Cases & Commentaries

Danger in Disruption

Commentary By Dorrie K. Fontaine, RN, PhD

The Case

A 23-month-old toddler was severely dehydrated
after vomiting due to gastric outlet obstruction. She had metabolic
alkalosis (pH = 7.58), and her last peripheral IV site had been
lost. The nurse caring for her that day was expert, had worked on
that unit for years, and had helped write unit and hospital
pediatric policies. One of these policies limited the number of IV
sticks in children, so the nurse requested that anesthesiology
attempt femoral access.

When the anesthesiologist arrived with an
assistant, they took the patient to a treatment room for sedation
before attempting to establish a femoral IV site. The nurse
informed them that hospital policy prohibited sedation in the unit
without monitoring. When her comments were ignored, she went to
alert the charge nurse and obtain a copy of the policy.

In the meantime, propofol was administered
without monitoring. Upon her return, the nurse observed that the
child was apneic and again requested monitoring. The
anesthesiologist replied that it wasn't necessary, applied a
painful stimulus, and noted that spontaneous respiration resumed.
He proceeded to prepare for the femoral stick, but the nurse
noticed that he did not use sterile technique and he contaminated
the needle. At this point, the nurse attempted to stop the
procedure, and the verbal exchange became heated. The
anesthesiologist threw the needle on the floor and walked toward
the door. The nurse firmly requested that he stay and monitor the
patient while she was still sedated.

The child was apneic briefly but recovered
without incident. The anesthesiologist did eventually insert a
peripheral IV and the re-hydration therapy resumed.

The situation was "saved" by the patient's nurse,
who in the midst of a very difficult encounter with a physician,
repeatedly made firm requests for adherence to policies designed
for safety. Despite her many years of experience, this nurse was
emotionally distressed by the event.

The Commentary

Unsafe care for a child. Emotional distress
for health care providers. This case represents the worst in
non-collaborative care highlighted by disrespect, problematic
nurse–physician interactions, and intimidating physician
behaviors. Issues raised include violation of policies and
standards of care, disruptive behavior, and emotional or moral
distress. The fact that the 23-month-old child eventually received
intravenous fluids and had no sequelae from the sedation without
appropriate monitoring is a testament to one child's resiliency and
strong nurse advocacy. I read this case with a sense of profound
sadness for all involved: three health care providers, including
the assistant to the anesthesiologist, the anesthesiologist, and
the nurse, and the child. I wish this case were unique.

Nurse–Physician
Communication and Disruptive Behavior

Nurse–physician
collaboration and communication stories continue to haunt. While
there are several emerging models of positive collaboration in
hospital settings, we have clearly not reached a zero tolerance
level for negative interactions in health care despite decades of
awareness and discussion. The evidence supports these facts:
serious conflicts between nurses and physicians are associated with
significant medical errors (1);
nurses report that disrespect and problems with collaboration
continue to occur and inhibit a healthy work environment (2-3);
both nurses and physicians report disrespectful communication, with
few speaking up about their concerns (4); and moral distress is present in both nurses and
physicians in record numbers.(5)
Recognizing that intimidating and abusive behaviors remained a
pervasive threat to patient safety, The Joint Commission made zero
tolerance for abuse in the workplace a National Patient Safety
Goal.(6)
That magnet hospitals support organizational structures enabling
more positive collaboration is one bright spot.(7-8) Magnet hospitals meet specific criteria for nursing
excellence and positive patient outcomes and are considered
"magnets" to attract and retain nurses. There are more than 340
designated magnet health care organizations in the United
States.

In the past, these disruptive behaviors were too
often shrugged off and not addressed. A series of abusive
interactions or a colleague's chronic bad attitude was dismissed as
"she is great in the operating room" or "he is incredibly
brilliant." When physicians are viewed as customers of hospital
administrators who must be catered to because they bring in
patients and revenue, then intimidating and abusive behaviors are
not reported and are largely ignored. Under these circumstances,
the message is clear as to who truly counts in the hospital
culture. Not patients. Not nurses. Many nurses leave institutions
and even the profession due to this abuse and disrespect.

Nursing and medical students in
2009 continue to be surprised and dismayed at the poor
communication and lack of respect they discover on the teaching
wards of the nation's premier hospitals. These behaviors will be
imprinted and unfortunately continue if the cycle of abuse is not
stopped. Because students in the health professions are still
educated in silos in their own disciplines, graduates have little
knowledge of each other's competencies and unique and overlapping
roles. Interprofessional education in medical and nursing schools
would provide early socialization and allow for shared knowledge
and collaborative teamwork in patient care.

Strategies to Foster Respect
and Positive Communication/Collaboration

One way to halt the abuse and
disrespect is to address it directly with confident
communication.(9)
Disruptive behavior "lingers" in health care because of a culture
of silence.(10)
"Silence Kills," a landmark study sponsored by the American
Association of Critical Care Nurses and VitalSmarts, found that
less than 7% of nurses and physicians speak up when they witness
disrespectful behavior, even if it threatens patient
safety.(4) The
good news is that more and more have developed confidence in their
ability to speak up to abuse and intimidation. By mastering
communication and confrontation skills, these individuals have
begun to change the culture of silence. Learning these
communication skills does not come naturally, but they may be as
important, or more so, than learning to read an
electrocardiogram.(11)

The approach to nurse–physician
relationships has begun to change, partly because of two factors in
health care: the patient safety movement and the chronic nursing
shortage. Increasingly, organizations have developed policies
addressing disruptive behavior after recognizing that such behavior
can jeopardize patient care, that toxic behaviors hurt the unit and
hospital, and that the behavior can create moral distress in
nurses.(12)
The best policies are developed jointly by physicians, nurses, and
administrators and articulate clear expectations and consequences.
Organizational leaders have the accountability to develop policies
that ensure that environments conducive to nurse–physician
collaboration will flourish.(13)
Positive collaborative behaviors can be fostered, incentivized,
rewarded, and embedded into the culture of an organization, but not
without clear policies and sanctions.

In this case, the physician chose to treat the
nurse in a disrespectful manner by not listening to her concerns,
not working together on a plan, and violating unit policies and
procedures for safe sedation practices. Did the nurse and physician
know each other? Had they worked together before? Was this the
first time this physician had been abusive and dangerous in patient
care? How do we eliminate this behavior in the workplace? Answers
to these questions provide a framework for considering solutions
based on patterns of behavior. Providers who know and respect each
other rarely engage in abusive behavior. If the physician's
behavior in this case would not surprise hospital leaders (because
of similar problems in the past), then the organization violates
the tenets of a healthy work environment by failing to address and
stop the abuse. The nurse could do two things: alert the nurse
manager immediately or speak directly with the physician. The
manager would first validate that the nurse did the right thing in
patient advocacy and then contact her physician counterpart, the
designated medical director of the pediatric unit. These two
colleagues are ultimately responsible in equal measure for safe
care of all children on the unit. They would gather all the facts
and meet with both parties, individually and together, as quickly
as possible. Using listening and mediation skills, a debriefing
should occur.(14) If
an honest exchange of facts and feelings can occur, there is a real
possibility that physician behavior will change. The physician
needs to be counseled, ideally by a wise supervisor using a firm
but caring approach. When this happens, patterns of behavior that
have been tolerated can be altered. Monitoring for continued abuse
of people and policies is the responsibility of physician and nurse
leaders; there need to be clear consequences for disrespect and
safety violations.

Using the second option, the nurse could attempt
to have a "crucial conversation" within 24 hours of the event by
speaking directly to the physician from the heart, acknowledging
the mutual goal of care and addressing the disrespect head on and
how it affected the care of the child.(15) Most nurses are not confident in their ability to do
this when emotions are running high and anger is expressed.
Training and skill development in having a crucial conversation are
needed. Several hospital systems are investing in training for the
entire health care team with good results. Many are using the
Crucial Conversations training provided by VitalSmarts as one
example.(10)
Maine Medical Center and the UMass Memorial Medical Center in
Worcester are examples of institutions that have invested in
systematic communications training for health care providers,
leading to sustained improvements in safety and quality.

The historical baggage of physician–nurse
relations needs to be unpacked and analyzed to identify the
inherent power and hierarchical imbalances; new creative strategies
need to be designed and tested. These could include:

  • Survey nurses and physicians for
    perceptions of disruptive behavior and the impact on patient
    safety.
  • Provide hospital-wide training in
    communication and conflict resolution.
  • Support organizational leaders to
    institute policies for zero tolerance of abuse and disrespect.
  • Encourage interprofessional education
    during medical and nursing school to engender respect for the
    uniqueness of each role.
  • Provide opportunities for nurses and
    physicians to have a dialogue about patient care issues and to get
    to know and respect one another as individuals.

Not all strategies need to
be punitive or focused on remediation. For example, nurses in one
critical care unit decided to deal with abusive behavior by doing
the opposite: celebrating positive behavior and collegiality by
honoring a "Physician of the Month" with a picture and a large
display inside the unit—peer pressure was indeed changing the
culture, and these nursing values were explicit. Efforts like these
can create the kind of cultural environment in which positive
behaviors and relationships can flourish, and negative ones can be
seen more clearly for what they are: outliers that harm patient
care and should not be tolerated in modern health
care.

Take-Home
Points

  • Disruptive behavior continues to be a
    major problem in hospital settings, creating intolerable patient
    safety risks and moral distress among caregivers.
  • The time to stop the abuse and
    disrespect is now, as the real cost to physical and emotional
    well-being impacts quality patient care.
  • Working together, nurses, physicians,
    and administrators can admit that change is needed and openly
    identify solutions through honest communication.

Dorrie K. Fontaine,
RN, PhD
S. H. Cabaniss Professor of Nursing and Dean

School of Nursing,
University of Virginia

References

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