The Impact of Disruptive Behavior on Nursing Care and Patient Safety

Transcription

1 The Impact of Disruptive Behavior on Nursing Care and Patient Safety Alan H. Rosenstein M.D., M.B.A. Vice President & Medical Director VHA West Coast Forum on the Future of Nursing October 19, 2009

2 Outline What is it? Have you seen it Who does it? Where does it occur? What causes it? What s the impact What can we do about it? Will it work? What if you don t do anything about? 2

3 Original Research from VHA West Coast has shown: 2002: High incidence of physician disruptive behavior with a significant impact on nurse satisfaction and retention 2005: A significant impact of physician and nurse disruptive on psychological factors and clinical outcomes of care 2007: A significant impact of physician and nurse disruptive on clinical outcomes of care in high stress areas : A significant impact of physician and nurse disruptive on psychological factors and clinical outcomes of care on patient safety

4 Disruptive Behavior: What is it? Disruptive behavior is defined as any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment. Yelling/ Raising voice Disrespecful interaction Abusive language Berating in front of peers Condescension Insults Abusive anger Berating in front of patients Berating in private Physical abuse Other

5 Disruptive Behavior: Have you seen it? Y E S Y E S Y E S Y E S Who & Where? Are there any particular specialties where disruptive events occur most often? 5 50% 40% 30% 20% 10% 0% General Surgery 28% Neurosurgery 20% 13% 10% 7% 6% Cardiovascular Orthopedic Anesthesia OB/GYN

6 What are you doing about it? Historical: New problem? Hierarchy Reluctance Conflict of interest Skill set Structure Commitment Call to action: Nurse satisfaction Patient satisfaction Patient quality Patient safety Reputation Litigation Joint Commission 6

7 Data and Implications 7

8 Have You Ever Witnessed Disruptive Behavior From a Physician or Nurse at Your Hospital? Have you ever witnessed disruptive behavior from a physician at your hospital? 100% 80% 60% 77% 51% 88% 78% 66% 40% 20% 0% Aggregate MD RNs Admin Other Joint Commission Journal on Quality & Patient Safety August 2008 Have you ever witnessed disruptive behavior from a nurse at your hospital? 100% 80% 60% 40% 20% 0% 65% 73% 77% 64% 48% Aggregate MD RNs Admin Other 8

9 How Often Does Disruptive Behavior Result in the Following? Never Rarely Sometimes Frequent Constant Stress Frustration Loss of concentration Reduced team collaboration Reduced information transfer Reduced communication Impaired Nurse-Physician relationship 9

10 How Often Does Disruptive Behavior Result in the Following? How often do you think disruptive behavior results in the following at your hospital? Stress Frustration Loss of concentration Reduced team collaboration Reduced information transfer Reduced communication Impaired RN MD relationships Never Rarely Sometimes Frequent Constant Significant Incidence 10 Joint Commission Journal on Quality & Patient Safety August 2008

11 11 Linkage Between Disruptive Behavior and Undesirable Behavioral Factors Occurring Sometimes, Frequent and Constant Percent Stress Frustration Loss of Concentration Reduced RN/MD Collaboration Reduced Information Transfer Reduced Communication

12 How Often Do You Think There Is a Link Between Disruptive Behavior and the Following? Adverse Events* Errors Patient safety Quality of care Patient mortality Nurse satisfaction Physician satisfaction Patient satisfaction Never Rarely Sometimes Frequent Constant *Adverse Events: Any undesirable clinical patient experience that occurred during the hospitalization 12

13 How Often Do You Think There Is a Link Between Disruptive Behavior and the Following? How often do you think there is a link between disruptive behavior and the following clinical outcomes at your hospital? Never Rarely Sometimes Frequent Constant Adverse events Medical errors Impaired patient safety Impaired quality Patient mortality Significant Incidence 13

14 Linkage of Disruptive Behavior to Undesirable Clinical Outcomes Occurring Sometimes, Frequent, and Constant 100 Percentage Adverse Events Errors Patient Safety Clinical Outcomes Quality of Care Patient Mortality Patient Satisfaction 14 Joint Commission Journal on Quality & Patient Safety August 2008

15 Are You Aware of Any Specific Adverse Event That Occurred as a Result of Disruptive Behavior Are you aware of any specific adverse events that did occur as a result of disruptive behavior? 25% 20% 18% 20% 21% 15% 10% 5% 12% 11% 0% Aggregate MD RNs Admin Other 15 Joint Commission Journal on Quality & Patient Safety August 2008

16 Comments: Most nurses are afraid to call Dr. X when they need to, and frequently won t call. Their patient s medical safety is always in jeopardy because of this. My concern is that the new nurses are afraid to call about patient problems and issues that truly need to be addressed in a timely manner impacting outcomes. Cardiologist upset by phone calls and refused to come in. RN told it was not her job to think, just to follow orders. Rx delayed. MI extended Poor communication post-op because of disruptive reputation resulted in delayed treatment, aspiration and eventual demise When patient brought to unit for GI bleeding patient saw MD yelling at nurses. Patient asked if that was his doctor. Yes. Patient refused treatment and was transferred to another hospital. I am retiring early and never recommend someone becoming a nurse Are you aware of any specific adverse events.? Yes. Death as a result of disruptive behavior. Staff nurses advocated for better patient care but MD would not willing to listen to reason. As a result patient died. The doctor chose to undo all the help that various staff had been working on for weeks to get this patient the help so badly needed. Yes, many incidents are preventable if both parties are willing to listen to each other, but many doctors are unwilling to accept a nurse s opinion just as some nurses are unwilling to listen to the opinions of LVNs, techs or CNAs, and it may have to do with the entrenched pecking order that exists at most hospitals. The disruptive behavior from nurses is much more upsetting because I expect that behavior from the surgeons NOT the nurses b/c I rely on them as my peers (RN)

17 Behavioral Initiators What causes people to act and react the way they do? People: - Age (generation) - Gender - Culture and ethnicity - Family/ life values and experiences - Training - Personality style Problems: Emotional intelligence Stress and frustration Fatigue/ Burnout Depression Substance abuse Situational: Environmental Provoked response Mood of the day

18 How does this all fit together? Multifactorial Input: Internal Deep seated values and perceptions Contributing factors Recent experiences Emotional Intelligence External Unexpected event Situational/ Environmental/ workplace contributions Output: Actions/ words Body language Non- actions 18

19 Nurse/Clinical staff consulted 1:1 with Manager Manager ensures event entry to MIDAS Nurse/Clinical Staff & Manager (together) consult physician in question Disruptive Behavior Occurs Manager & Nurse/Clinical Staff to determine and act on one of four following interventions Manager (alone) consults physician in question Manager informed via MIDAS entry Intervention and outcomes of consultation entered into MIDAS Complaint closed Mgr. consults with VP, CMO as appropriate to consult physician Nurse/Clinical Staff address with Physician Issue Resolved? No Yes Enter event into MIDAS for trending Complaint closed Manager & VP determine or Nurse/ Clinical Staff request to go to HR Directly HR conducts formal investigation of disruptive behavior in connection with VP & CMO Based on determination issue addressed by CMO and Chief of Staff with physician or referral to MEC for formal hearing Update: Recommendations: Ten Point Plan 1. Cultural commitment/ Leadership endorsement 2. Recognition and awareness - Self - Staff 3. General education - Unit/ Department - Medical Staff - Administration - Board - Students 4. Advanced Education/ Training - Diversity - Competency (Knowledge/ Technical/ Communication) - Assertiveness 5. Collaboration/ Communication tools 6. Clinical Champions 7. Policies and procedures 8. Reporting mechanisms 9. Compliance adherence: Intervention/ Feedback 10. Reinforcement of patient safety initiatives Commitment Leadership Championship Policy Accountability Consistency Compliance Process Reporting/ Follow up : Confidentiality Consistency Follow through Intervention* Feed back Education: General education (all staff) Structured education Phone etiquette/ Charm school Sensitivity/ Diversity training Assertiveness training/ Linguistics Conflict/ Anger management Time/ Stress management Nothing changes No feedback Fear of retaliation Lack of confidentiality Other MIDAS DISRUPTIVE BEHAVIOR PROCESS Agg MD RN 19

20 Conclusion Serious issue Sensitive issue Significant impact Understand React Enforce Commitment Policies & Procedures Training & Education * Risks of non- compliance 20 [email protected]