Stamping Out Rudeness in the Name of Patient Safety

When healthcare teams are exposed to rudeness, clinical outcomes and teamwork suffer. Vanderbilt University Medical Center has developed a process for resolving disruptive behavior among clinicians.

Rudeness has become the attitude du jour.

From the highest branches of our government to our friends' Facebook comments, "I respectfully disagree," has been replaced with, "You're an idiot." Or worse.

Some say it's refreshing to see people casting off superficial niceties and, "telling it like it is." Those who express dismay over the loss of social decorum get labeled "snowflakes," meaning they are thin-skinned, easily offended, and can't handle the truth.

But rudeness causes problems that go beyond hurt feelings, suggests a recent study published in the journal Pediatrics.

Researchers found that when NICU teams were exposed to rude comments from a patient's mother during a simulation training exercise, diagnostic and intervention parameters were negatively affected as were team processes such as workload sharing, helping, and communication.

A previous study published in Pediatrics in 2015, found that when NICU teams were exposed to rudeness by an expert observing them during a training simulation, they had lower diagnostic and procedural performance scores than the control groups that were not exposed to rudeness.

Researchers say that rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance.

For good reason, The Joint Commission calls rudeness and its cousins, incivility, lateral violence, and bullying behaviors that undermine patient safety. TJC has called for hospitals and healthcare systems to prevent them from occurring.

Vanderbilt University Medical Center is tackling these issues through the Vanderbilt Center for Patient and Professional Advocacy.

Disturbances in the Force
Part of the center's work is to help address issues of professionalism for physicians and advanced practices nurses, says William O. Cooper, MD, MPH, director of the Vanderbilt Center for Patient and Professional Advocacy.

"We do this work for Vanderbilt nurses and physicians, but we also have several sites around the country where we support their work in terms of processing their data and providing analysis and training of their leaders on how to address professionals who are associated with more than their fair share of, as we occasionally call them 'disturbances in the force'," he says.

These disturbances can include interactions with patients, colleagues, or staff members.

"If you have a nursing professional who has encountered a surgeon who, every time she brings up the surgical time-out, the surgeon says, 'No, we're on the same page let's just proceed,' she may not bring it up the next time," says Cooper.

One of the center's goals is to prevent this type of behavior from becoming a pattern.

"We work really hard to try to prevent physicians, advanced practice nurses, and other professionals from having the really unfortunate consequences of having these patterns develop, including malpractice suits and harassment suits," he says.

No Judgment Here
Everyone has an off day here and there so it's important to look at data to see if particular patterns are emerging.

"We assess and analyze various sources of data, including patient complaints and staff complaints, to [identify] those professionals who are associated with a disproportionate share of those data points," Cooper says.

"Ninety-seven percent of professionals won't have significant amounts of trouble, but those small numbers that do create a whole lot of disturbance."

Over a 25-year period, which ended in 2015, fewer than 2% of all physicians practicing were responsible for half of all malpractice dollars paid out, researchers have found.

At Vanderbilt, physicians and APRNs are made aware of individual complaints just so they are aware one was received.

When they develop a pattern, a trained peer messenger takes them aside and says, 'I'm here as your peer today. I'm part of our professionalism committee. I just wanted to let you know that for some reason, your practice appears to be associated with more patient complaints than your colleagues,'

"What we find is that 80% of the time, they'll self-correct," Cooper says.

For those who don't self-correct, a conversation is then had between the provider and someone at a higher level of authority.

"Even those folks that rise up to the authority-level conversation that haven't [already] self-corrected, about 60% of those end up self-correcting," he says.

Perhaps this success is due to the way the message is delivered.

"By sharing information with them in a non-judgmental way, you can really turn things around for them. The ripple effects for that individual and their coworkers and their patients is really phenomenal," Cooper says.

"There has to be a shared vision and values that aren't just around being the best. It's very important to have aspirational goals, but also that we will treat our colleagues with respect."