Write-Ups, Retribution, and ‘DARVO’

Getting “written up” in a patient safety reporting system (PSRS) sucks. Most of us are trying to be excellent clinicians and colleagues and are totally blindsided by a complaint about our behavior. It can feel confusing, frustrating, and hurtful. “Why can’t they just say it to my face?” When there is a misunderstanding, we ask: why can’t we just communicate effectively?

A functioning culture of safety should capture and address behaviors that may cause patient harm. When a complaint seems like utter nonsense, we often shake our fists and wonder, “why is the system being manipulated?” or “should a PSRS even accept reports on conduct?”

Good faith complaints may include concerns like miscommunication, micro- and macroaggressions, incivility, bullying, and abuse. However, a disgruntled employee may report hoping to harm a coworker’s professional standing. A report may provide both honest information about harmful behavior and be motivated by hope for punitive action.

Unfortunately, while some complaints about behavior can be exaggerated, biased, or even malicious, there are also plenty of bullies in health care. Whether cognizant or not, they use their power to mistreat and harm those around them. Ample evidence demonstrates disruptive behavior seriously threatens patient safety, causing errors and other preventable harm. Although less than 20% of physicians are labeled as disruptive, they impact greater than 98% of members of the health care team (Anaesthesiol 2021;34:387-91).

Analysis of the Co-Worker Observation Reporting System (CORS) demonstrates that while the vast majority of clinicians have zero reports made about them, 3% of physicians generate about 44% of complaints (Jt Comm J Qual Patient Saf 2016;42:149-64). The patients of surgeons who have received more coworker complaints suffer higher rates of medical and surgical complications (AMA Surg 2019;154:828-34). When harmful behavior goes unevaluated and uninterrupted, patients and staff suffer.

Malicious reporters may even use the PSRS to attack colleagues who threaten their power. In one technique, called DARVO, the offender may “Deny the behavior, Attack the individual doing the confronting, and Reverse the roles of Victim and Offender such that the perpetrator assumes the victim role and turns the true victim into an alleged offender” (J Aggress Maltreat Trauma 2020;29:897-916).

Ideally, all reports about professionalism would be non-judgmental, truthful, and lead to personal and group reflection on how the incident could have been avoided. But safety reporting systems serve as a funnel for dysfunctional reporting behaviors, too. For some organizations, patient safety reports provide the only obvious avenue to anonymously report genuine conduct issues.

It takes a shrewd eye and a deep understanding of the local culture to have a shot at recognizing the difference between a legitimate conduct problem and someone with an axe to grind; something that needs individual intervention versus a systems intervention.

PSRSs exist in an organizational cultural that includes psychological safety, hierarchy, leadership styles, moral climate, production pressures, and an organization’s ability to embrace and explore conflict. Despite many institutions adopting an “if you see something, say something” philosophy, without high levels of psychological safety, workers can’t communicate directly without fear of retribution. Looking for a safe, anonymous way to report invariably puts more pressure on the PSRS to fill the gaps.

Anonymous reports bypass conflict-based interpersonal interactions. The author can document candidly and push the issue to a manager. The documentation process insulates employees concerned that direct communication will be dismissed, or worse, weaponized against them. In the absence of other pathways, the PSRS may be the only psychologically safe resource for clinicians to share concerns over disruptive, harmful conduct (J Clin Nurs 2021;30:e41-4).

When the standards of professional conduct are set by the dominant class in a hierarchical structure, implicit and explicit bias are used to maintain the status quo (J Vasc Surg 2020;72:1828-9). Racial and gender minorities are at particular risk of targeting via the PSRS, as seen in other professional evaluations (J Natl Med Assoc 2020;112:117-40; Ann Surg June 2021). Underrepresented and minority physicians tell stories of being ostracized and singled out for conduct (asamonitor.pub/3OaZviQ). Black, Latino, LGBTQ, and women clinicians often find themselves on the receiving end of unfair patient safety reports. It is critical that reviewers heighten their sensitivity to minoritized populations, tune in to patterns of discrimination, and prevent unfair treatment of vulnerable individuals.

Well-functioning quality improvement teams utilize incident reports to identify risks and to analyze critical events (To Err is Human: Building a Safer Health System. 2000). Perspectives on a report’s content will vary. The person filing a report believes it is filed in good faith, while the person being reported may perceive it as unfair, petty, inaccurate, or intentionally twisted. The group reviewing the incident will offer yet another perspective within the context of the organization. Immense discernment is needed to decipher the etiology, intent, or appropriateness of conduct-related incident reports.

When safety reporting systems are co-opted to air interpersonal conflicts, different harms may result. A culture of toxicity – driven by shame and blame – may result, rather than one of safety (J Grad Med Educ 2020;12:525-8). Anonymous reporting protects the reporter from retribution but leaves the recipient with no recourse to respond. Recipients may lament a missed opportunity to resolve the matter more directly and restore a frayed relationship. These situations may further damage communication, negatively impacting both patients and workplace culture.

Despite the promise of anonymous reporting, a thorough investigation of a report by the departmental representative may reveal the involved parties. The department PSRS representative should employ discretion and remain impartial when performing their investigation. Their goal is to filter the chaff of interpersonal conflict and identify the potential systems issues lurking below. They must also be keen to recognize potentially destructive uses of the system, such as DARVO, which falsely identifies the perpetrator as the victim.

Without training, we cannot expect patient safety reports to meet our ideal standard: written in a factual, respectful, non-judgmental style that assumes good intent. Have we provided and reinforced training for clinicians? Have we intentionally designed the reporting process to encourage a human-centered attitude?

In one innovative approach, Children’s Hospital of Pittsburgh spent four years training their residents in the use of a PSRS (Patient Saf 2021;17:e373-8). The brilliant program implemented didactic sessions from intern year throughout residency to educate residents on the proper use of a PSRS. They implemented a simplified system and monthly quality meetings. Finally, they dedicated faculty and staff to facilitate discussions and provide mentorship. Feedback was provided for incident reports, and a culture of safety was fostered throughout their residency training. Over the four-year period, submissions rose by a factor of 10, and the number of serious harm events decreased by almost 50%.

Receiving a conduct complaint can be difficult, even devastating. Our shared goals should improve safety and culture, not promote retribution. It is vital that reporting systems and investigation processes avoid traumatizing clinicians. Robust support structures must be embedded to reduce the risk of unintended negative consequences.

Clear, impartial, effective communication is essential to ensure all members of the health care team feel supported, rather than targeted. Additionally, reviewers must be strategic in assessing the cultural milieu of reports. When conduct is in question, investigators should evaluate the validity of complaints, recognizing the risk of misunderstandings, bias, retribution, and DARVO. Outcomes should be communicated transparently.

Effective PSRS reviewers require consistent training in remaining impartial during investigations. Any repercussions should be fair and just, with the goal of enhancing a culture of safety for the benefit of both patients and clinicians. Trends may be noted in individual and group behavior, helping to determine if individual resources or systems-level interventions will be most effective.

We must critically review and improve our reporting systems. We must understand how culture and conflict impact their use. The uses and potential abuses of reporting reflect one facet of organizational culture. Leaders must ensure that policies, practices, and procedures promote a flattened hierarchy – a particular challenge in medicine. How are we supporting communication skills? How are we maintaining relationships through conflict? What does accountability look like where we work? Is it safe to speak up where we work?

For example, in the author’s (SB) hospital, the labor and delivery (L&D) nurses anonymously submitted a PSR against the anesthesiology department. After cesarean delivery, the report claimed patients were receiving pain medication at inappropriately frequent intervals on the post-partum unit. Further investigation revealed an inefficient hand-off system between L&D PACU nurses and post-partum nurses. Their interdepartmental frustrations focused inappropriately on the anesthesiologists. A new hand-off tool was developed, and the patient safety issue was resolved. The behavior modeled in this scenario centered around constructive, relationship-centered communication – working together with nurses to find a solution. An unbiased investigation revealed the root of the problem that was not obvious at first. This interaction enhanced trust and communication among the teams, rather than sowing animosity.

Do you know how safety reporting works at your workplace? You can ask where reports go, who reviews them, and with what aims. Is there any training on how to report effectively? What is done to decrease punitive, targeted reporting? Given the unique risks to minoritized clinicians, what are leaders doing to mitigate how implicit and explicit biases impact reporting?

Being “written up” doesn’t have to be a nightmare. The PSRS can be a tool for uncovering genuine safety problems, including unhelpful or even injurious behavior. Through high-quality reporting and a holistic approach to organizational culture, we can prevent harm to our patients and each other.