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Communication key to reducing disruptive behaviors
How to facilitate a safe environment for patients, staff
How many times a day do you hear or read the word "safety"? If you are a typical quality wonk working in an acute care setting, it must number at least in the dozens. But when you think safety, are you prefacing it with another word? Patient? Workplace? Employee? All are important, and all are at risk if communication breaks down, problems with disruptive staff members are not addressed, and you do not regularly assess how well staff communicate and what safety issues need to be addressed.
The topic is important enough to be the subject of a 2008 alert from the Joint Commission that stressed the importance of behaviors that can undermine a culture of safety. It has also been a popular topic of research, including a new study in the American Journal of Obstetrics and Gynecology1 by Alan Rosenstein, MD, MBA, medical director of clinical efficiency and care management at Valley Care Hospital in Pleasanton and medical director of Physician Wellness Services, a physician employee assistance program company based in Minneapolis.
In this study, which follows on from work Rosenstein did earlier on the role of disruptive behavior on the nursing shortage and a similar study released last month on disruptive employees in the emergency room setting, he looked at the impact of disruptive staff on patient outcomes in an obstetric setting and appropriate ways of addressing it.
"I think people are starting to get the relationship between respectful workplaces and safety," Rosenstein says. "We have a tradition of being a hierarchical profession, with very autonomous physicians, who are important revenue sources for hospitals. Physicians have been seen as godlike. But we are not. And there is a business case that when a physician is disruptive, it affects productivity and efficiency. And there is now a proven relationship between it and bad things happening to staff and patients."
He says maybe a quarter of organizations are giving the requirement to maintain a safe work environment serious consideration, another 40% are working at it but are not doing enough, and another quarter are doing nothing, maybe because their culture will not support such efforts.
What to do
The first step is to have a code of conduct and define what is inappropriate behavior and what is not. There are some differences from location to location, but 95% of what is deemed disruptive or offensive in one hospital will be considered in the same way at another, says Rosenstein.
You also have to ensure that whatever standards you apply are interpreted in the same way from case to case, Rosenstein says. "Whoever is in charge of interpreting the event must recognize that people do not intend to be disruptive, that they may be in a stressful situation where they become less tolerant of errors or slowness," he notes. "There is a gray line of perception and interpretation, and whoever is in charge has to know that there are always two sides to every story."
The person has to be skilled in facilitating and conflict management, with a knowledge of human behavior and great communication skills. Rosenstein recommends it be a physician, because then other physicians cannot come to a discussion of an event and say that the person on the other side of the desk can't possibly understand what it is like to be a busy doctor in a stressful situation. Director-level staff from safety, risk management, medical staff or human resources are good suggestions for where to find people to handle disruptive staff.
Getting physicians to change is not easy, Rosenstein continues. "We have been trained through harassment and hazing. There is low self-esteem and little if any training in team collaboration skills. It is changing a little now in medical schools, but the emphasis is still on communication with patients, not other team members."
The best approach is to have policies that relay information in a non-confrontational manner, explain the business and clinical reasons for improving behavior and communication, and teach the skills in a supportive manner that acknowledges the time constraints of a modern doctor, he says. "If you tell someone they have to go off to some communication seminar for a weekend, they may not respond well." With all the niceness, though, has to come a real message that disruptive behavior is not going to be tolerated and that the reputation of the physician is on the line. In a world of constantly available information, the last statement alone should get the attention you need.
Statistics show that 80% of nurses and 50% of doctors say they see disruptive behavior at work, but there is nowhere near the number of complaints that those numbers suggest. When you have that level of frustration, you are bound to see more mistakes and lower quality care, he says.
The issue has been growing in importance and will continue to, says Deborah Anderson, principal at PivotPoint, a healthcare consulting firm based in St. Paul that specializes in behavioral change. Her organization has been surveying healthcare organizations for years, collating some 72,000 responses. "Almost everyone sees it," she says. "Only 10% or fewer will report that they never see disruptive behaviors."
Shifting the culture
What it takes to be successful in creating a program that will change behavior is more than a two- or four-hour training session, Anderson says. "You need a culture shift and from the top down know what is healthy behavior and what is bad behavior. Everyone has to know the difference." Mostly, everyone does except those bad apples. "A third grader knows when someone is being mean."
What works is something akin to how people got smoking cessation to take hold, she says. "First, they made everyone stop smoking in offices and waiting rooms. Then there were smoke-free environments and some awful smoking room. Then it was moved off campus completely. We're on that kind of journey with bad behavior where we start with something small and it builds awareness. Then we move onto something bigger."
Anderson says there is a growing body of data that prove that if you treat your workmates badly, you probably aren't great with patients, either. Patients do better when they come from facilities that have this down, she says. "Rolling your eyes at someone is always bad. Good communication is always important. And if you roll your eyes at someone, you may lose out on important communication that someone will not pass on to you because you have belittled them. That can undermine safety."
Autocrats do not get feedback, to the point of wrong place/wrong patient surgery which happens about 40 times a week in this country. "It is critical to be engaged in healthy behavior," she says. "It sets the tone. Will patients tell you what is wrong if you can't communicate effectively? Will they follow your directions or think you are not listening if you are not respectful?"
Tool kit to the rescue
One group that has made the link between workplace safety, patient safety, and effective communication is the Emergency Nurses Association (ENA). The group recently released a toolkit, complete with articles, sample surveys, and other resources that anyone can access, says AnnMarie Papa, DNP, FAEN, the current president of the organization and interim clinical director of the emergency department at the Hospital of the University of Pennsylvania in Philadelphia.
She says that patient safety has taken a lot of the spotlight lately, but it is increasingly acknowledged that unsafe workplaces for employees impact patient safety. The increased realization of its importance to patient safety, requirements from the Joint Commission that it be considered a sentinel event, and Occupational Safety and Health Administration mandates that you have to have a plan in place to prevent workplace violence have helped put it on an equal footing with patient safety measures.
Along with the Joint Commission standards, there are rules coming down the bend that will require organizations to have smooth working teams, Rosenstein says. "Accountable Care Organizations, when they come to fruition, will mean that the people you get into bed with for business have to be people and organizations that are respected, trustworthy, and team players. This will be required."
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