Disrespectful Behaviors: Part 2

In the health care industry, widespread disrespectful behavior exists among all levels of organizations and staff. The stubborn strength of this problem lies in its quiet ability to undermine critical conversations.¹ Last month, in part 1 of this 2-part series, I discussed why disrespectful behaviors arise and persist. In part 2, I delve into some strategies to address disrespectful behaviors and the effects they have.

Establish a no-retribution policy for those who report disrespectful behavior. This policy must be established at the beginning of organizational efforts to reduce disrespectful behaviors.

Open a dialogue about disrespectful behavior by using surveys from the Agency for Healthcare Research and Quality (www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html) to question staff. Managers can incorporate questions about disrespectful behaviors when visiting locations they are in charge of and hold focus groups to have frank discussions.

Create a code of conduct (or code of professionalism) to serve as a model for interdisciplinary collegial relationships and collaboration (mutual trust and respect that produces willing cooperation).² Clearly articulate the standards of behavior desired, as well as unacceptable behaviors.³ Do not allow any exceptions.⁴

Establish a standard, assertive communication process for health care staff who must convey important information. Numerous communication techniques are available to help staff accomplish this, including Situation, Background, Assessment, and Recommendation (SBAR); Describe, Express, Specify, and Consequences (DESC) script; and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS).

Establish an escalation policy to manage conflicts about the safety of a prescription or situation when the standard communications process fails to resolve an issue. Staff must know who to call for help in getting a satisfactory resolution. Be sure this policy provides an avenue for resolution outside the typical chain of command in case the conflict involves a subordinate and his or her supervisor.

Develop an intervention policy that has full leadership support to consistently address disrespectful behaviors. An effective policy includes zero tolerance for disrespectful behaviors regardless of the offender’s standing in the organization, fairness to all parties, consistency in enforcement, a tiered response to infractions, a restorative process to help people change their behavior, and surveillance mechanisms.⁴ This policy should also address any system issue that perpetuates disrespectful behavior (eg, issues that affect workloads, staffing, budgeting, education, communication, handoffs, environmental hazards, stressors).

Provide mandatory education for all staff about appropriate professional behavior and the impact of disrespectful behavior, as defined by your code of conduct.^5,6 Provide skill-based and roleplay training in communication methods, relationship building, business etiquette, conflict resolution, assertiveness training, team training, behavioral techniques to confront and address disrespect, and how to report disrespectful behaviors.

Implement a confidential reporting/ surveillance program for detecting disruptive behavior and measuring compliance with the code of conduct. Offer a formal reporting program and an informal process for unwritten reports. Encourage anyone who experiences or witnesses disruptive behavior to report the event⁷; do not assume that the absence of reports of disrespectful behavior means it is not occurring. Other means of surveillance should be employed, including feedback from patients and families, staff and patient surveys, focus groups, informal dialogue, peer and team evaluations, and routine inquiries.

Create a positive environment. Certain aspects of the workplace environment are key to combatting disrespect, including a fair and just culture, respectful management of serious adverse events, and transparency.⁵ Another factor is visible leadership commitment to a respectful culture, which requires leading by example. Leaders should set the tone with an attitude of mutual respect for the contributions of all staff, remain open to questions and new ideas, and reward outstanding examples of collaborative teamwork, respectful communication, and positive interpersonal skills.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.

References

• Zimmerman T, Amori G. The silent organizational pathology of insidious intimidation. J Healthc Risk Manag. 2011;30(3):5-6,8-15. doi: 10.1002./jhrm.20055.
• Kramer M, Schmalenberg C. Securing “good” nurse physician relationships. Nurs Manage. 2003;34(7):34-38.
• Porto G, Deen J. Drawing the line. Effective management strategies for disruptive behavior. Patient Saf and Qual Healthcare. 2008:20-4,26-8.
• Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-858. doi: 10.1097/ACM.0b013e3182583536.
• Pennsylvania Patient Safety Authority. Chain of command: when disruptive behavior affects communication and teamwork. Pa Patient Saf Advis. 2010;16(7)(suppl 2):4-13.
• The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008;(40):1-3.
• DuPree E, Anderson R, McEvoy MD, Brodman M. Professionalism: a necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf. 2011;37(10):447-455.