and/or actions of workplace harassment is unacceptable and incompatible with decent work. As such, employers are responsible for promoting an environment of zero tolerance. 43
Conclusion
Harassment/bullying reflects workplace disrespect. Ironically, a work environment based on caring/compassion has one of the highest rates of harassment. When these incidents go unaddressed, it fuels the bullies and enables them to continue their malicious behaviours. As a result, the costs to healthcare organizations are phenomenal from a liability perspective of patient safety, financial costs, staff morale, and legalities. Leaders hold strategic positions to create and enforce change. However, consistency and pro-action, as opposed to complacency and reaction, are necessary to address and eliminate workplace harassment. Although intricate planning is needed for variability of incidents, people involved, external mediators, and so on, failure to address/enforce such crippling incidents not only inflates operational costs and liability but more importantly jeopardizes health/life.
