Understanding and responding to bullying and related behaviors in healthcare workplaces.

INTRODUCTION During the past decade, terms such as bullying, mobbing, emotional abuse, and incivility have entered the vocabulary of contemporary employment relations. A multidisciplinary cohort of researchers and practitioners has been performing the spadework of introducing these topics to the worlds of research and practice. The feature articles in this issue by Dianne Felblinger and William Swiggart and colleagues are welcome contributions to this growing body of literature. As the authors of the two pieces aptly recognize, bullying and related behaviors are a relevant concern within the healthcare sector. As they further acknowledge, such behaviors can impact workplace morale, patient care, and even litigation costs. They invite us to consider both the individual and organizational aspects of disruptive and abusive employee misconduct. This commentary will respond to both articles and offer additional remarks on understanding and addressing these destructive workplace behaviors. Swiggart and colleagues (2009) have provided a comprehensive description of the Vanderbilt University School of Medicine program for identifying, treating, and remediating disruptive behaviors by physicians. Under the program, complaints lodged by patients and others are used to identify physicians who may be behaving disruptively. When necessary, a full assessment evaluates the circumstances surrounding a physician's counter-productive behavior. This leads to an individually tailored plan of education and counseling. As described, the Vanderbilt program focuses largely on the circumstances and actions of the offending physician. In the case of individuals such as the fictitious Dr. Jane Doe, this makes sense. Her conduct has been inappropriate, disruptive, and potentially harmful to co-workers and patients. She also appears to be a good candidate for education and counseling. The Vanderbilt program appears to deal with such cases in a fair and respon- sive manner. Too many times, discussions about bullying and emotionally abusive conduct dismiss the possibility of working with the offending employee, but here this rehabilitative goal is paramount. However, the Vanderbilt program is not without its limitations. As described, it implicitly downplays how a negative organizational culture or acts by other individuals may trigger or contribute to behaviors deemed "disruptive." For example, expressions of anger, derogatory comments about the institution, avoidance of meetings and individuals, and non-participation (Swiggart, et al., 2009, fig. 1) may be entirely defensible responses to a dysfunctional, hostile, and/or non-inclusive work environment. Ironically, targets of severe bullying at work may react in just such a manner. In short, both context and organizational culture count when assessing individual behavior. The Dr. Doe scenario used by the authors-wrongful behavior addressed with the possibility of effective counseling-highlights the remedial value of the Vanderbilt program, but other scenarios would identify the blind spots of an approach that focuses largely on the individual. In today's healthcare workplaces, unavoidably high stakes are dovetailing with severe economic pressures, contributing to stress and conflict. Thus, we need to expand our view to grasp fully the dynamics of disruptive employee behavior in these settings. FOCUSING ON ORGANIZATIONS Felblinger's (2009) contribution takes that broader perspective, emphasizing both how bullying and incivility may impact organizations and how organizational climate may facilitate disruptive behaviors. On the employment relations side, unwanted effects may include higher turnover and absenteeism, reduced commitment to the organization, and physiological and psychological symptoms experienced by the targets of bad behavior. In terms of healthcare services, negative consequences may include reduced patient safety, more patient errors and adverse events, and lower quality of care. …