The estimated cost of measurable medical errors that harmed patients was 17.1 billion in 2008—despite safety protocols that have been in place at healthcare organizations since 1999.1
Research indicates that a significant percentage of preventable errors occur because of unaddressed workplace conflicts. In surveys of more 1,700 nurses, physicians, clinical-care staff and administrators conducted by Vital Smarts in 2005 and again in 2010:2
- More than half reported seeing their co-workers break rules, make mistakes, fail to support others, demonstrate incompetence, show poor teamwork, act disrespectfully or micromanage.
- Despite awareness of potential risks to patients, less than 10 percent of physicians, nurses, and other clinical staff directly confronted their colleagues about their concerns.
While the Accreditation Council for Graduate Medical Education now expects new physicians to have mastered the basics of teamwork, communication, interpersonal skills and professionalism, conflict resolution wasn’t part of the traditional medical school curriculum.
”Few doctors are willing to confront colleagues about disruptive behavior, incompetence, failure to follow safety protocols or how they treat office or hospital staff,” says notes Dr. Alan Rosenstein, medical director for VITAL WorkLife. “When conflict arises, they have neither the natural inclination or highly developed skills for addressing it.”
Silence Isn’t an Option Anymore
Since 2008, when the Joint Commission issued Sentinel Event Alert #40 titled, “Behaviors that undermine a culture of safety,” physicians, as well as administrators, have became responsible for taking action when they witness disruptive outbursts or discover workplace conflicts that put patient safety at risk.
“The mandate to confront disruptive or unprofessional behavior is now part of medical professional’s job description,” says Matt Steinkamp, vice president of service delivery for VITAL WorkLife. “Physicians can’t turn a blind eye to their colleagues’ behavior and nurses shouldn’t suffer in silence.”
Typical sources of conflict include:
- Incompetence, lack of needed skills or poor work ethic on the part of physicians or staff that impacts patient safety or continuity of care
- Challenges by nurses and staff to the traditional power structure, or unwillingness on the part of physicians to embrace team-based care
- Resistance to changes in processes, workload, call schedules or technologies (e.g., electronic medical records)
- Administrators who are viewed as “high-handed” or unappreciative of staff and physician contributions
- Turf issues or power struggles among physicians that manifest themselves in unreturned consult calls
- Horizontal nurse-on-nurse bullying
“When medical professionals at any level in the hierarchy aren’t called on inappropriate behavior, it breeds fear, resentment and frustration—and can create a workplace culture where fear of abuse trumps concern for patient safety,” says Steinkamp.
Over time, employees will avoid certain co-workers even if their skill set is essential to patient care—for example, the night shift nurse who won’t wake an on-call physician because of past abuse.
“The research clearly demonstrates that when medical professionals can’t communicate effectively and honestly, the workplace becomes unnecessarily stressful and patient safety is put at risk,” explains Rosenstein.
Negative Side Effects of Unresolved Conflict
Conflict in and of itself isn’t bad—conflict often leads to new ideas, processes, improved communication and development of new skills. When administrators refuse to hold high-performing physicians accountable for disruptive behavior or physicians and nurses won’t speak up when they’re experiencing conflict:
- It becomes harder to recruit and retain skilled physicians and staff
- Patients may seek care from another source after witnessing an unpleasant confrontation—even if their own physician wasn’t involved
- Malpractice suits and insurance costs may dramatically increase
Knowing When and How to Intervene
While healthcare administrators can’t be expected to jump into action every time a doctor is condescending to a nurse or a nurse withholds needed information from a peer, they should promptly intervene whenever:
- Patient safety or satisfaction is compromised
- The conflict is affecting the morale or changing the attitudes of staff or colleagues
- Staff members are changing behavior or rearranging their schedules because of the conflict
- Employees not directly involved in the conflict are becoming caught up in it (the smaller the medical group or work group, the more likely this is to happen.)
- Significant amounts of time and energy are being devoted to dealing (or not dealing) with the conflict
When alerted to a potential problem, administrators are advised to:
- Respond promptly when complaints are made or conflicts become evident
- Investigate sources of conflict in a neutral and impartial manner
- Make the parties involved accountable for changes in behavior
- Provide resources and coaching around conflict resolution.
Changing the Workplace Dynamic
The Agency for Healthcare Research and Quality cites 12 barriers to a creating a civil, mutually supportive workplace:
- Hierarchical culture
- Lack of resources or information
- Ineffective communication
- Conflict
- Time
- Distractions
- Workload
- Fatigue
- Misinterpretation of data
- Failure to share information
- Defensiveness
- Conventional thinking
Of those barriers, administrators have the ability to control workloads, ensure adequate resources and address scheduling issues that lead to fatigue. The other issues require administrators to establish clear guidelines for expected behavior and workplace civility—and have in force clear consequences for employees who violate those guidelines.
Training and coaching around effective communication and conflict resolution should also be provided to challenge conventional thinking, reduce defensiveness, promote sharing of information and encourage staff at any level to speak up whenever patient safety is at risk or there’s a fear that information has been misstated or misinterpreted.
“There’s no cookie cutter approach that will apply to every situation or personality type,” says Steinkamp. “Most conflicts are simply conversations that haven’t happened yet. Given the power differential that’s existed between doctors and nurses, they may need extra help in getting difficult conversations started. The same is true between physicians, where collegial or competitive relationships can make open communication difficult.”
Conflict Resolution: A Case Study
A physician at a midsize family practice clinic was engaging in bullying behavior—abrasive, swearing and raising his voice. Staff were walking on eggshells around this physician. Patients complained about overhearing his rants.
VITAL WorkLife stepped in and took a multifaceted approach that touched every level of the organization:
- Worked with the physician to raise awareness about the intentions and outcomes of his behavior, and helped him develop a script that allowed him to ensure his needs would be met without the negative consequences of his current modes of communication
- Worked with nursing staff to address patterns of passivity and develop more effective ways of addressing issues and providing feedback to physicians
- Worked with the clinic administrator to define expectations for civil behavior and consequences of not following those guidelines
- Helped educate staff physicians about expectations and their responsibilities in regard to maintaining a culture of civility
As a result of this intervention, not only were the problems associated with the physician resolved, but the organization as a whole had a better understanding of how to communicate about and resolve conflicts.
Getting to the Root Cause of Problems
In the case above, the organization used a combination of intervention services and training and consulting services to implement a coordinated and comprehensive approach to the conflicts that had been going on for some time—and were escalating.
Other organizations have preferred to work solely with individual physicians. Those with The Physician Wellness Resources have sometimes suggested that physicians who seem to be embroiled in conflict with peers or staff to contact the EAP. Discussions with physician peer coaches can be particularly valuable for some physicians. Another option is to provide ongoing coaching to physicians who seem to be prone to more aggressive behavior that incites conflict. In either case, the goal is to help physicians understand why they are engaging in behavior and assist them in more productive methods of addressing their issues or grievances.
Similarly, Senior EAP consultants and peer coaches can help physicians who are concerned about addressing conflicts they’re observing, avoiding or being pulled into, in a manner that is productive and respectful. This can reduce or eliminate a major cause of stress and job dissatisfaction for some physicians.
We Can Help
For more information about how Physician Well Being Resources, our Physician Intervention program or our training and consulting solutions can help you address conflict in your organization, contact us online or at 877.731.3949.
Sources:
1 Van Den Bos, Jill, Rustagi, Karan, Gray, Travis, Halford, Michael, Zierkiewicz, Eva, and Shreve, Johnathon, The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors, Health Affairs, April 2011 vol. 30 no. 4 596-603, http://content.healthaffairs.org/content/30/4/596.short/ accessed June 18, 2012
2 Maxfield, David, Grenny, Joseph, Lavandero, Ramón and Groah, Linda, The Silent Treatment Why Safety Tools and Checklists Aren’t Enough to Save Lives, VitalSmarts, Association of periOperative Registered Nurses (AORN), & American Association of Critical Care Nurses (ACCN) 2010. http://www.silenttreatmentstudy.com/, accessed March 29, 2012.
