Creating CollegialRN-MD Relationships

Kathleen Bartholomew, RN, MNkathleenbart@msn.com

Seattle, Washington

Significance

•Moral Distress•Work Environment•Patient Safety •Retention/Recruitment•Job Satisfaction

Where Did This Conflict Begin?

• Socio-economic Originssocialization

• Gender Roles• Nature of the Profession• Education• Stein’s doctor/nurse game

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

• 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

JCAHO Statistics*

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

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)

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

32.8% linked DB with adverse events35.4% linked to medical error24.7 % to compromising patient safety12.3% to mortality (Rosenstein, 2011)

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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 careReluctant to callIncomplete or unclear communication

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.

Changing the Culture of Medicine

Negative -Neutral-Teacher-Collaborative-Collegial

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

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)

Shared pool of meaning

Crucial Conversations

CollegialCollaborativeTeacher-StudentNeutralNegative

Kramer-Schmalenberg Scale

Physician Pressures

• decreasing reimbursement• increasing workload• rising malpractice costs• loss of autonomy and respect• bureaucratic red tape• decreasing morale

Nursing Pressures

• higher acuity• heavier patient load• physically heavier patients• nursing shortage• less time with patients• more compressed/complex workload

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

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

P P

A A

C C

“Every system is perfectly designed to exactly achieve the results it consistently produces”

Don Berwick

Breaking the cycle:

1. Unveil the problem2. Raise individual and collective self esteem

-Susan Roberts

Solutions #1 Administrative Support: Establish Board Commitment

ZERO TOLERANCE

State expected behaviorsShare the visionOne standard for every employee –

the same rules for all roles

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St. Rita’s Medical Center

Assess 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

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Birthing a New Language

Desirable Unprofessional Disruptive

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• 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

St. Rita’sBirthing New Feedback Mechanisms

Solution #2: Demonstrate the impact

New Nurse Training

Kathleen Bartholomew, RN, RC, BSNurse Manager, Orthopedics and Spine

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

Kramer/Schmalenberg

Mobility

•Posterior Precautions–Avoid 90 degrees of hip flexion

(Dr Toomey prefers 70 degrees)Avoid bringing knees togetherAvoid internal rotation of affected leg

Anterior Precautions

• No hip hyper-extension• No hip external rotation > 45 degrees (avoid these movements together)

No limitations on hip flexionPillow between knees while in bed and sittingNo crossing knees or tailor sitEncourage short steps, walk through gait ok.

Dr. Phillips

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)

Dr. Pritchett

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

Dressings

• 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

Blood

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

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

• 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)

# 3 Link safety and the relationship…

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)

# 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

#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

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Birthing Employee / Medical Staff Alignment

Privilege Limitation or Loss

MEC / Disciplinary Action

MEC Action

Collegial Guidance

STARS / Thank You Notes A

B

C

D

E

Termination

Suspension

Written Warning

Document: Verbal or Written Warning

Physicians

Employees

INTERVENTIONS

STARS / Thank You Notes

Hickson’ Pyramid

Disciplinary Action Authority Intervention

Awareness InterventionInformal Meeting

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

M. Wheatley 1994

Opportunities

1. Administrative Support-Zero Tolerance Policy & Action Plan

2. Show the impact of preferences on patient care3. Link relationships and communication to

safety4. Assess the relationship climate - survey5. Educate

- Assertiveness and Interpersonal RelationshipTraining- SBAR and the role of the nurse

6. Powerful Equalizers - name/clothes 7. Coffee Corps and shared meals

8. Feedback as norm for all staff9. Hold the vision – daily communication

TCAB at the bedside10. Formalized collaborative models11. Acknowledge excellent relationships *12. Attend medical rounds, staff meetings,

practice improvement 13. Support joint celebratory & educational

events

“ If you want to create an alternative future,

you have to change the way people speak and listen to each other”

Peter Block