Dr. Crude and the bystander effect

By Cynthia "Cindy" Clark | 08/10/2016

To stay silent is to condone.

Before taking a faculty position, I was employed as a psychiatric nurse/therapist specializing in adolescent mental health, substance-abuse intervention and recovery, and violence prevention. I had the good fortune of working with an amazing team of mental health professionals who treated a variety of conditions and disorders. Many of our patients were violent, adjudicated youth with long histories of severe substance abuse and criminal activity.
 
Cynthia ClarkOur work was challenging and sometimes dangerous. I have often been asked, “Were you or members of your team ever injured by one of your clients?” And the answer is no, although there were some close calls. Like the time a gang of violent youth drove onto the campus of our treatment center and circled the building while wielding a sawed-off shotgun and threatening to shoot one of our African-American counselors. It was terrifying, but, fortunately, the police responded, handled the situation without incident, and no one was hurt.
 
But if someone asked me if a co-worker ever harmed me, the answer would be yes. Unbelievably, the assault came from a psychiatrist. Here’s what happened.
 
Who do you think you are?
Years ago, as the nurse manager of an inpatient adolescent unit, one of my many responsibilities included organizing and facilitating treatment planning for our clients and their families. Each psychiatrist met individually with the team to review his or her clients’ treatment plans. The team consisted of the lead psychiatrist, psychologists, nurses, social workers, recreational therapists, teachers, occupational therapists, and nutritionists. My job was to organize each session so that the team was assembled and ready to go. They were busy and eventful days, with planning and coordination key.
 
One particularly busy day, as I was preparing for our meeting, I noticed that one of our patients was struggling with what appeared to be symptoms from excessive dosage of her prescribed antidepressant. The patient—I will call her Anna, not her real name—was complaining of nausea, headache, agitation, and restlessness. She was clearly anxious and diaphoretic. Of course, we were concerned about her, but comforted by the fact that we planned to discuss her treatment plan later that morning. In the meantime, we withheld her morning dose of the medication, recorded her vital signs, and closely monitored her condition.
 
Image of man yelling at womanWhen her psychiatrist—I will call him Dr. Crude—arrived on the unit, I was relieved because Anna was still not feeling well. As Dr. Crude entered the treatment-planning room, I quietly mentioned that Anna might be experiencing symptoms related to heightened dosage of her antidepressant and expressed a need to discuss her condition first during morning rounds.
 
Imagine my shock—and fear—when he grabbed me forcibly by the shoulders, threw me angrily against the wall, jammed his finger into my chest, and, with spittle spraying from his mouth, accused me of “playing doctor,” chastised me for my audacity and impertinence, and asked in an enraged tone, “Who do you think you are?” He was beyond angry—furious, in fact—as he continued to berate me in front of my teammates.
 
I was certain one or more of them would come to my aid, but that did not happen. They sat stunned and silent, looking on with horrified expressions. After what seemed like forever, Dr. Crude let go of me and stormed out of the unit. Moments later, the tears came, and my teammates rushed to console me. When I asked what kept them from intervening, each one immediately apologized, stating that they were so stunned by what they observed they were completely immobilized.
 
Observers of violence
As I reflect on that experience and the lack of response from my teammates, I’m intrigued by their behavior. What kept a top-notch group of individuals, all highly trained, highly educated, and well-schooled in behavioral health and conflict de-escalation, from intervening on my behalf? There is a term used in psychology for people’s failure to help a person in distress. It’s called the bystander effect, a term coined by social psychologists to study if and how the presence of others discourages a person from intervening in an emergency situation. Researchers found that the greater the number of bystanders, the less likely any one of them will help.
 
There are various terms to describe bystanders. They are also called witnesses, accomplices, and indirect victims. I prefer the term “witness,” defined as someone who sees, hears, or knows about incivility, bullying and/or violence happening to someone else. Regardless of the term, actions of witnesses, whether intentional or not, contribute to the outcome of an uncivil or bullying event. The impact of bullying on witnesses is clear: Observing uncivil or bullying behavior, particularly over time, can have detrimental effects on one’s health, including mental health. Like targets of workplace bullying, witnesses of bullying may develop symptoms of guilt, anxiety, and depression. In some cases, they may disengage or leave unhealthy workplaces altogether.
 
Witnesses react to bad behaviors in various ways. Some take the side of the offender by doing nothing, laughing at the target, or encouraging the offender to mistreat the target. Others give silent approval by simply looking on and doing nothing. In my situation with Dr. Crude, the witnesses were so horrified and shocked by his behavior they were rendered helpless. As noted earlier, some social psychologists believe that the more observers there are to a bad situation, the less likely they are to intervene. That’s known as the “diffusion of responsibility” effect—believing someone else will step in and help.
 
Reward for silence
In some cases, the offender or bully is protected. That’s what happened with me. When I reported the incident to the medical director and the CEO of the facility, I was told to “let it go” because Dr. Crude topped the list of psychiatrists admitting patients to the facility and we “wouldn’t want to upset him.” Not only was I encouraged to let it go, I was offered a salary increase, which, to me, was hush money in return for my silence. Soon after, when my reports went unacknowledged, I left the organization knowing I could not be party to this type of behavior. Exposure to acts of incivility and bullying impacts everyone involved: the target, witnesses, patients, other co-workers, families of those being targeted, and, ultimately, the organization.
 
While there is no universal formula for effective intervention and being a supportive witness, here are some suggestions. Take a personal stand against incivility and bullying behavior. Make it clear to your friends and co-workers that you will not be a participant. Set a positive example. Do not tease, spread gossip and rumors about others, or laugh at off-color jokes or distasteful comments. Beware of offensive emails and/or social media postings. Do not forward them to others or respond to them in a conspiring manner.
 
In the workplace, witnesses may be useful and even compassionate when incivility or bullying occurs. They may listen to the victim and offer a sympathetic ear. However, it is the rare co-worker who puts his or her own well-being or job security on the line by giving an objective, detailed account of the incident to supervisors or HR representatives. Many co-workers—concerned about becoming a target themselves, or being identified as a complainer—are unwilling to address the situation. Also, many workplaces lack guidelines to deal with offenders as well as clear policies regarding confidentiality, so there is no roadmap and, sadly, a lack of support for reporting uncivil behavior. Even worse, rather than showing support, the person reporting the incident may be labeled a troublemaker or “whistle-blower,” a term that, for many, has a negative connotation.
 
Fortunately, there are witnesses who take immediate action to stop the offender and support the target by using words and/or actions to intervene. Evidence suggests that when witnesses take safe and effective action to support targets of incivility, there is greater likelihood that the behavior stops.
 
Practice, practice, practice
In an ideal world, witnesses intervene when each incident of incivility and bullying occurs. However, each situation is unique and complex, and stepping in to intervene is not as easy as some would like. Intervening on another’s behalf and, ultimately, mastering this type of intervention take courage, skill, and practice, practice, practice.
 
For instance, let’s imagine that you witness a colleague (Belle) berating another colleague (Alice) in the presence of a patient and his family. You determine that the incident calls for an immediate response, but what can you say? How comfortable do you feel saying something like, “Belle, it’s not OK to yell at Alice, especially in front of patients. If you have concerns, let’s discuss them in private.” In my experience, individuals often express a desire to intervene, but lack the appropriate skills.
 
Effective intervention requires practice and skill building, which may be accomplished through workshops, online modules, role-playing, and simulation. But most of all, successful intervention requires support from leadership at all levels of the organization.
 
Every organization must take a stand against negative and disruptive behavior by developing, implementing, and widely disseminating clear, confidential, and comprehensive policies and procedures that foster a healthy work environment. Supervisors and HR representatives must take reports of incivility and bullying seriously and conduct thorough, confidential investigation, protecting all identified parties. Implementing team charters that reinforce civility and norms for respectful interactions and protection of patient safety are crucial steps toward creating and sustaining healthy work environments.
 
Organizations must invest in educational programs that raise awareness about the negative impact of incivility on workplaces while simultaneously reinforcing and building upon existing organizational strengths. Positive role modeling at all levels of the organization is essential. For workers to intervene, leaders must model the way and reward others who bear active witness to bad behavior. The bottom line is, we can no longer stay silent.
 
Cynthia “Cindy” Clark, PhD, RN, ANEF, FAAN, nurse consultant for ATI Nursing Education, founder of Civility Matters, and author of Creating & Sustaining Civility in Nursing Education, is a psychiatric nurse/therapist and an expert in fostering civility and healthy workplaces.
 
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