Promoting Professionalism: The Importance of Effectively Managing Disruptive Behaviour

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Promoting Professionalism The Importance of
Effectively Managing Disruptive Behaviour

• Derek Puddester MD MEd FRCPC
• Director, Faculty Wellness Program
• uOttawa

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(No Transcript)
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At the end of this 90 minute workshop,
participants will be able to

• Define disruptive behaviour and summarize its
  causes, manifestations, and impacts
• Describe a staged approach to preventing and
  intervening in cases of disruptive behaviour
• Apply key strategies and solutions to a series of
  cases provided by the facilitator and those
  raised by participants

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Acknowledgments

• Parts of this workshop have been developed in
  collaboration or partnership with others,
  including Dr. Dorothy Shaw (UBC), Dr. Joy
  Albuquque (OMA PHP), Dr. Paul Farnan (BC PHP),
  and Dr. Michael Kaufman (OMA PHP)

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What is reasonable behaviour? (Pfifferling)

• Communicates with others clearly directly,
  displaying respect for others
• Supports policies promoting cooperation and
  teamwork
• Complies with established practice standards
• Addresses concerns about clinical judgments with
  associates directly privately
• Addresses dissatisfaction with policies through
  the appropriate grievance channels
• Uses conflict resolution skills in managing
  disagreements

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Definitions of DB and Background

• Disruptive behaviour Problematic communication
  and behaviour that ultimately affects patient
  care (e.g. inappropriate anger, inappropriate
  action, inappropriate response)
• (St. George) repeated episodes of sexual
  harassment racial or ethnic or sexist slurs
  loud, rude comments intimidation or abusive or
  offensive language persistent lateness throwing
  instruments sarcasm or cynicism threats of
  violence vengeful litigation demands for
  special treatment refusal to treat
• (CPSS) verbal or nonverbal behaviour which may
  demonstrate disrespect to others in the
  workplace, affect or have the potential to affect
  adversely the care provided to patients reflect
  a misuse of a power imbalance between the parties

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• (North Carolina PHP) chronic pattern of
  contentious, threatening, intractable, litigious
  behaviour that deviates significantly from the
  cultural norm of the per group, creating an
  atmosphere that interferes with the efficient
  functioning of the health care staff and
  institution

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What disruptive behaviour is NOT

• Behaviour specific to a form of illness (e.g
  mania)
• Behaviour specific to a form of impairment (e.g.
  alcohol abuse)
• Feedback, criticism, or advocacy offered in good
  faith and in the spirit of improved patient care
  (e.g. letter to the editor,
• Mandatory reporting or lodging an appropriate
  complaint
• Testifying against a colleague or hospital
• Doing unpopular or controversial acts

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Literature trends

• Well established literature, increasingly
  interprofessional
• Most literature from US, Canada, Australia, New
  Zealand
• Found in all health professions
• No one broadly accepted definition or conceptual
  framework
• Less tolerated, higher expectations for effective
  behaviour

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• Direct linkages between DB and patient safety,
  sustainability of health professionals, and
  quality of workplace health
• Few studies on prevention and interventions, yet
  most studies comment on need for proactive and
  systematic approaches
• Safety literature clearly emphasizes systematic
  approaches, with specific mention of
  undergraduate teaching
• Policies, alone, do not have an impact on
  prevention of DB

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Prevalence

• Literature suggests trends are on the rise
• 1- 5 (Linney, 1997)
• 6 of physicians have gt25 complaints on same
  theme in 5 years (Hickson, 2002)
• 3 5 (Leape, 2006)
• 95 of members of the American College of
  Physician Executives report DB is an issue they
  confront regularly. 83 complaints on
  disrespect, 51 for refusal to complete tasks
  or carry out duties, 41 yelling, 37 for
  insults. 56 report complaints between
  physicians and physician assistants/nurses, and
  63 felt physicians are treated more leniently
  than other professionals

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• Medical students and Residents
• 94 of programs report the presence of problem
  learners
• 6.9 residents identified as disruptive (Yao,
  2005)
• 50 of medical students report experiencing
  abusive behaviour from colleagues or supervisors
  (Phelan, 1993)
• Disruptive behaviour in undergraduate training is
  associated with later disruptive behaviour,
  patient errors, and college complaints/discipline
  (Papadakis, 2005)

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Examples of Disruptive Behaviour (Pfifferling)

• Fails to comply with practice standards
• Is disrespectful or discourteous a majority of
  the time
• Criticizes staff or learners in front of others
• Shames others for negative outcomes
• Communicates indirectly about others (colleagues,
  patients)
• Ignores existing policies/standards and/or
  creates their own

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Unreasonable Behavior

• Swears or uses consistently unprofessional
  language
• Uses behaviour that can be viewed as
  inappropriate (intimidation, harassment, sexist,
  racist), dangerous (threats, violence), and/or
  criminal (assault, slanderous)
• Bullying
• Threatens associates with retribution, litigation
  or violence

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Other ways of classifying behaviour

• Aggressive anger, blaming, use of shame,
  intimidation, harassment, language, threats,
  violence
• Passive chronically late, slow/no response to
  pages/calls/emails, refuses to monitor email, not
  complete charts in a reasonable timeframe, lack
  of flexibility, refusal to collaborate, lack of
  collegial participation
• Passive-Aggressive disrespect, endless emails
  without focus or solution, unapproachable stance,
  confusing or mixed body language, inappropriate
  affect and/or speech, indirect insults or
  malignment

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Possible Aetiologies

• Axis I or Axis III
• Emerging recognition of axis II
• Emerging maladaptive traits (e.g. arrogance)
• Unhealthy workplace
• Personal stress
• Life transition difficulties
• Burnout

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Classic Profile

• Known as an expert in their field, may be viewed
  as difficult to replace (e.g. House)
• Incredibly busy, often due to taking on all
  aspects of clinical care
• See themselves as clinically superior and others
  as less competent (and often dont disguise these
  opinions)
• Enduring lack of insight
• Isolated single, no children, few friends,
  minimal activities, may use money to purchase
  social recognition (e.g. charity, donations)
• Rarely seek assistance
• Path of destruction in their wake expect
  systems to adjust to their needs even if this
  hurts colleagues or larger systems

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Which disciplines? (Neff, 2002)

• 27 Surgery
• 25 Family/General Practice
• 17 Internal Medicine
• 10 Psychiatry
• 8 OBGYN
• 6 Anesthesia
• 10 double boarded

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Known causes (Neff, 2002)

• 78 had Axis I Disorder
• Major depressive disorder 40 -50
• Bipolar 6
• Dysthymia 17
• Sexual disorder 5
• OCD 2
• Alcohol dependence 13 (Abuse 6)
• Impulse control disorder 2
• ADHD 2
• 28 had Axis II Disorder (NOS, Narcissism, OCPD)

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Impact of Disruptive Behaviour

• (Pfifferling, 1999) undermines practice morale,
  heightens turnover, decreases productivity,
  increases risk, causes peer distress
• (Youssi, 2002) destabilizes patient care strains
  peer relationships, decreases nurse-physician
  communication, discomforts patients, stigmatizes
  profession
• (Rosenstein, 2002) directly correlated to
  increased work stress and burnout of nurses, as
  well as have significant contribution to nursing
  turnover and exit
• (Institute for Safe Medication Practice)
  pharmacists frequently experience disruptive
  behaviour that immediately impacts care

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• 7 of medication errors due to intimidation of
  nurses by physicians (Institute for Safe
  Medication Practices, 2004)
• Students report intimidation, harassment, and
  abuse negatively influence their choices of
  postgraduate training, employment, and perception
  of the supervisory relationship (LeClerc, 1988)

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FWP Perspective - Quotes

• I just started here and have this disruptive
  doches been a problem for a long time but no
  one told me
• I think I have a borderline doc and dont know
  what to do
• No one has sorted this guy out but Ive had it
  and am going to
• Im meeting with this disruptive doc in an hour
  and wonder what I should do?
• But
• Do you have a policy on behaviour? (no)
• Have you adequate documentation? (no)
• Have you tried any strategies with follow up and
  documentation? (no)
• Have you consulted with legal counsel? (no)

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Identification

• Establish consensus on the local level on
  definitions, expectations, and standards
• e.g. Standards of Ethical Practice and
  Professional Behaviour (uOttawa, 1993),
  Declaration of Professionalism (uOttawa, 2005),
  Hospital Codes of Conduct
• Annual evaluations (e.g. 360), informal/formal
  complaints process
• Pattern recognition may require consultation with
  local expert in behaviour

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Response options to DB? (Rosenthal)

• Nothing (wait until its someone elses problem
• Terribly quiet chat
• Protective Support
• Diverting patient flow
• Exporting the problem
• The Wise Men Committee
• Contacting the regulatory body
• Medic

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Better approach Universal Precautions
(Farnan)

• Be proactive conduct policies, annual
  evaluations, complaints processes, staff/faculty
  development, grand rounds
• Be reactive be consistent, timely, procedural,
  and fair
• Be thoughtful watch your assumptions (e.g Axis
  II) and challenge your stigma (e.g. Axis I)
• Be mindful of your role you are not the
  clinician!

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When a complaint is raised

• Use your institutions complaints policy to guide
  your behaviour
• If there is no policydevelop one
• Key principles
• Listen
• Dont take sides
• Request a documented complaint
• Give tips and suggestions regarding complaints
  (e.g. specific, neutral, I-statements,
  non-inflammatory, suggested action)
• Commit to action, do so, report back
• Document

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Complexity of Investigating Complaints

• Solid detective work with all of the same
  challenges
• Accuracy of statements
• Memory and recall issues
• Need to verify and have witnesses (and
  statements)
• Need to have supporting documentation
• Search for patterns vs unique anomalies
• Effort of documentation and record keeping
• Privacy legislation

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Considering steps towards resolution

• Is safety an issue?
• Is patient care compromised?
• Are you obligated to report to Chief of Staff?
  The College?
• Is a formal break or leave required?
• Are emergent health issues relevant and
  warranting intervention?
• Oris there time to consider other aspects of
  intervention?

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Preparing to Respond

• What is your role?
• Do you need advice (e.g. Chair, Chief of Staff,
  Counsel, College, FWP, PHP)?
• Are there mandatory reporting issues?
• Do you have adequate documentation?
• Could the situation be readily managed via a
  conflict resolution process (e.g. mediation,
  conciliation, facilitated resolution) rather than
  a disruptive behaviour process?

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DB Process Initial Meeting (Leader)

• Know exactly what you want out of the agenda
  prior to starting the meeting
• More informal, non-threatening
• Neutral territory or their office
• Acknowledge their worth and value
• Review confidentiality, privacy, and
  documentation issues
• Indicate the background and policies that guide
  the process
• Advise them of the specific complaint(s) and the
  reported impact on others
• Review the standards that are expected and the
  discrepancy noted

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• Move into joint problem solving
• Seek their perspective be an active listener
• Offer assistance
• State what they need to stop, start, and maintain
• Monitor your boundaries (you are NOT their
  clinician)
• Review and summarize
• Book follow up
• Close warmly and with appreciation
• Send a follow up written summary of discussion
  and outcomes, keep notes for your file

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Follow up meeting (improved behaviour)

• Review original complaint, first meeting,
  commitments
• Report that you were spotted doing something
  right!
• Encourage and praise
• Restate expectations of Organization
• Close matter, but note openness and willingness
  to help if required in future

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Follow up meeting (ongoing problems)

• Formal meeting, leaders office, firm tone
• Two leaders (Initial leader and their superior or
  collaborator)
• Review original complaint, action plan,
  documentation
• Report new data and updated behaviour using
  documentation
• Key issue insight, openness, willingness to
  change?
• Note that behaviour must stop immediately
• Review consequences
• Develop action plan and monitoring plan
• Book follow up meeting in 7 14 days

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Third Meeting Intervention

• Consider bringing more people into the meeting
• Invite them to bring a supportive person
• Formal tone
• Review all facts and documents again
• Review action plan and how it is viewed to have
  failed
• Consider if more warnings are required or if it
  is time to administer consequences

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Consequences

• Period of formal remediation and monitoring
• Mandatory education
• Mandatory assessment (IME)
• Loss of privileges (clinical, teaching, research)
• Report to College

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Comprehensive Assessment

• Seek advice early on a multidisciplinary
  assessment
• Ask practical and useful questions
• Be objective out of institution resources (out
  of town)
• Be careful who is the referring physician?
• Clarify who pays for the assessment, who gets the
  detailed results, and what specific information
  you are seeking (you do not get the whole
  chart!).
• Develop a process to ensure the assessment is
  moving forward in a thorough and timely manner

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Sample questions

• Is there a physical or mental health problem
  (including substance use)?
• What is the level of insight and judgment?
• What is the risk of SI/HI?
• What is the risk to patient safety?
• Is there evidence of a genuine willingness to
  engage, meaningfully, in assessment and treatment
  recommendations, if indicated?
• What are the relevant intervention and treatment
  recommendations?
• Is there a need for ongoing monitoring of
  behaviour?
• Are there mandatory reporting issues?

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If referred to the FWP or the PHP

• It is reasonable to request and expect written
  confirmation that the following occurred
• That a meeting took place
• That the physician agreed to referral to
  appropriate resource for assessment (and those
  details, including when)
• That you will be asked to contribute objective
  collateral history
• That the physician participated meaningfully in
  the assessment
• A report with all recommendations was sent to
  their Family Physician
• Relevant recommendations will be shared with the
  workplace with details of an implementation
  strategy
• A follow up meeting will be held to facilitate
  re-integration to work, or other work
• Ongoing monitoring will be discussed

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Assessment Strategies

• Family physician history, PE, investigations
• Psychologist personality and psychopathology
  measures, psycho-educational evaluations
• Psychiatry mental illnesses or substance abuse
  issues
• Addiction Specialist
• Behavioural contracting
• Learning/workplace monitors (role, reporting,
  confidentiality)
• Identified coordinator (custodian of health
  information, reporting, confidentiality) who
  takes lead and acts as bridge between learner and
  institution
• Role of courses and treatment programs

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Request a proper assessment or else

• Dr. Disruptive has a curbside consult
• Depth and breadth of consult limited
• Dr. Disruptive is fit for work.
• Lack diagnostic opinion and data
• Lack clear and specific recommendations
• Lack an ability to ask for follow up and review
  of change

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Roles for PHOs

• Advocate for national guidelines on respect in
  the workplace
• Partner with new generations of other professions
  (nursing) and set a new joint standard
• Connect with on the ground efforts grounded in
  professionalism and physician health

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• Offer training sessions in disruptive behaviour
  targeted at residents
• Offer training sessions in assertiveness training
  (peer and with supervisors)
• Partner with university efforts on Residents as
  Teachers programs and focus on disruptive
  behaviour

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• Advocate for Codes of Conduct for all
  universities, teaching sites, and other training
  environments (with teeth - ? linked to contracts)
• Embed training in DB in annual orientations
• Recognize and award professional behaviour

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Cases

• 10 minutes per case
• Scribe/Reporter - 2 key points each
• Group format
• What are the issues?
• What is the process?
• What is the best/worst outcome?

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Dr. Allan

• Dr. Allan is a PGY-1 in family medicine and is
  new to your University. He is currently on the
  medicine CTU and has a heavy call schedule. The
  pharmacy calls you in your capacity as program
  director to report a major concern. They allege
  Dr. Allan signed a prescription in the name of an
  inpatient using the name of a staff physician and
  has delivered the script to the hospital pharmacy
  for dispensing. He has identified himself as the
  patient, not as a physician.

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Busted at Accreditation

• Overheard during a college accreditation review
  meeting with residents
• Q. Are there any concerns about intimidation
  and/or harassment in your program?
• A. Yes there is a member of staff who yells at
  us on the ward and at the nursing station, when
  reviewing our patient histories. He has some
  unusual expectations as to how histories are to
  be written out and presented and you feel like
  you are walking on egg shells in case you didnt
  quite get it right. Then yesterday he yelled at
  me and called me stupid in front of a patient
  because he didnt agree with my differential
  diagnosis. I wouldnt normally have said
  anything, because hes such a good teacher in our
  academic half day sessions, but hes really upset
  most of our residents. I spoke to the site
  director, but because hes senior, she brushed it
  off after all she experienced it too.

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Allegations

• You are the clerkship co-ordinator for OB/GYN. A
  junior clerk is brought to you by one of her
  colleagues with a concern about unwanted touching
  from her senior resident while on call. She
  reports that the resident touched her face twice,
  despite being verbally and physically
  discouraged. In addition, he is described as
  repeatedly knocking on her door at 0400 to be
  friendly. She paged her colleague (who was on
  call for paediatrics) to sit with her until
  morning as the call room doors do not lock. She
  has made a formal complaint. You are tasked with
  meeting with the resident, obtaining his version
  of events, and trying to understand the full
  story.

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Joe, MSII

• Joe is a student who has been chronically late
  for PBL sessions. Joe then proceeds to dominate
  the group discussion and expects to be updated on
  what happened before Joe arrived. The group has
  discussed the ground rules which included
  punctuality, respect and shared airtime but
  no-one has actually given Joe feedback that these
  behaviours apply to him. It seems that the group,
  including the tutor, find Joe to be
  intimidating. The tutor is coming to you for
  advice and guidance.

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Dr. Jones

• You are a new site education director for the
  department of pediatrics. In your first year you
  are struck at how many complaints you have
  received about Dr. Jones. During a clinical
  skills session on abdominal examination, Dr.
  Jones made derogatory comments just before the
  group met the patient a young Chinese girl who
  spoke little English. Shes probably Hep B
  positive, most of them are. Dr. Jones went on to
  make comments that the medical students in the
  group found offensive in terms of their visible
  minority status and gender. You wont have any
  trouble getting ahead, its us white males that
  are disadvantaged. Of course, you wont have
  trouble either, women are favoured these days,
  even though they are not as productive. He
  provided excellent medical instruction along with
  other comments reflecting his dissatisfaction
  with the current state of the Canadian medical
  profession. The group was very uncomfortable
  speaking directly to Dr. Jones and this is not
  the first time you have heard this complaint.