if you see something, say something: managing professionalism lapses in the moment maria wamsley,...

If You See Something, Say Something: Managing

Professionalism Lapses in the Moment

Maria Wamsley, UCSF Department of Medicine

Juan Ruvalcaba, UCSF-Fresno Department of Family and Community Medicine

February 17, 2016

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Roadmap• Causes of unprofessional

behavior• Levels of managing

professionalism lapses• Four-step process for

responding to a professionalism lapse “in the moment”

• Practice!

A case• It is 2 AM. A second year resident is on overnight call. The

ICU is full and she is admitting a seriously ill patient with sepsis, in severe pain from metastatic cancer, to the floor. She is repeatedly called by the nurse from another floor about a patient on her coverage list. This patient was signed out with explicit instructions not to increase pain meds for his chronic pain. The patient is demanding to be seen. The nurse is insisting that she come to the floor.

• After the fourth call, the resident screams at the nurse, uses harsh language in referring to the patient and slams down the phone, all in earshot of a busy nursing unit. The nurse then turns and snaps at the patient care assistant.

4

Professionalism values• Professionalism represents a set of values that

guide our work: Patient & family

Student

Resident

Faculty

Other health professionals

Department Staff

• Compassionate, Respectful, Collaborative

• Integrity & accountability

• Pursuit of excellence

• Fair and ethical stewardship of resourcesJAMA, December 22/29, 2010—Vol 304,

No. 24

Highly Publicized Illegalities

Involving Health Professionals

Disruptive Behaviors

Daily Incivilities

Conflicts of InterestDisregard of EBSP

Collective

Tolerance

Consequences of Unprofessional Behavior

• Create an environment where unprofessional behaviors are modeled for others to emulate

• Unprofessional behaviors are associated with• Low staff morale and turnover• Poor adherence to practice guidelines• Medical errors and adverse outcomes• Malpractice suits• Loss of patients

Why do Professionalism Lapses Occur?

Why do Professionalism Lapses Occur?

HALT: Hungry, Angry, Lonely, Tired

Personal stressors

Inter-Personal stressors

• Competency• Distractions• Psychological• Substance Abuse• Physical Illness

• Unshared mental models

• Disagreement• Poor communication• Poor understanding of

role

Why do Professionalism Lapses Occur?

Situational stressors System stressors• High workload

• Emotion in clinical setting:• Death• Trauma• Violent patients• Angry families

• Inefficient workflow• Conflicting policies• Culture• Hierarchical system

Opportunity for improvement (not a disciplinary event)

Learning to address unprofessional behaviors in learners and colleagues starts with embracing a series of assumptions about professionalism:• We all aspire to adhere to the highest standards

of professionalism but sometimes fall short of the mark.• We all would want to know if our behavior is not

meeting professional standards; if our reputation as a professional is suffering because of patterns of maladaptive behavior.

• We all have the potential to improve our behavior and attitudes with the help of our community of mentors, staff, and colleagues.

Levels of managing lapsesIntensity ApproachI) Low intensity end of

spectrum & appears isolated

II) Serious but isolated event

III) Persistent problem

IV) Egregious professionalism lapses or persist in actions despite coaching, counseling, or correction.

Coaching in the moment

Counseling/Conversation after the moment

Correction & Consequences conversation

Sanctions up to dismissal

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step CommentRecognize the underlying emotion

“I” phrases are hard to argue with.

Relate to the offender Displaying empathy lowers risk of defensiveness/verbal attacking or accusations.

Re-establish the professionalism norm

Connect the behavior back to the subject of the inappropriate comment as a humanizing moment.

Redirect the conversation

Moving on reinforces the coaching nature of the conversation.

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step Example CommentRecognize the underlying emotion

“I see you’re upset.”

“I am sorry that this is so frustrating for you.”

“I” phrases are hard to argue with.

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step Example CommentRecognize

Relate to the offender

“I can understand why you would feel frustrated in this situation.”

“I have definitely gotten upset in similar situations; it’s understandable that you would feel frustrated.”

“I agree that it is challenging to manage conflicts like this.”

Displaying empathy lowers risk of defensiveness/verbal attacking or accusations.

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step Example CommentRecognize

Relate Re-establish the professionalism norm

“Let’s try to remember that the xxx’s are doing the best they can in this situation and likely also feel frustrated.”

“I find it helpful to remember that we all actually have similar goals; let’s not let how upsetting this is prevent us from working together effectively.”

Connect the behavior back to the subject of the inappropriate comment as a humanizing moment.

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 secondsStep Example CommentRecognizeRelate Re-establishRedirect the conversation

“What can we do to help this patient?”

“Let’s work together on figuring out how to resolve this.”

“Maybe there’s a way to avoid this situation in the future.”

Moving on reinforces the coaching nature of the conversation.

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step CommentRecognize the underlying emotion

“I” phrases are hard to argue with.

Relate to the offender Displaying empathy lowers risk of defensiveness/verbal attacking or accusations.

Re-establish the professionalism norm

Connect the behavior back to the subject of the inappropriate comment as a humanizing moment.

Redirect the conversation

Moving on reinforces the coaching nature of the conversation.

Critical elements to the conversation

• Makes it clear that you don’t endorse the situation

• Stops the group from engaging in similar activity

• Doesn’t call names– doesn’t accuse anyone of being unprofessional

• Does express empathy for both the disruptor and those who were disrupted

A Case…

Practice!• Break into pairs• Decide who will be the “lapser” and who

will be the “intervener” (you will switch roles for Case 2 so everyone has a chance to practice.

• Read the part of the Case 1 that pertains to your role

• Practice the 4 step framework (7 min)• For those of you who are the “lapser”

please track how your “intervener” moves through the steps

• Debrief in pairs (5 min)

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step CommentRecognize the underlying emotion

“I” phrases are hard to argue with.

Relate to the offender Displaying empathy lowers risk of defensiveness/verbal attacking or accusations.

Re-establish the professionalism norm

Connect the behavior back to the subject of the inappropriate comment as a humanizing moment.

Redirect the conversation

Moving on reinforces the coaching nature of the conversation.

Debrief

Practice!

• Move on to Case 2• Switch roles• Read the part of Case 2 that pertains to you• Practice the 4 step framework (7 min)• Debrief in pairs (5 min)

Framework to coach for improvement opportunities In the Moment

Coaching in the Moment: Four steps in 90 seconds

Step CommentRecognize the underlying emotion

“I” phrases are hard to argue with.

Relate to the offender Displaying empathy lowers risk of defensiveness/verbal attacking or accusations.

Re-establish the professionalism norm

Connect the behavior back to the subject of the inappropriate comment as a humanizing moment.

Redirect the conversation

Moving on reinforces the coaching nature of the conversation.

Summary• Professionalism is a skill to be practiced, not an

inherent trait• Professionalism lapses are inevitable due to personal,

interpersonal, situational and organizational stressors• Coaching in the moment is a strategy that can

address professionalism lapses (4 R’s)• Recognize the emotion• Relate to the offender• Recalibrate the correct behavior• Redirect the conversation

Acknowledgement and Thanks

• Catherine Lucey, MD• Maxine Papadakis, MD• Tess Lang, MD• Victor Laluz, MD