if you see something, say something: managing professionalism lapses in the moment maria wamsley,...
DESCRIPTION
Roadmap Causes of unprofessional behavior Levels of managing professionalism lapses Four-step process for responding to a professionalism lapse “in the moment” Practice!TRANSCRIPT
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
Creative Commons LicenseAttribution-NonCommercial-Share Alike 3.0 Unported
You are free:• to Share — to copy, distribute and transmit the work • to Remix — to adapt the work Under the following conditions:• Attribution. You must give the original authors credit (but not in
any way that suggests that they endorse you or your use of the work).
• Noncommercial. You may not use this work for commercial purposes.
• Share Alike. If you alter, transform, or build upon this work, you may distribute the resulting work only under a license identical to this one.
See http://creativecommons.org/licenses/by-nc-sa/3.0/ for full license.
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