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Analysis

How to Address Inappropriate Patient Behavior

By Christopher Cheney  
   September 20, 2018

Training care teams to deal with disrespectful behavior includes role modeling and rehearsing.

Clinicians do not have to endure disrespectful patients and family members.

That's the message from a Utah-based physician who is training her care team to address inappropriate behavior at the bedside that creates an unhealthy workplace.

"Ignoring disrespectful behavior shuts everybody down. You get off track—it's disruptive. It's like ignoring an elephant in the room," says Amy Cowan, MD, MS, a physician at George E. Wahlen Veterans Affairs Medical Center in Salt Lake City, and a faculty member of the Department of Internal Medicine at the University of Utah in Salt Lake City.

"What I have found is disrespectful behavior erodes the team," she says.

Cowan wrote about calling out disrespectful behavior this month in JAMA Internal Medicine.

Inappropriate behavior can temporarily paralyze care team members, she wrote.

"When I walk into an examination room, I expect the general interaction to proceed in a predictable manner, and usually it does. Sometimes, however, a patient or family behaves or reacts in an unexpected or outrageous way, which is surprising, shocking, or even confusing. I often find myself stunned, feet weighted, mouth paralyzed. My mind whirls to make sense of the unexpected departure from the customary script."

Tactics and training
 

This week, Cowan told HealthLeaders how she handles these situations and how she is training care team members to react.

"I try to keep it simple. If I can normalize for my team that freezing happens, then people can notice it in themselves that it is happening. Then they can call upon one simple phrase. I call on phrases like 'cut it out' or 'let's keep it professional.' It has to be something you can think of quickly before things get ramped up," she says.

Cowan has made training to address disrespectful behavior part of the rounding process.

"Before we round, I will pose a question to the group: 'When was a time when you were a target?' Or, 'When was a time when you noticed someone's bad behavior targeted toward someone else?'" she says.

"We talk about what was noticed, what went well, what they could have done different. That segues into how I deal with inappropriate behavior. For me, it's finding that line I can think of quickly on the fly. When you freeze, you have to have something you can call upon quickly to say, so you can move on."

In preparing care team leaders to address disrespectful behavior, role modeling is key, Cowan says.

"Part of this is role modeling that it is OK to create an environment of compassion where people are kind to each other. Part of that role modeling is making it clear that you don't have to tolerate super disrespectful behavior."

Rehearsing is also crucial, she says. "If I keep practicing, even though I will freeze, maybe I will feel more comfortable leaning into that discomfort of confronting someone."

Re-engaging patients
 

After addressing inappropriate behavior, Cowan circles back to most patients to find out why interactions went awry.

"I have to really mean it. I have to be authentic that I am curious about where the behavior is coming from. I don't do it for everybody. For some patients, I am not going to explore the hate," she says.

Cowan holds these conversations later in the shift or the next day.

"I come back and say, 'Is this a good time?' Then I just say it, 'Yesterday during rounds, this is what I observed. What did you mean by that?' Oftentimes, I find there was some sort of incident that happened when I wasn't there. Maybe a nurse or other doctor was rude to the patient, or the patient and the family didn't feel a doctor was on their side. There was some sort of unmet need or something was going on behind the scenes. You drill down and figure out how we can do better with our communication."

Most of these follow-up conversations generate a positive result, but some don't, she says. "Sometimes, I end up reinforcing that we have to be respectful to each other."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Rehearsing phrases such as 'let's keep it professional' can help caregivers react immediately to inappropriate behavior.

Rolemodeling is essential for physician leaders to effectively train care teams to address disrespectful patients.

Follow-up conversations with patients within a day of a disrespectful interaction fosters effective communication.


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