Case & Commentary (4/5) - AHRQ WebM&M

Pediatrics | October 2009
Danger in Disruption
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
by Dorrie K. Fontaine, RN, PhD

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
1. Baldwin DC Jr, Daugherty SR. Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US. J Interprof Care. 2008;22:573-586. [go to PubMed]

2. Ulrich BT, Lavandero R, Hart KA, et al. Critical care nurses' work environments 2008: a follow-up report. Crit Care Nurse. 2009;29:93-102. [go to PubMed]

3. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203:96-105. [go to PubMed]

4. VitalSmarts.com. Silence Kills: The Seven Crucial Conversations in Healthcare. [Available at]

5. Rushton CH. Defining and addressing moral distress: tools for critical care nursing leaders. AACN Adv Crit Care. 2006;17:161-168. [go to PubMed]

6. Joint Commission Resources. National Patient Safety Goals. [Available at]

7. Schmalenberg C, Kramer M, King CR, et al. Excellence through evidence: securing collegial/collaborative nurse-physician relationships, part 2. J Nurs Adm. 2005;35:507-514. [go to PubMed]

8. Schmalenberg C, Kramer M. Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Crit Care Nurse. 2009;29:74-83. [go to PubMed]

9. Fontaine DK, Gerardi D. Healthier hospitals? Nurs Manage. 2005;36:34-44. [go to PubMed]

10. Grenny J. Crucial conversations: the most potent force for eliminating disruptive behavior. Crit Care Nurs Q. 2009;32:58-61. [go to PubMed]

11. Thornby D. Beginning the journey to skilled communication. AACN Adv Crit Care. 2006;17:266-271. [go to PubMed]

12. Barnsteiner JH, Madigan C, Spray TL. Instituting a disruptive conduct policy for medical staff. AACN Clin Issues. 2001;12:378-382. [go to PubMed]

13. Arford PH. Nurse-physician communication: an organizational accountability. Nurs Econ. 2005;23:72-77, 55. [go to PubMed]

14. Gerardi D. Using mediation techniques to manage conflict and create healthy work environments. AACN Clinical Issues. 2004;15:182-195. [go to PubMed]

15. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When Stakes Are High. New York, NY: McGraw Hill; 2002. ISBN: 9780071401944.

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