What follows is a true story.

Kelly (not her real name) walked into the ICU to draw a stat. While she was there, the lead phlebotomist entered and asked her if she had taken her break. Kelly responded that she hadn't received the lead phlebotomist's text message to do so, as was the protocol. The lead phlebotomist went ballistic in front of the ICU staff, the patients, and their families. To say Kelly was bullied doesn't begin to explain the aggression she endured.

As is typical for bullies, this is not the first time the lead phlebotomist unloaded on Kelly. The Workplace Bullying Institute (WBI) defines workplace bullying as "repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators."¹ How phlebotomists and laboratory personnel interact with each other and with other members of the healthcare team influences job satisfaction and profoundly impacts patient safety. Studies show intimidating and disruptive behaviors, like the display of temper directed at Kelly, set medical errors in motion and increase the cost of patient care and risk of legal liability.²

When disruptive, bullying behaviors lead to breakdowns in communication, patients suffer. Research conducted from 1995 to 2005 found that ineffective team communication is the root cause for almost 66 percent of all medical errors.³ But facilities that have better communication---as would be expected where bullying is not tolerated---function at a higher level in many regards. Studies show when the exchange of information is effective and respectful within and across department lines, not only does the patient benefit, it promotes a culture of safety and mutual support in the workplace, reducing staff turnover and improving job satisfaction.^2,3 

Bullying Behaviors

The Agency for Healthcare Research and Quality (AHRQ) identifies disruptive behavior as any behavior that shows disrespect for others, including any interpersonal interaction that hinders the delivery of patient care. According to Gerald B. Hickson, MD, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, TN, disruptive behavior can include:^2,4 

• Verbal abuse/outbursts
• Sexual harassment
• Yelling
• Profanity
• Vulgarity
• Threatening words or actions

Bullying can also present as work interference or sabotage, which prevents work from getting done.¹ This can be particularly risky for patients caught in the middle, where accuracy, timeliness and precision in specimen collection, processing and testing are crucial in producing a meaningful test result and proper diagnosis.

Equally harmful and disruptive to patient care are passive-aggressive actions, such as refusing to perform assigned duties or quietly exhibiting uncooperative attitudes during routine activities. Such subtle but deliberate tactics are frequently demonstrated by healthcare professionals in positions of power, with 72 percent of bullies being bosses.^2,5 Kelly's was one.

The Joint Commission, the primary accrediting body for American healthcare organizations, identifies the following as passive-aggressive behaviors:²

• Reluctance or refusal to answer questions
• Failure to return phone calls or pages
• Condescending language or voice tone
• Impatience with questions

Contributing Factors

Why does bullying occur? One reason is healthcare occupations have long been known to be highly stressful compared to many other jobs. Healthcare professionals are exposed to numerous demands, ranging from staffing shortages, time pressures, shift work, budget constraints, and fatigue, all while caring for difficult and ill patients in a high-stakes environment.⁶ Given the pressures, it’s no surprise that individuals who possess characteristics such as self-centeredness, immaturity, or defensiveness are more likely to demonstrate bullying behavior due to their lack of coping or conflict management skills.² Add to the mix unrealistic expectations and fear of lawsuits, and the workplace can quickly become a caustic cauldron of blame and bad behavior. When intimidation and disrespect are allowed to boil over within and among departments, communication and trust erodes, jeopardizing patient safety. 

The Laboratory Perspective

A 2010 survey conducted by the Center for Phlebotomy Education found that over 63 percent of respondents did not feel respected by other healthcare professions.⁷ Reasons given include the perception that phlebotomists and/or laboratory personnel are less educated and are thereby undervalued by other healthcare professions. One surveyed phlebotomist lamented “they never include us or speak to us.” A phlebotomy manager commented that “some nursing and physician staff look upon phlebotomy as beneath their profession.”

Even when credit is due, the laboratory’s efforts in providing quality patient care are sometimes overlooked, as described by one MT (ASCP) phlebotomy supervisor: “Whenever our hospital publishes an article featuring how an ED or surgical patient was successfully treated, there is no recognition of the laboratory’s contribution to the diagnosis or follow-up therapy.” Such attitudes are not only disrespectful, they demoralize. They can also lead to conflict between professions over proper procedures, as illustrated by the following comment from a laboratory assistant: “I represent the lab and lab policies when I draw blood. Many times lab policies are questioned and in some instances nurses and/or doctors refuse to believe and follow them.”

On the Receiving End

So what are the personal effects of bullying on phlebotomists and laboratory personnel? Some tell-tale signs include:⁸

• Feeling sick before your work week starts
• Obsessing about work at home
• Using paid time off for “mental health breaks"

Phlebotomists and other healthcare personnel who are on the receiving end of bullying can experience fear and anxiety, depression, and develop a type of post-traumatic stress disorder leading to psychological harm and actual physical illness.⁹ The cost can be high to both one’s physical health and career. According to a 2007 WBI-Zogby Survey, 45 percent of those targeted by bullies suffer stress-related health problems.¹⁰ A 2010 national survey revealed that two-thirds (66%) of bullied employees had to lose or give up their jobs in order to make the bullying stop.¹¹

Frequency

Unfortunately, menacing behaviors in healthcare environments are not rare. Multiple surveys reveal that the majority of patient care providers have experienced or witnessed bullying in the workplace, with one survey finding 40 percent of clinicians have kept quiet or remained passive rather than question a known bully.^2,5,9 Studies show healthcare workers are 10 times more likely to be assaulted, with bullying being the most common form of violence against women.¹²

While most research focuses on bullying and unprofessional behaviors among doctors and nurses, such conduct is not limited to one gender, and occurs among laboratory staff as well. A British survey of more than 1,000 clinical and administrative healthcare workers found that 44 percent of nurses and 35 percent of other staff reported experiencing "peer bullying" in the workplace within the previous year. Allied health professionals are bullied by doctors, each other and patients.^2,12 Especially upsetting for students and new graduates is horizontal violence, a peer-to-peer form of bullying where senior staff consider bullying a rite of passage during clinical rotations. Among students:¹²

• 53% report they have been insulted;
• 40% report being humiliated;
• 34% report rude, abusive or unjustly critical behavior.

Bullying in the workplace is also a global problem. A worldwide survey found 64 percent of respondents claimed to have been bullied, with Europe having the highest rate at 83 percent compared to 65 percent of Americans.¹²

Kelly brought the lead phlebotomist's aggressive behavior to the attention of her manager to no avail. Her confrontation in the ICU was the last straw. She cleaned out her locker that day and left for good. "I couldn't go on working in a place that allowed such unprofessional behavior to continue," she said.

References

1. Workplace Bullying Institute. Definition of workplace bullying. workplacebullying.org/individuals/problem/definition Accessed 1/08/20.
2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40, July 9, 2008.https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-40-behaviors-that-undermine-a-culture-of-safety/ Accessed 1/8/20.
3. Impact of Communication in Healthcare. Institute for Healthcare Communication. July 2011. http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ Accessed 1/8/20.
4. Hernandez, JS. Confronting Conflict in the Lab. How Managers Can Curb the Effects of Disruptive Behavior. Clin Lab News. July, 2011; 16-17.
5. Workplace Bullying Institute & Zogby International. U.S. Workplace Bullying Survey. September 2007. http://workplacebullying.org/multi/pdf/WBIsurvey2007.pdf Accessed 1/8/20.
6. Centers for Disease Control and Prevention (CDC). Exposure to Stress: Occupational Hazards in Hospitals. http://www.cdc.gov/niosh/docs/2008-136/pdfs/2008-136.pdf Accessed 1/8/20.
7. Center for Phlebotomy Education, Inc. Survey Says: Respect from Other Healthcare Professions. Phlebotomy Today-STAT! https://www.phlebotomy.com/pt-stat/stat0710.html.  Accessed 1/8/20.
8. Workplace Bullying Institute. Early signs of bullying. http://www.workplacebullying.org/individuals/problem/early-signs/ Accessed 1/8/20.
9. Riggio R. Cutting Edge Leadership. Workplace Bullying: Applying Psychological Torture at Work. Psych Today. http://www.psychologytoday.com/blog/cutting-edge-leadership/201002/workplace-bullying-applying-psychological-torture-work Accessed 1/8/20.
10. Workplace Bullying Institute. Who gets targeted. http://www.workplacebullying.org/individuals/problem/who-gets-targeted/ Accessed 1/8/20.
11. Workplace Bullying Institute. Bullying Contrasted With Other Phenomena. http://www.workplacebullying.org/bullying-contrasted/ Accessed 1/8/20.
12. Dellasega C. Bullying Among Nurses. Am J Nurs. 2009; 109(1):52-8. http://www.nursingcenter.com/prodev/ce_article.asp?tid=1156786 Accessed 1/8/20.