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Featured Articles


ADDRESSING DISRESPECTFUL BEHAVIORS AND CREATING A RESPECTFUL, HEALTHY
WORKPLACE–PART II

March 10, 2022
 * 
 * 
 * 
 * 

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,
predicable, 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!


ADDITIONAL RESOURCES

 * Website
   
   * Workplace Bullying Institute

 * Books
   
   * Curry L. Beating the Workplace Bully: A Tactical Guide to Taking Charge.
     New York, NY: American Management Association, AMACOM. 2016.
   
   * Namie G, Namie R. The Bully at Work: What You Can Do to Stop the Hurt and
     Reclaim Your Dignity on the Job. 2nd ed. Naperville, IL: Sourcebooks. 2009
   
   * Namie G, Namie R. The Bully-Free Workplace: Stop Jerks, Weasels, and Snakes
     from Killing Your Organization. Hoboken, NJ: Wiley. 2011.

 * Videos, Podcasts, and Webinars
   
   * Workplace Bullying Institute. Various videos, podcasts, and webinars,
     including survey results, illustrative cases, tutorials, implementation
     strategies, and news stories. YouTube. 2012-2022.      

 * Recent Survey Results
   
   * Workplace Bullying Institute. 2021 WBI U.S. workplace bullying survey: the
     fifth national scientific WBI study: Zogby Analytics, pollster. 2021. 
   
   * ISMP. Survey suggests disrespectful behaviors persist in healthcare:
     practitioners speak up (yet again)—part I. ISMP Medication Safety Alert!
     Acute Care. 2022. 27(4):1-5.   

 * Guidance Documents and Tools
   
   * Acas. Handling a bullying, harassment or discrimination complaint at work.
     2021.  
   
   * American Medical Association. Bullying in the health care workplace. A
     guide to prevention and mitigation. 2021.   
   
   * Cooper CL, Swanson N. Workplace violence in the health sector: state of the
     art. Geneva, Switzerland: International Council of Nurses; World Health
     Organization; 2013. 
   
   * NHS Employers. Bullying in healthcare: resources and guidance to help build
     a positive culture and a supportive environment. Guidance from the NHS
     Staff Council’s Health Safety and Wellbeing Partnership Group (HSWPG).
     2019.


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