1. Gould, Kathleen Ahern PhD, RN

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At the 2014 American Association of Critical Care Nurses (AACN) annual National Teaching Institute, I was thrilled to see Dr Lucian Leape receive the AACN Pioneering Spirit Award for international leadership in patient safety. Leape, an adjunct professor of health policy at the Harvard School of Public Health, is internationally recognized as the father of the patient safety movement. He was a member of the Institute of Medicine's Quality of Care in America Committee, which published 2 landmark articles; "To Err Is Human: Building a Safer Health System" in 1999 and "Crossing the Quality Chasm" in 2001.1 His accomplishments are many, and his humility is heartwarming. He is willing to be the voice of a new era of health care and say the simple words that lead to change: I'm sorry.


Dr Leape acknowledges that medicine has not always fostered a culture of respect, even though it is one of the most fundamental factors in collaborative relationships and essential to improve quality and safety of patient care. Unfortunately, many nurses recall egregious examples of verbal abuse and humiliation as frequently as they report great examples of teamwork and collaboration. However, this is changing.


Some of you may remember hearing Dr Leape last year at the 2013 National Teaching Institute in Boston. As a keynote speaker, Dr Leape's address referred to the "elephant in the room"-something that everyone in health care can't help being aware of but that some are still uncomfortable talking about: a culture of disrespect. A culture of disrespect, Dr Leape said, is an environment that "teaches, tolerates, and sometimes rewards disrespectful behavior."2 Unfortunately, it has been accepted in medical education and in clinical practice for too many years. Disruptive behavior on the part of physicians has been an issue few have talked openly about, yet Dr Leape acknowledges the problem and invites us to join him to make sure it becomes a remote issue and one that is not passed down to the next generation of nurses. Leape bravely admits that disrespect has been a problem in health care.


Disrespect is a threat to patient safety because it inhibits teamwork, blocks communication, undermines morale, and inhibits compliance and implementation of new practices. In 2012, Leape and colleagues identified a broad range of disrespectful conduct, suggesting 6 categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.3 Leape encourages us to recognize these behaviors and work to identify strategies to change these behaviors, including self-reflection.


A few years ago, the National Patient Safety Foundation selected Leape to lead a think tank to direct the key concepts that will transform health care toward a culture of safety. The Lucian Leape Institute4 was established in 2007 to bring forth new approaches and innovations to expedite the creation of sustainable improvements. The core concepts for this work include


* medical education reform,


* active consumer engagement in all aspects of health care,


* transparency as a practiced value in everything we do,


* integration of care within and across health care delivery systems, and


* restoration of joy and meaning in work and ensuring the safety of the health care workforce.



To translate these goals into the workplace, we must dissolve all remnants of the past culture of disrespect. To do this, we must adopt models such as AACN's Health Work Environment and incorporate new practices. And, we must study and appreciate the harmful effects of disrespect.


Nurse-physician relationships, disruptive physician behavior, and institutional response to such behavior may impact work satisfaction. Rosenstein5 reported the results of a study of 1200 nurses, physicians, and hospital executives from a network of community-owned hospitals and health care systems. The study suggests that daily interactions between nurses and physicians strongly influence nurses' morale. All respondents were very concerned with the significance of nurse-physician relationships. And although all respondents saw a direct link between disruptive physician behavior and nurse satisfaction and retention, the groups differed in their beliefs about responsibility, barriers to progress, and potential solutions. The findings suggest that the quality of nurse-physician relationships must improve. A survey shows that disruptive behavior on the part of the physicians greatly affects nurses' job satisfaction and morale.


Many studies and workforce think tanks have concluded that our work environments must improve; the problems may be found in many disciplines including our own. We are all searching for the same thing, joy and meaning in our lives and work. I encourage you to read a report from a team at the Leape Institute entitled "Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health."6 This report challenges us to question ourselves by asking if we can answer yes to 3 questions each day:


1. Am I treated with dignity and respect by everyone?


2. Do I have what I need so I can make a contribution that gives meaning to my life?


3. Am I recognized and thanked for what I do?



We may also reframe these questions to see if we are treating our colleagues with dignity and respect, acknowledging their contributions, by recognizing and thanking them for what they do.


It is a powerful exercise from both perspectives.


Thank you, Dr Leape, for your honesty and wisdom. I am proud that our profession organization has recognized your efforts to change our culture and help us move toward a safer health care system!


Kathleen Ahern Gould, PhD, RN

Dr Lucian Leape... - Click to enlarge in new windowDr Lucian Leape

Editor in Chief Dimensions of Critical Care Nursing


Adjunct Faculty


William F. Connell School of Nursing


Boston College


Chestnut Hill, Massachusetts




1. News: Lucian Leape, NPSF Institute receive AACN award. Accessed May 29, 2014. [Context Link]


2. McTiernan P. Lucian Leape on the elephant in the room. PS blog. National Patient Safety Foundation. May 28, 2013. Accessed May 26, 2014. [Context Link]


3. Leape L, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012; 87 (7): 845-852. [Context Link]


4. Accessed May 29, 2014. [Context Link]


5. Rosenstein AH. Original research: nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs. 2002; 102 (6): 26-34. [Context Link]


6. The Lucian Leape Institute and the National Patient Safety Foundation. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health. 2013. Accessed May 29, 2014. [Context Link]