Creating Collegial RN-MD Relationships

1. Creating CollegialRN-MD Relationships Kathleen Bartholomew, RN, MN kathleenbart@msn.com Seattle, Washington

2. Significance Moral Distress Work Environment Patient Safety Retention/Recruitment Job Satisfaction

3. Where Did This Conflict Begin? • Socio-economic Origins • socialization • Gender Roles • Nature of the Profession • Education • Stein’s doctor/nurse game

4. Research in a nutshell... Collaboration alone does not work Enhancing opportunities for communication does not work Units with good relations have decreased mortality rates (Knaus 1986, Baggs 1992) Poor MD/RN relations effect morale, satisfaction, retention

5. Physicians and nurses do not agree on: Beliefs about responsibility Barriers to progress Potential solutions Rude behaviors affect cognition Mortality, patient safety and teamwork are affected by behaviors

6. JCAHO Statistics* *http://www.jcaho.org/accredited+organizations.htm

7. 2004 Survey “…less than 15% of physicians and nurses perceived that they had an “excellent” relationship with each other, …less than 25% were “very good” (Buerhaus)

8. Disruptive Relationships * Verbal abuse from physicians 90-97% * 76% witnessed negative RN-RN behaviors 67% saw link btw behaviors and medical error - 71% resulted in med error - 29% resulted in death (Rosenstein)* 370 ER staff - 57% noted DB from physicians - 52% noted DB from nurses

9. 32.8% linked DB with adverse events 35.4% linked to medical error 24.7 % to compromising patient safety 12.3% to mortality (Rosenstein, 2011)

10. Call from IHI and Patient Safety experts to address communication gaps contributing to errors (2006) • Description of gaps • 84% of sentinel events involved communication errors • 67% involved physicians Delay in care Reluctant to call Incomplete or unclear communication

11. Overt: • name-calling, sarcasm, bickering, fault-finding, back-stabbing, criticism, intimidation, gossip, shouting, blaming, put-downs, raising eyebrows, etc. • Covert: • unfair assignments, eye-rolling, ignoring, making faces (behind someone’s back), refusal to help, sighing, whining, sarcasm, refusal to work with someone, sabotage, isolation, exclusion, fabrication, etc.

12. Changing the Culture of Medicine Negative -Neutral-Teacher-Collaborative-Collegial

13. www.silencekills.com • 84% of MD’s have seen coworkers taking shortcuts that could be dangerous to patients • 88% of MD’s say they work with people who show poor clinical judgment • Fewer than 10% of MD’s, RN’s and clinical staff directly confront their colleagues about concerns

14. Evasive Action? • 30.7% leave the hospital • 24% refused to work or changed schedule (Advisory Board) >30% of administrators, nurses and MD’s could name a nurse who left in the last year specifically because of a poor interaction (Rosenstein)

15. Crucial Conversations Shared pool of meaning

16. Kramer-Schmalenberg Scale Collegial Collaborative Teacher-Student Neutral Negative

17. Physician Pressures decreasing reimbursement increasing workload rising malpractice costs loss of autonomy and respect bureaucratic red tape decreasing morale

18. Nursing Pressures higher acuity heavier patient load physically heavier patients nursing shortage less time with patients more compressed/complex workload

19. Transformational Forces Research and Technology Rising Costs Patient Needs and expectations Progressive subspecialization Access to healthcare Pay for performance Initiatives Growing MD Dissatisfaction J. Bujak

20. What is our goal? Nurses and physicians working together cooperatively, sharing responsibility for problem solving, conflict management, decisions, communication and coordination to improve outcomes Baggs 1992

21. P P A A C C

22. “Every system is perfectly designed to exactly achieve the results it consistently produces” Don Berwick

23. Breaking the cycle: 1. Unveil the problem2. Raise individual and collective self esteem-Susan Roberts

24. Solutions #1 Administrative Support: Establish Board CommitmentZERO TOLERANCEState expected behaviorsShare the visionOne standard for every employee – the same rules for all roles

25. St. Rita’s Medical CenterAssess extent of disruptive behavior impacting daily care - acknowledge problem.Survey Questions • Perception of DB impact on patient care • Effectiveness of handling DBs • DB frequency • Impact of DBs

26. Birthing a New Language Disruptive Desirable Unprofessional

28. St. Rita’sBirthing New Feedback Mechanisms • Transparency and Disclosure • Physician interventions will be shared with employees involved in events • Physicians advised zero-tolerance for overt or subtle retaliation • Timeout Language • As staff sense an event is escalating . . . end the conversation and ask for help from other staff and manager

29. Solution #2: Demonstrate the impactNew Nurse Training Kathleen Bartholomew, RN, RC, BS Nurse Manager, Orthopedics and Spine

30. “The responsibility falls on nurse managers to develop, nurture, and support equal power relationships between nurses and physicians.” Kramer/Schmalenberg

31. Mobility (Dr Toomey prefers 70 degrees) Avoid bringing knees together Avoid internal rotation of affected leg Posterior Precautions Avoid 90 degrees of hip flexion

32. Dr. Phillips Anterior Precautions No hip hyper-extension No hip external rotation > 45 degrees (avoid these movements together) No limitations on hip flexion Pillow between knees while in bed and sitting No crossing knees or tailor sit Encourage short steps, walk through gait ok.

33. Dr. Pritchett Anterior/Precautions (con’d) No crossing legs. No tailor sitting No active extension with external rotation (If good leg is in neutral, extension of operated leg is ok -Golfer’s lift)

34. Anterior Precautions (con’d) Dr. Toomey • Do not bend hip greater than 80 degrees • Keep legs apart with pillows in bed/sitting • Keep hip slightly bent at all times, using a • pillow under the thigh when in bed and for exercises • Don’t let the leg roll outward

35. Dr. Crutcher - 1/2” steri-strips cut in 1/2 closely • spaced after applying tincture of benzoin • Dr. Peterson - 6” ace wrap over knee with ted hose • Dr. Wilson - full length 1” steri-strips • Dr. Zorn - DSD change 1st day POD • Dr. Phillips - Don’t even think of pulling the drain Dressings

36. Blood Dr. White - gives auto blood in PACU Dr. Cather - give 1 unit auto if drain> 500cc call if Hct < 26 Dr. Richardson - call if Hct < 27 Drs. Toomey, Downer, Zorn - Hct < 30 Family member of any physician - Hct <20

37. Impact of DB on Peers • Undermines practice morale/initiative • Decreases self esteem • Withholding information • Heightens turnover • Steals from productive activities • Increases risk for substandard practice • Causes distress among colleagues J.H. Pfifferling

38. # 3 Link safety and the relationship… • 67% saw link between disruptive behavior and medical mistakes • 18% knew of a mistake that occurred because of an obnoxious doctor (Rosenstein) • 40% withheld medication concerns; As a result, 7% contributed to med error (Safe Medication Practices)

39. Joint Commission orders code of conduct for bad behavior The Joint Commission says health care facilities, labs and other related organizations by next year must establish a code of conduct that defines and sets out a process for handling unacceptable behavior by health care workers, such as rude language, temper tantrums and bullying. The Commission said such behavior can impact patient care by causing breakdowns in provider communication and teamwork. Chicago Tribune (7/10) , MSNBC (7/9)

40. # 4 Formal Collaborative Models e.g. MD – RN Summits • Garner MD and RN champion • Pre-survey for top 5 concerns from each group • Meet and share concerns over a minimum • of a 2 hour dinner meeting • Follow-up in six months • Future Summits: peer evaluations and feedback • e.g. “Coffee Corp” at St. Rita’s

41. #5 Accountability Structure • Behavioral standards integrated into job • descriptions • Set expectation that staff communicate • Peer counseling for outliers • Focus on pattern of behavior • Peer Review Committee as surveillance system

42. Birthing Employee / Medical Staff Alignment Physicians Employees Termination Privilege Limitation or Loss E Suspension MEC / Disciplinary Action D Written Warning C MEC Action Document: Verbal or Written Warning Collegial Guidance B STARS / Thank You Notes STARS / Thank You Notes A INTERVENTIONS

43. Hickson’ Pyramid Disciplinary Action Authority Intervention Awareness InterventionInformal Meeting

44. “When people of shared purposeare given access to the relevant data and allowed to engage in soulful dialogue, magic happens.”M. Wheatley 1994

45. Opportunities 1. Administrative Support -Zero Tolerance Policy & Action Plan Show the impact of preferences on patient care Link relationships and communication to safety Assess the relationship climate - survey Educate - Assertiveness and Interpersonal RelationshipTraining - SBAR and the role of the nurse Powerful Equalizers - name/clothes Coffee Corps and shared meals

46. 8. Feedback as norm for all staff Hold the vision – daily communication TCAB at the bedside 10. Formalized collaborative models 11. Acknowledge excellent relationships * 12. Attend medical rounds, staff meetings, practice improvement 13. Support joint celebratory & educational events

47. “ If you want to create an alternative future, you have to change the way people speak and listen to each other” Peter Block