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Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace–Part II

In late 2021, ISMP conducted a survey on disrespectful behaviors in healthcare. Any behavior that discourages the willingness of staff or patients to speak up or interact with an individual because they expect the encounter will be unpleasant or uncomfortable, fits the definition of disrespectful behavior. See Table 1 in our 2021 article for examples of disrespectful behaviors in healthcare.

More than 1,000 practitioners spoke up and clearly exposed the ongoing tolerance of disrespectful behaviors in healthcare, suggesting that offenders have operated with impunity for years. In our February 24, 2022 newsletter (Part I), we published the results of our 2021 survey, which revealed widespread disrespectful behaviors that involved multiple offenders and were seen at all levels of the organization and among all disciplines, genders, and ranks. Despite more than 2 decades of emphasis on safety, little or no improvement has been made, and in some cases, an increase in the prevalence of disrespectful behaviors was found in comparison to the results of previous ISMP surveys conducted in 2003 and 2013. Tragically, not only do disrespectful behaviors negatively impact the targets of the behaviors, but the stubborn strength of this problem also lies in its ability to undermine critical conversations and adversely impact patient safety. Our surveys showed that disrespectful behaviors in healthcare have contributed or led to unsafe practices, medication errors, and adverse patient outcomes. 

Most of the 2021 survey respondents were not satisfied with organizational efforts to address disrespectful behaviors, often reporting that leaders had ignored the behaviors. Furthermore, a deep sense of frustration was evident in respondents’ comments, suggesting that now is the time for action. In Part II of our report, we provide recommendations to help address this problem and develop a healthy workplace, defined as a work culture that provides the freedom to work without fear, and with no risk of embarrassment, rejection, or punishment for speaking up. Please keep in mind, disrespectful behaviors in healthcare have been a longstanding problem for which there is no simple solution. In fact, in Part I of our report, we asked organizations that have been working on this problem to contact us so we could learn more about strategies that have previously worked. It is quite revealing that we received only one response to this request from our sister organization, ISMP Canada, suggesting that solutions to the problem are not abundant. For this reason, several approaches to the problem are recommended, and a list of additional resources that can help address this problem is provided. Disrespectful behaviors in healthcare are not too complex to reverse, but it requires deliberate, intentional, and persistent actions to start the process.

Addressing Disrespectful Behaviors in Healthcare

Set the Stage

Create the foundation for a healthy workplace. The conditions that allow disrespectful behaviors to occur and thrive are deeply rooted in the organizational culture. Thus, cultural transformation is key to combating disrespectful behaviors and creating a supportive and nurturing environment built upon shared values. Several key factors facilitating this cultural transformation are implementing a fair and Just Culture (May 20, 2021; July 12, 2012; June 17, 2020), respectful management of serious adverse events, and transparency so staff feel safe speaking up about disrespectful behaviors without fear of reprisal. 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; maintain an ongoing dialogue with the entire organization to help ensure that a commitment to a respectful culture is not fleeting; and reward outstanding examples of collaborative teamwork, respectful communication, and positive interpersonal skills.

Commission a mixed-composition steering committee. Establish a steering committee from all ranks and disciplines in the organization dedicated to maintaining a healthy workplace and ensuring respectful behaviors are exhibited among staff. Since organizational leaders might be the offenders, staff will be keenly aware of the conflict-of-interest with an all-leadership steering committee. A steering committee comprising all ranks (e.g., leaders, managers/directors, frontline staff) and disciplines (e.g., physicians, pharmacists, nurses, other healthcare professionals, human resources) brings the advantages of multiple perspectives and credibility. Have the committee educate itself about disrespectful behaviors, define the behaviors, list examples of the many forms it can take, and establish an action plan that specifies how to identify disrespectful behaviors, respond to them, and measure the success and sustainability of organizational efforts.

Prohibit retaliation against reporters. Establish a “no retribution” policy for those who report disrespectful behaviors. To promote reporting, this policy must be established at the very onset of organizational efforts to reduce disrespectful behaviors.

Open the dialogue. Survey staff anonymously and confidentially to assess their perceptions about the workplace culture, the prevalence of disrespectful behaviors, and how the culture and disrespectful behaviors have impacted them, their patients, and the organization. Incorporate questions about disrespectful behaviors into safety rounds. Hold focus groups during which frank discussions can be held with objective facilitators to keep the conversation productive. Also use the data gathered from complaints, unscheduled employee absences, and exit interviews to identify problems and monitor progress. Despite being uncomfortable, dialogue on this issue is crucial to the development of more effective and respectful ways of interacting with each other. Show staff that their feedback is taken seriously by using the results of collected data to inform the development of supportive programs and resources.

Establish a standard communication strategy. Develop a standard process for staff who must convey important information to a colleague. Utilizing a standard communication process to aid in clinical communication can streamline the process and limit the opportunity for disrespectful behaviors. TeamSTEPPS, an evidence-based teamwork system to improve communication and teamwork skills, describes many communication techniques. Examples include:

  • SBAR or ISBAR: Situation, Background, Assessment, and Recommendation/Request; the adapted tool, ISBAR, includes Identity of the caller, receiver, and patient

  • DESC Script: Describe what you observed, heard, or perceived; Express concerns using “I” statements and nonjudgmental terminology; Specify or inquire about an alternate course of action; discuss positive and negative Consequences

  • I-PASS: Illness severity, Patient summary, Action list for the new team, Situation awareness and contingency plans, and Synthesis and ‘read-back’ of the information

  • I PASS the BATON: Introduction, Patient information, Assessment, Situation, Safety concerns, Background of the patient, required Actions, Timing, Ownership, and Next (plan, anticipated changes)

  • ANTICipate: Administrative data, New clinical information, Tasks to be performed, Illness severity, and Contingency plans for changes

  • SHARQ: Situation, History, Assessment, Recommendations/Results, and Questions

  • GRRRR for Great Listening: Greeting, Respectful listening, Reviewing, Recommending/Requesting, and Rewarding

Establish an escalation policy to manage conflicts about the safety of an order. An escalation policy must be established to manage conflicts about the safety of an order when the standard communication process fails to resolve an issue. Staff must know whom to call for assistance to reach a satisfactory resolution. Be sure the process provides an avenue for resolution outside the typical chain of command in case the conflict involves a subordinate and their supervisor. Following a Two-Challenge Rule is one option. The rule requires communication of critical information twice to the same person. If there’s no resolution, the matter is automatically referred to at least one other person (outside the typical chain of command) before a final decision is made. Another option is the Most Conservative Response Rule (MCRR). In the event of an impasse, this technique suggests that the involved staff accept the most conservative (and safest) option being considered until more information is available to avoid unsafe decisions. If a concern fails to be addressed, staff need a clear and immediate process to take the matter to another individual. If the patient’s condition requires immediate attention, a rapid response team should be called.

Prevention

Establish a code of conduct. A necessary first step involves establishing a code of conduct (or code of professionalism) that declares an organization’s intolerance of disrespectful behaviors and serves as a model of interdisciplinary collegial relationships (different but equal) and collaboration (mutual trust and respect that produce willing cooperation). The code of conduct should:

  • Validate that mutual respect regardless of rank or status is an organizational core value

  • Assert the organization’s commitment to providing a safe and healthy workplace

  • Describe the standard of mutually respectful behaviors expected of all staff, as well as prohibited disrespectful behaviors—don’t assume staff know this, so be specific and clear, and provide examples of both expected and prohibited behaviors

  • Specify that the code of conduct applies to all

  • Outline the responsibility for all to report workplace disrespectful behaviors (witnessed or experienced) and the steps to do this

Another crucial factor to consider—all staff must believe in the code of conduct. Addressing disrespectful behaviors must start with an absolute belief by all staff that no one deserves to be treated with disrespect, even in the wake of a harmful error. Furthermore, the code of conduct should not allow any exemptions. If staff with rank or those who generate the most revenue are excused from accountability for their disrespectful behaviors, the code of conduct will have little impact. 

Provide mandatory awareness-raising education. Provide mandatory hospital-wide education for all staff about disrespectful behaviors on an annual basis. The purpose of the mandatory education is to raise awareness of disrespectful behaviors and the problems they create; communicate mutual respect as an organizational core value; motivate and inspire staff to help create a healthy workplace; articulate the organization’s commitment to achieving this goal; and to create a sense of urgency around doing so. Also, do not forget to include labor union representatives, if applicable, in the awareness-raising education so they can mutually agree on the code of conduct and help create a healthy workplace. Consider the following key topics for the awareness training:

  • Defining disrespectful behaviors and why they happen

  • Characteristics of offenders and statistics about targets

  • Negative impact of disrespectful behaviors on targets (emotional, social, physical) and those who witness them

  • Negative impact of disrespectful behaviors on patient safety and the organization, and how it threatens the quality of care

  • Organizational code of conduct and leadership support for the core value of respect and creating a healthy workplace

  • Relationship and team building

  • Behavioral techniques to confront and address disrespectful behaviors, including standard communication and conflict resolution processes

  • Duty to report disrespectful behaviors confidentially, steps for reporting, and a “no retribution” policy

  • Organizational policies on investigation of complaints and interventions to address disrespectful behaviors

Accountability

Encourage confidential reporting. Implement a confidential reporting program for disrespectful behaviors, which may be submitted by staff who have experienced or witnessed the behaviors or by a labor union representative (if applicable) on behalf of a staff member. Both a formal reporting program and an informal process for unwritten reports should be offered and detailed in reporting policies and procedures. The report should be handled confidentially, and the privacy of reporters should be ensured. The “no retribution” policy for reporting should be well known to staff and upheld. Periodic updates should be provided to reporters about addressing disrespectful behaviors, but details should remain confidential.

Investigate all reports. Reports of disrespectful behaviors should be taken seriously. As soon as the reports are received, assigned members of the steering committee should assess the situation thoroughly and confidentially in a way that is fair and sensitive to the targets of disrespectful behaviors, witnesses, and the accused offender(s). For example, you may want to talk to the reporter first to learn more about the event, how the disrespectful behaviors made them feel, and what they think might help resolve the problem. Keep in mind that it might be difficult for the reporter to talk about an event, especially if they are upset about what they have experienced or witnessed, the disrespectful behaviors have happened repeatedly, or they are worried about the consequences of reporting the disrespectful behaviors. You may also want to determine upfront if the alleged disrespectful behaviors are potential legal infractions (e.g., sexual harassment, unlawful discrimination), which might require a different process for investigation. Talk to any witnesses of the disrespectful behaviors and the accused offender to fully understand the event. The steering committee members might consider the evidence they have at this point to determine if the complaint is substantiated, how serious the allegations are, and whether the disrespectful behaviors seem to be intentional or repeated. Keep a record of the investigation, and do not forget to update the person who reported the disrespectful behaviors about the status of the submission.

Establish and implement interventions to address disrespectful behaviors. While disrespectful behaviors may not be intentional and there may be other explanations for the lapse in respectful behaviors, all substantiated events should be consistently addressed. Unfortunately, there is no one-size-fits-all intervention. Even adopting a zero-tolerance policy in organizations with a history of disrespectful behaviors is doomed to be ineffective, according to the Workplace Bullying Institute (WBI), page 20). Individuals have to unlearn disrespectful behaviors that have been practiced and rewarded for years. The WBI suggests that offenders should be given a chance to try, fail, and do it right the next time. Learning requires patience, education, and coaching.

Thus, a graded response to disrespectful behaviors should be determined by the seriousness and frequency of the event. Consider treating first-time infractions much like an at-risk behavior, with assessment and coaching of the individual so the offender clearly sees the risk associated with their behavior, offer education to offset deficiencies in speaking up and listening skills, and request a commitment to respectful behavior in future conduct. Repeated episodes of disrespectful behaviors might be managed similar to a reckless behavior, with progressive disciplinary sanctions imposed as needed. Behavioral constraint, not personality changes, and long-term correction of the conduct should be the optimal goal of any intervention. The importance of a consistent, prompt, predictable, and appropriate response to disrespectful behaviors cannot be overemphasized.

Make needed system changes. Because disrespectful behaviors in the workplace often occur as a result of systemic factors, prevention and mitigation efforts should require addressing any system issues that promote and perpetuate them. Common system problems that lead to disrespectful behaviors include staffing shortages, excessive workloads, power imbalances, subpar management skills training, inequities in resource allocation, communication breakdowns, physical hazards, and environmental stressors.

Develop a surveillance system. Measure staff compliance with the code of conduct, and make sure any disrespectful behaviors previously addressed have actually stopped. However, to be clear, no organization should assume that the absence of reports of disrespectful behaviors means they are not occurring. Other means of surveillance to identify disrespectful behaviors should be employed, which include feedback from patients and families, staff and patient surveys, focus groups, informal dialogue, peer and team evaluations, and direct inquiries at routine intervals (e.g., during safety rounds). Surveys appear to be a reliable surveillance tool. Also ensure that targets, witnesses, and accused offenders are being treated fairly. 

Support

Establish a support system. Experiencing, witnessing, or being accused of disrespectful behaviors can have a harmful impact on staff and their colleagues. To ensure their wellbeing and offer them support while a complaint is being investigated and addressed, involved staff should be encouraged to access available resources such as an employee assistance program, dignity advocates, or cultural ambassadors. Labor unions can also provide support for these individuals. Additionally, some organizations have trained and mobilized specific staff support crisis teams, which respond to the targets, witnesses, and offenders of the behavior. Functioning much like a trained rapid response team, experts on the management of disrespectful behaviors in healthcare triage staff in severe emotional distress and provide support to those afflicted. Access to, or utilization of, a support crisis team may be key to the sustainability of a respectful, healthy workplace.

Conclusion

Creating a healthy workplace requires action on many fronts: transformational culture change; modeling kindness, civility, and respectful conduct, especially by managers and leaders; educating staff on the core value of respect and an appropriate code of conduct; conducting an evaluation of respectful behaviors as part of an annual performance evaluation; promptly investigating and fairly addressing reports of disrespectful behaviors; learning to communicate assertively and work in teams; and supporting frontline changes in daily routines that increase the sense of fairness, collaboration, and individual responsibility. Unfortunately, time alone does nothing to stop disrespectful behaviors—ignoring them emboldens offenders, condones the disrespectful behaviors, normalizes them, and allows the offenders to continue to dominate with cruelty. We urge organizations to take steps to actively prevent and correct disrespectful behaviors today!

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