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Are there bullies in the world of advanced practice providers (APPs)? How is bullying defined in a clinical environment? In this podcast, hosted by Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, three APPs from different hospitals debate incivility and workplace culture. They also address interpersonal relationships among APPs, physicians, and nurses.
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Diane McLaughlin: Hi, I’m Diane McLaughlin from Mayo Clinic in Florida on behalf of SCCM and the APP Resource Committee, bringing you a special edition of iCritical Care Podcast, this time focusing on instability and bullying in the workplace. I have some special guests with me, if you don’t mind introducing yourselves.
Kimberly Ichrist: I’m Kimberly Ichrist. I work at the Ohio State University Wexner Medical Center in Columbus, Ohio.
Kyle Patchen: I’m Kyle Patchen and I work at the University Hospital in Cleveland, Ohio.
Diane McLaughlin: I don’t know about you guys, but over the last two years, I’ve noticed a change at the bedside, which is that people aren’t as patient as they used to be and are snapping at each other a little bit more. And the word “bullying” is being thrown around outside of the nursing circle, where it’s been quite prevalent, but we’re seeing this leaking into providers, namely APPs, which could be partially because of the increase of APPs in the workforce, but is also seen with physicians. If you were to talk about what bullying looks like, how would you define it for me?
Kimberly Ichrist: I think that there are certain actions that I would say I would consider bullying, which would be repeated, unwanted, harmful actions that can cause distress to the recipient or even offend or humiliate that person.
Diane McLaughlin: This is something that’s somewhat deliberate to harm somebody. That’s probably where it gets a little bit tricky because, Kyle, we all have off-days, right?
Kyle Patchen: Right, and I think that one thing that we have to remember is how easily the lines can get blurred. Let’s say that we’re in rounds and a suggestion is made and it’s not well taken by another team member; the action is maybe not deliberate to cause harm or belittle an individual. Is it actually bullying or is it just maybe the teammate did not respond as well as they could have? At least in today’s culture, I’m finding that the term “bullying” really gets thrown around almost loosely when we are all working in a high-stress, high-stakes environment. I think that we really need to focus on the definition, how we actually use the term “bully.”
Diane McLaughlin: Unprofessional behavior isn’t necessarily the same as deliberately bullying somebody, but does it create a negative culture that allows this to exist? What do you think, Kimmy?
Kimberly Ichrist: I truly do believe that it can because, if it keeps repeating itself with the same person to the same recipient, that becomes a lot of distress for the person that’s receiving it.
Diane McLaughlin: Then what is the difference between bullying and instability?
Kimberly Ichrist: I think instability would be more of being rude or disrespectful to the person and have a negative impact on that recipient who’s receiving it.
Diane McLaughlin: That’s more like unprofessional behaviors?
Kimberly Ichrist: Yes, like eye rolling, eyebrow raising. There could be some sarcasm. Those are just a few that I would say.
Diane McLaughlin: That’s something else that’s changed within probably the last decade, that a lot of humor now is more sarcasm based. But if you don’t have the same type of humor that aligns, then that could potentially be perceived negatively.
Kimberly Ichrist: This is the thing, there are some cultures that I worked in and there were a lot of attendings, fellows, and nurses that, the culture was sarcasm but it wasn’t hurtful or cause a person distress, and they would have some sarcastic humor. But of course, in that area, it was well tolerated if somebody said, Hey, I didn’t appreciate that, or we are very vocal if that caused any harm to that person. That’s just one area that I worked at that it was there.
Diane McLaughlin: Then I have to ask, do these definitions change dependent upon who you’re talking to?
Kimberly Ichrist: I think maybe the recipient, how they perceive it, because the actions are so broad, but I think that we need to focus on the repeatedness and if it’s causing somebody distress in the workforce, I think that that’s where you need to focus on, that’s what I would say, and not focus on somebody just having a bad day.
Diane McLaughlin: Kyle, do you think some of what would need to happen in addition to finding repeated behaviors would be maybe looking at the sensitivity of the individual?
Kyle Patchen: I think that complicates things a little bit, and that’s why we are in this culture that really throws around the word “bullying,” because what we really need to be focusing on ultimately is intentionally demeaning behavior, and that’s how I would more look at bullying and incivil behavior. I think that those two words can really be intertwined, that if you’re intentionally trying to belittle, undermine, demean somebody, then that is, in my mind, intentional bullying and incivil behavior in the clinical environment. But also we are in a culture where there is a blurring hierarchal structure. As providers now, between PAs, NPs, MDs, and DOs, our roles as providers are becoming more and more similar. There’s no longer a hierarchy. I think that some of the behavior that we start to see in the clinical environment comes from maybe different providers. If I’m an NP and there’s an MD, I’m feeling undermined that maybe I have a knowledge base that is a little bit different than their own, and that’s where some of this incivil behavior and this bullying can arise from.
Diane McLaughlin: How do you correct that?
Kyle Patchen: Well, I think that the start is really just talking about it and acknowledging it. It’s certainly an issue that is not going to be solved in this short discussion. But I think that just making us all aware as social human beings and working in a social environment that there’s a lot of high stress, high stakes, that we really have to keep reminding ourself of everybody’s roles, responsibilities, and also contributions that we make to the team that we’re a part of and also the purpose that we’re practicing in the clinical environment.
Kimberly Ichrist: I do agree with Kyle. I think that the most important thing is, if you start having some of these bullying gestures or instability gestures, the first thing is, was it the first day that it happened? Second of all, bring the person to the side and have that discussion if it really, truly is causing you some distress.
Diane McLaughlin: What’s interesting is one of the organizations that has actually started looking at bullying is the AMA; they’re acknowledging that this is something that exists within the physician workforce. This is the same organization that had a campaign to stop scope creep or expanding the scope of advanced practice providers. How do you put those two thoughts together in terms of interacting within these different roles?
Kyle Patchen: As we are in the infancy of this topic, I think that, again, it takes conversations like this. We have to set our differences aside at some point. I’ve been fortunate enough to work on a very collaborative surgical team where there’s a healthy amount of mutual respect for each other’s roles. I’m not a surgeon, and the surgeons I’m with know that, it’s evident. However, I am skilled and have the ability and time and ultimately it’s my role to take care of patients in the preoperative, postoperative, and outpatient phases of the patient’s care. Between us there’s no animosity, there’s no contention because our roles are clearly defined.
I think that some of the issue arises where you work, let’s say, in an ICU and you now have an NP and intensivist working together. I can intubate, the intensivist can intubate. I can put in a chest tube, the intensivist can put in a chest tube. I can float a Swan, the intensivist can float a Swan. Now you’re really starting to blur the lines and roles and responsibility of who does what. I think that it takes a healthy amount of mutual respect from each individual, be it the NP, PA, MD, DO, what have you, all of us as providers ultimately to appreciate the contributions that each other can make for a team.
The days of one physician orchestrating all the control for the patient, those are gone. We now know that patients do better and they’re out of the hospital quicker when consultants are on board, when you have multiple teammates, and I’m not even going to start referencing the data that shows APP-run ICUs and the progress that those patients make. But I think it starts ultimately leveling the playing field and just having a discussion on why we are here. The degree next to our name ultimately becomes a little bit insignificant. You have a nurse practitioner that’s been practicing for 20 years, you’re telling me that they’re going to be better than a fellow fresh out of their fellowship as a new attending. Clinical experience is not defined by the degree that you have, it’s defined by your clinical experience.
Diane McLaughlin: So Kimmy, to piggyback on that, is respect something that you earn or that you’re given?
Kimberly Ichrist: I think that, in the work environment, everybody should be professional and everyone should have respect for each person, their job, their title. But I do feel as though everyone should be professional. The work environment should be a culture of respect, and it needs to be there. The one way to do that, just be professional. You don’t have to agree with one’s beliefs. You don’t have to agree with the way that someone chooses to live or love. That should be out the door. It should be what you’re doing, taking care of the patients and leaving your personal stuff out of it. If everybody focused on that, I think that the work environment would not have this problem.
Kyle Patchen: But, Kimmy, what do we do when you have somebody that, I think there should be a baseline of mutual respect for each other in each other’s roles, but also you have to respect yourself and not only your knowledge base, but the knowledge that others may have that you don’t. So what do you do when you have a new provider on your team and clinically there is room for improvement? At least in my practice, in today’s day and age, we as providers aren’t really taught to take constructive criticism; feedback is ultimately not welcomed. I was fortunate enough to go through a hybrid residency where, after every patient encounter, I received feedback from a colleague that was there, be it a physician, an NP, what have you, and even after reporting or presenting to an attending after the presentation, I would receive feedback. So I went through a very intense upbringing, going into a provider role of welcoming feedback to improve your ultimate clinical practice. But how do you handle newer providers or, not even new providers, just providers that don’t welcome feedback when maybe there is room for improvement?
Kimberly Ichrist: To be honest, everybody has their own personality, their own way of telling someone, to give them feedback with whatever it is, right? But at the end of the day, we have to respect the position. There are people above me that might have learning or training or just the policies in which we have established here where I work, those are the policies which were set. There might be somebody that chooses to do something that’s not policy based. I’m just giving an example. But the thing is, you have to respect their position and talk to them. If they’re not receptive to the discussion, first of all, I always make sure that I’m being respectful and I need to make sure that what I’m saying to the person, they’re understanding in a professional manner. But if they’re not going to receive the information, then that’s when I would just go up to the next person that’s above them, if it becomes a problem.
Diane McLaughlin: This all sounds great, but I got to be real. I have those moments that I completely disagree with what we’re doing for a patient or the care that we’re providing. And sometimes it’s challenging not to say something in a way that absolutely could be taken the wrong way.
Kimberly Ichrist: I feel like there are times where, especially if you’re having a discussion with a medical doctor and you’re a nurse practitioner, yes, there might be those times, and I would feel as though it’s a discussion more than disrespect. I think that that’s the culture in which we all need to have. If somebody’s suggesting something, a different plan of care for a patient, I feel like whatever position you hold, you should be open to whatever that person is saying.
Kyle Patchen: But Kimmy, I think you’re feeding into the issue with what you said, you said medical provider or doctor. I think that we really should be changing our language and shaping it to just level the playing field, and we’re just providers. Be it, as I’ve stated, nurse practitioner, physician assistant, DO, or MD, we are all providers there. So, I think in your mind, you have to first get rid of the hierarchy. If you’re having a disagreement with the provider on the team, whatever their role may be, I think that we should be allowed the opportunity, everybody should be allowed the opportunity, to speak up and say, I have a different view in caring for this patient and this is why. If you’re quoting literature or previous experience or both or maybe you see something that the other team member doesn’t, that’s why we have teams. We don’t have a team for one MD with two APPs following around, describing for them, putting in orders, and writing the note. It should be a team approach. But also what we have to do is be constantly up to date with the literature, be always trying to improve our practice and accepting that what we’re doing right now is ultimately going to change in 15 or 20 years. So what do we actually know in terms of an education? We are kind of lifelong students, I would venture to say, that we should all be venturing to learn and grow together.
Diane McLaughlin: But Kyle, how many people do know that are in our same role, that don’t operate like that? I think this is why there’s some discord. A lot of physicians don’t like the word “provider” and they want to make sure that they’re being referred to as “physician,” which is different than how they would like us to be referred to.
Kyle Patchen: I guess I can appreciate that just because, speaking openly, I don’t like being called an APP. I’m a nurse practitioner, I’m not a physician assistant. I have a different education and training. But ultimately, regardless, just like there are good MDs, there are bad MDs; good NPs, bad NPs; good PAs, bad PAs. You think that the people that practice poorly are those that get so stuck on this role and they act like, “Okay, I’ve achieved the medical doctorate, I know everything, I’ve gone through residency, maybe a fellowship, and I am the clinical leader. You all need to follow me blindly.” It’s 2022; that’s just not how we practice anymore. Hospital systems operate differently. They’re reimbursed differently. We don’t have time to have one captain of the ship anymore. It takes a team approach. Regardless of what you think, or you don’t like the word “provider,” that’s what we all are. We are providing clinical care to the patients that we’re serving.
Diane McLaughlin: This is focused a lot so far on provider-to-provider conflict or between physicians and APPs or more lateral violence. But I’ve been seeing it come from the other direction too, where nursing is kind of known for this culture, picking on medical residents and microanalyzing every move that was made or not made. How do you manage that, Kimmy?
Kimberly Ichrist: This could be a hot topic in itself. When you’re a new provider, it can be challenging to have the nursing trust you and respect you. With that being said, there might be some gestures that might not be welcoming. What I have to say to that, with my experience, is you have to first tread lightly and you have to give the nurse respect. But like I said, if it’s repeated action, then you must have a discussion with that individual. You really do. There have been nurses that have issues with my practice or my orders. I do explain it. I’m being really honest here, I think that the first step is to just give them respect. If it’s a continued behavior, you do have to set them aside and have that conversation.
Kyle Patchen: I think that’s an important point because nursing is a profession and we can all speak for this, just all being nurses. You’re raised in an older, they’re a young culture, and that has just historically been the culture of nursing. So now, you’re a seasoned nurse and you have residents coming in and they are deferring from the standard of care that you are used to. You may lash out at them a little bit more aggressively. Ultimately, I think I would venture to say it’s incivil behavior. Instead of educating, let’s say, the resident, just speaking about that from what I’ve experienced, it could be handled a little bit better. We don’t have to be so incivil among each other. But again, we’re raised in an incivil culture. I think that, at least from nursing, that carries over. But Kimmy does make a good point regarding it starting with respect, regardless of what anybody’s doing. If we’re speaking about nurses, if there is a lack of education or awareness of a clinical issue, you do need to give that person respect and respectfully let them know what’s going on. Then from there, if it’s a repeated behavior and they’re not willing to take the actions to improve their performance, then I think at that point we need to go up the chain of command and maybe have an assistant manager, what have you, look into that.
Diane McLaughlin: I want to play a little bit of a game, just humor me here, where I’m going to give some examples of things that I’ve seen or heard about in clinical practice and you tell me if it’s bullying or not bullying, okay? Are you guys game for this?
Kimberly Ichrist: Sure.
Diane McLaughlin: All right. A nurse complains to her colleague that the provider never lets them give sedation.
Kimberly Ichrist: Well, you have to say the word “never” is a pretty strong word. I would not call that bullying or instability. I would consider that as the nurse’s perception.
Kyle Patchen: I would agree. Nursing tends to be an all-or-nothing profession, especially as a bedside nurse, they’re just all absolute. But just hearing that, I would say it’s not bullying.
Diane McLaughlin: But maybe unprofessional.
Kyle Patchen: With more context, I think that we could be able to say more, maybe it’s unprofessional or incivil behavior, but again, with the absolute that we’re given right now, I’m not hearing anything that’s bullying or incivil.
Diane McLaughlin: A physician rounds in the morning and undoes everything that the overnight physician did.
Kyle Patchen: Are you practicing where I’m practicing at now?
Diane McLaughlin: I know this never happens. This has never actually ever happened anywhere.
Kyle Patchen: Again, answering that one first, trying to set aside the experiences that I’ve witnessed and perceived before, I think that does border incivility, especially if it’s a repeated thing, that the plan of care is going 180 every 12 hours, just because of the provider. I think that, talking about respect, if a plan of care has been set, unless there is clear, hard-set reason to defer from the plan of care, we shouldn’t be alternately going back and forth between, say, patient’s on Precedex during the day, propofol at night, Precedex during the day, propofol at night. For a patient that simply needs to be sedated and without any other clinical reason to be changing sedation, I would say that that is more incivil behavior.
Kimberly Ichrist: There are situations where that can be, working the night shift, that you have a plan, you’re the one at the bedside and things change during the day. So if I come back the next night and they’re like, Well, the plan changed, I’d say the first question is, so what happened or what is the thought process? So in that aspect, I wouldn’t consider that incivility, but if it was repeated with the same attending or the same fellow, then I could see that that could be a problem. Like I said, if it’s repeated behavior and it’s always with your orders, then I would have that conversation.
Diane McLaughlin: All right. What about, you’re getting signout from a colleague and your back is turned to that person and you’re just flipping through the chart and rolling your eyes to yourself, not openly, what is that? I swear that’s not me.
Kimberly Ichrist: Those are gestures that, especially if it continues, need to be discussed.
Kyle Patchen: Well, it depends because, when I’m getting a report, I have my sheet in front of me and the computer chart open, and I’m looking at labs as the person’s talking and I’m looking at imaging, and I tend to be more short and let the person speak during report. They can give it to me how they want. If I have questions, I’ll ask. But as I’m getting a report of the patient, I’m looking at labs, I’m looking at imaging, I’m reviewing procedure notes, what have you, consultant notes, while I’m getting a summary. So ultimately, you would be saying that you’re going to talk to me about my behavior. What do you want me to do, be staring right at you during a report? I think that if it’s really bothering you, we can have a discussion. But ultimately, taking the context that I’m doing what Diane’s describing right now, I’m looking at the patient while you’re giving me a report, there’s nothing to it.
Diane McLaughlin: All right. Well, I think that’s all the time we have for today. I think there’s a lot to think about in terms of what’s bullying and what’s incivility and how we can change ourselves to make the environment better. On behalf of SCCM, this is Diane McLaughlin, and we look forward to joining you next time. Thank you.
Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound committees and is a social media ambassador for SCCM.
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