Effective communication strategies for managing disruptive behaviors and promoting patient safety

Abstract

OBJECTIVE

To describe and analyze strategies for professionals to communicate effectively when managing disruptive behaviors at the hospital and to promote patient safety.

METHODS

This is a descriptive and qualitative study conducted with 29 health professionals at a public hospital in Ceará, Brazil. Data were collected in 2014 by means of an in-depth interview, analyzed using the content analysis technique with MAXQDA® software, and discussed according to patient safety references.

RESULTS

The interview transcripts resulted in 27 contextual units of analysis that address effective communication strategies for managing disruptive behaviors, such as team meetings with open dialogue; performance evaluation and feedback; and exercising leadership with emphasis on individual support, training, recognition, and mutual respect.

CONCLUSIONS

Individual and group strategies that focus on communication skills and establishing mutual respect at work act as barriers for disruptive behavior and, if properly adopted, have a positive impact on patient safety.

Keywords:
Interdisciplinary communication; Interpersonal relations; Social behavior; Attitude of health personnel; Patient safety

Resumo

OBJETIVO

Descrever e analisar estratégias de comunicação interprofissional efetiva no gerenciamento de comportamentos destrutivos no trabalho hospitalar e promoção da segurança do paciente.

MÉTODOS

Estudo descritivo e qualitativo, desenvolvido com 29 profissionais de saúde de hospital público no Ceará, Brasil. Os dados foram coletados em 2014, mediante entrevista em profundidade, analisados pela técnica de análise de conteúdo, com o software MAXQDA®, e discutidos segundo referenciais da segurança do paciente.

RESULTADOS

Emergiram 27 unidades de contexto da análise do conteúdo abordando estratégias de comunicação efetiva para gerenciamento de comportamentos destrutivos, destacando-se: reuniões em equipe com diálogo aberto, avaliação de desempenho e feedback; e exercício da liderança com ênfase no suporte individual, treinamentos, reconhecimento e respeito mútuos.

CONCLUSÕES

Estratégias individuais e grupais focalizadas em habilidades de comunicação e estabelecimento de respeito mútuo no trabalho atuam como barreiras a comportamentos destrutivos e, se adequadamente instituídas, têm impacto positivo na segurança do paciente.

Palavras-chave:
Comunicação interdisciplinar; Relações interpessoais; Comportamento social; Atitude do pessoal de saúde; Segurança do paciente

Resumen

OBJETIVO

Describir y analizar estrategias de comunicación interprofesional efectiva en la gestión de comportamientos destructivos en el trabajo hospitalario y promoción de la seguridad del paciente.

MÉTODOS

Estudio descriptivo y cualitativo, desarrollado con 29 profesionales de salud de hospital público en Ceará, Brasil. Los datos fueron recolectados en 2014, mediante entrevista en profundidad, analizados por la técnica de análisis de contenido, con el software MAXQDA^®, y discutidos según referenciales de la seguridad del paciente.

RESULTADOS

Emergieron 27 unidades de contexto del análisis del contenido abordando estrategias de comunicación efectiva para gestión de comportamientos destructivos, destacándose: reuniones en equipo con diálogo abierto, evaluación de desempeño y feedback; y ejercicio del liderazgo con énfasis en el soporte individual, entrenamientos, reconocimiento y respeto mutuos.

CONCLUSIONES

Estrategias individuales y grupales enfocadas en habilidades de comunicación y establecimiento de respeto mutuo en el trabajo actúan como barreras a comportamientos destructivos y, si adecuadamente instituidas, tienen impacto positivo en la seguridad del paciente.

Palabras clave:
Comunicación interdisciplinaria; Relaciones interpersonales; Conducta social; Actitud del personal de salud; Seguridad del paciente

Introduction

Disruptive behavior at work, also known as unprofessional behavior, occurs when professionals are disrespectful in their workplace and may involve incivility, psychological violence, or physical/sexual violence. This concept is widely discussed in the health care literature because it combines human behavior, the care process, and patient safety¹.

This is particularly noticeable in hospital environments, where the hierarchy of power and the ambiguity of tasks play a significant role in the origin of these behaviors. In general, when considering the hospital hierarchy, nurses are often in a vulnerable position and have little autonomy - which is characteristic of the work process in Brazilian health care. Although nurses are held accountable for ensuring patient safety, they must often cope with intimidating situations that hinder effective and timely communication and may prevent them from intervening appropriately to prevent harm².

According to some studies, disruptive behavior directly affects patient care because important information is not adequately shared^1,3. When workers are the target of disruptive behavior, they are often too afraid to communicate with others and may even avoid sharing their thoughts with the offenders. This silence leads to submission, lack of autonomy, loss of creativity and initiative, and diminished interest in questioning treatment plans with fellow doctors, for example. The result of this rupture is a greater occurrence of incidents in the care they provide⁴.

In a recent study, one participant reported disruptive behavior on the part of physicians, who would intimidate nurses so they would not question their conduct/prescriptions for the sake of "keeping the peace". Moreover, the nurses reported situations in which they were unable to communicate the needs of patients effectively because of these behaviors. They reported feeling uncomfortable when the physicians contacted them to talk about their patient care³.

Considering that patient safety is the main subject of this study, we sought to understand how this behavior affects patients; in other words, how this behavior attempts to reduce the risk of harm associated with health care to a minimum acceptable level⁵.

The evidence that disruptive behavior is a threat to patient safety reveals its immediate and long-term negative effects health workers, organizations, and patients. Health workers experience a combination of intense feelings such as fear, anger, shame, confusion, uncertainty, isolation, insecurity, frustration, and even depression. These feelings significantly hinder their capacity to think and make the right decisions and may even affect their performance⁶.

Institutional disregard is a learned behavior that is supported and reinforced by an authoritarian culture found in most hospitals. Therefore, an organizational culture rooted in generalized dysfunctional disregard is a substantial barrier to patient safety⁶.

Moreover, permitting these behaviors affects job satisfaction and the retention of nurses. Institutions must become aware of these consequences and create policies, norms, and procedures to effectively deal with such a serious problem and reinforce adequate patterns of behavior⁷.

Furthermore, nurse leaders must be aware of their responsibility in implementing and enforcing policies, processes, and education to approach and mitigate disruptive behavior⁸.

Institutions can adopt a number of strategies to reduce disruptive behaviors in the workplace, such as education and training on effective communication among the members of the health team^4,6,9.

Effective communication includes assertive behaviors when transmitting, receiving, and interpreting information with clarity and mutual respect. Other appropriate solutions to the problem include the use of objective and non-libelous language that fosters communication and respectful relations and a channel or system to report disruptive behaviors¹⁰.

In all cases, the aim is to ensure an open and effective interprofessional communication from problem identification to the use of effective communication tools and mechanisms.

A search of the Brazilian literature from 2006 to 2017 resulted in 14 papers on effective communication. In these papers, patient safety was considered a goal - an interdisciplinary and interprofessional issue - that is full of weaknesses and potential¹¹.

Thus, it is important to produce more knowledge on the problem of disruptive behavior in Brazil since studies on effective communication are still incipient, especially regarding strategies that favor patient safety.

A conceptual analysis was conducted on disruptive behaviors at the workplace with medical professionals, nurses, and nursing technicians of a public teaching hospital in northeastern Brazil¹². After the workers were questioned about their experiences with these behaviors, they were asked to list some strategies that best address this issue in the institution.

The aim was to describe and analyze effective communication strategies among professionals when managing disruptive behavior in a hospital setting and to promote patient safety.

Method

This is a descriptive study with a qualitative approach conducted at the largest public hospital in the municipality of Fortaleza, state of Ceará, Brazil. This institution is a reference in general and vascular surgery, emergency care, internal medicine, obstetrics, and neurology as well as kidney and liver transplants.

The hospital offers 525 beds for inpatients, 63 specialties and subspecialties, and other health services. It is also one of the largest training centers in the country and it is certified by an interministerial ordinance as a teaching hospital for qualifying health professionals in 24 medical specialties.

According to data of the institution, the medical staff consists of 3196 professionals, including those who sat a public exam to work at the institution and cooperative members. In all, the hospital has 1883 nursing professionals, 995 physicians, and 318 workers of other categories (speech therapists, psychologists, pharmacists, physiotherapists, dietitians, social workers, and occupational therapists).

Given the higher prevalence of disruptive behaviors in critical units¹, we decided to include the professionals of these practice scenarios. Critical care units are for gravely sick patients with a potential risk of death and therefore play a pivotal role in Brazilian health care¹³.

In our study, the criteria for inclusion were physicians, nurses or nursing technicians and professionals who had been providing care at the institution for at least a year. We excluded workers who were on leave during the data collection period for any reason, whether holidays, on medical leave or otherwise.

Physicians and nursing professionals were chosen because they have close contact with patients, which allows a better perspective on the impact of disruptive behaviors on safe care. Furthermore, physicians were chosen because they are responsible for the prescribed therapy and daily evolution. The nursing staff was chosen because it provides direct and indirect 24-hour care that involves intervening and managing all the clinical, administrative, social, environmental, and educational aspects of care.

In addition, in an integrative review on the subject, most of the 70 papers were analyzed with the physicians and nurses since they find it easier to identify and discuss cases of disruptive behavior in the workplace¹.

The subjects were selected using the convenience sampling technique. Once the project was presented and the subjects were individually invited to participate, 29 accepted the invitation. Of these participants, 6 were physicians, 10 were nurses, and 11 were nursing technicians/assistants. They were asked to talk about their experiences with disruptive behavior at the hospital and the strategies they would adopt to manage this behavior with a focus on effective inter-professional communication. The number of physicians and nurses was relatively disproportional because there were more nurses in the investigated units and they were more eager to talk about the subject of the study.

The adopted data collection technique was in-depth interviewing.

Data were collected from March to July 2014 and ended when the information reached a point of saturation. The interview investigated the professional experiences of workers on the subject of the study, with the questions: How do you view your daily work in this unit? Have you ever experienced or heard of disruptive behaviors at work?; and Can you think of an example of this type of behavior? It also investigated the worker’s ideas and values regarding the subject, with the questions: What do you think about this type of conduct? Do you have any suggestions for the hospital administrators and leader to manage these behaviors?). This article summarizes the findings related to the respondents' suggestions for managing these behaviors on a daily basis.

The interviews were recorded and subsequently transcribed. The data were organized using the content analysis technique proposed by Bardin¹⁴.

This technique consists of the following three stages: Pre-analysis; Exploration of the material; Treatment of the results, inference, and interpretation. The pre-analysis consists of organizing the material and selecting the documents for analysis. Next, the interviews were fully transcribed to create the body of research. The transcriptions were arranged in columns to make notes and mark similarities and contrasts using the "text highlight color" tool in Microsoft Word^®(14.

In the exploration stage, the material is encoded and all the raw data is organized and divided into units to describe the most important characteristics of the content. Encoding involves choosing the registry units and context and selecting the count rules. Then, the content was categorized (choice of theme categories). The categories are classes used to gather a group of elements (registry/context units) based on common characteristics, such as similar expressions and suggested strategies on the issue. Finally, we proceeded with the treatment and interpretation of results. In this stage, we returned to the theoretical framework to support the analysis of the study¹⁴. Such frameworks are a set of manuscripts and policies related to patient safety worldwide, with an emphasis on human and systemic factors involved in adverse events in health care^1,5,15-16.

In this study, the phrase or sentence was defined as the registry unit and the paragraph was defined as the context unit. The context unit, in turn, contains a part of the message (superior in content to the registry unit) that is ideal to encode and understand the exact meaning of the registry unit. In the transcript of the context units, we used brackets [] to indicate the additions or comments that shed further light on the context.

To complete content analysis, the data obtained in the interviews were processes in a professional text analysis software called MAXQDA®¹².

The anonymity of the respondents was guaranteed using codes for the professional category in which they worked, represented by the letter P for physician; N for nurse; NT for nursing technicians; and NA for nursing assistants, followed by the Arabic number of the order of the interviews.

This article presents the findings of a broader study entitled, “Comportamento Destrutivo no Trabalho em Saúde: análise de conceito”. The project was approved by the Research Ethics Committee (CEP) of the hospital in which it was conducted (CAAE: 24266513.0.0000.5040). All the workers signed two copies of an informed consent statement - one for the researcher and one for the participant.

Results and Discussion

The interviewed professionals acted in different units of the hospital, namely emergency, intensive care, obstetric inpatients, neurology, delivery room, surgery center, and maternity center. The average age of the respondents was 33.8; 9.8 years since graduation; 5.3 years working at the hospital; and 44.4 weekly work hours. Most of the respondents were women (n = 25) since they are often the majority in the nursing profession. Moreover, most of the workers had been contracted through a cooperative (n = 23) and they worked more than 40 hours a week (n = 18).

Once the professional profile was determined, we asked questions related to their work dynamics and, above all, their experiences with disruptive behavior at their workplace. Some statements include examples of the disruptive behavior they experienced on a daily basis:

I had a problem with one [nursing assistant in the night shift]. I went to do a transfusion and I calculated dripping in hours [and said:] in a few hours you can ask for the second [blood] bag. [And she replied:] look, I will bring it and hook it up? I said: you will not hook it up, it is the nurse’s job to hook up the blood bad! And she answered: I hook it up until the head’s shift so why can´t I hook up yours? (N5)

The nurse down there [in the ER] decided when she was going to receive the patient, she wanted to decide which patient was coming. The doctor would say one thing and she would decide another, understand? For some reason, you know, she thinks she's the head of the unit. (P2)

He thinks that he can shout and be abusive like that because he is a doctor, because of the status and education. (NT7)

There are lots of stories like that, of surgeons who are rude with residents, with technicians, of throwing supplies at us... here in the nursing head office, we have some stories like that, too. (P5)

Disruptive behavior in health care can be manifested through abusive, intimidating, disrespectful, and threatening attitudes among team members⁷.

Once the situations and cases of disruptive behavior were identified in practice, the participants were asked to suggest strategies to deal with this behavior on a daily basis. Chart 1 summarizes the effective communication strategies suggested by the participants to manage disruptive behavior, divided into two categories of analysis:

Table 1:
Thematic categories of analysis for the interviews about strategies to manage disruptive behaviors. Fortaleza, CE, 2014 (n = 27 UC).

Thematic category (UR/UC)	Definition	Elements extracted from the statements to identify strategies (UR/UC)
1. Team meetings with open dialogue, performance assessment, and feedback (15)	It covers the participants’ perception of the need for team meetings in which they can talk openly, assess their performance, and provide continuous feedback.	Hold team meetings and provide feedback (3) Assess performance (2) Enable open dialogue/conversation (5) Adopt an ethical and professional attitude (3) Foster the following-up of organizational routines and protocols (2)
2. Leadership with an emphasis on individual support, training, recognition, and mutual respect (12)	Presents strategies of the participants for establishing an authentic leadership that focuses on supporting workers individually and as a group, recognizing their work, and promoting mutual respect in interprofessional relations.	Offer courses, training, and lectures on the subject (4) Promote professional recognition (3) Exercise leadership effectively (2) Foster mutual help and respect (2) Improve interpersonal relationships (1)

• Source: Research data, 2014.

Team meetings with open dialogue, performance assessments, and feedback

One of the strategies mentioned by the workers was regular meetings that focus on assessing performance and providing permanent feedback not only among certain categories but with the entire team, in which they could address specific problems and collectively plan solutions.

The more she [head of staff] is present, I think the meetings, monthly meeting directly with nursing management to discuss the care, the nursing routines, I think is the best way to communicate, clear everything up and see what we can improve, adjust the points [...]. (E10)

The suggestion is to not have meetings with only one category, just with nursing technicians, just with nurses ... it could be a meeting with all the categories, to try to raise a question about the problems of conflicts, those things. (TE10)

According to the participants, the coordinators should promote feedback for the presented conflicts so all the workers could address and solve them together. Moreover, during the meetings, the respondents mentioned they could discuss the points that need improvement.

Hospital managers and health workers must and should promote respect in the workplace based on open communication and situational awareness, feedback regarding team issues, education, accountability, and shared decision making¹⁷. Good communication is imperative not only within the health team that provides care to users but also among managers and all the person involved in care.

Therefore, the involvement of not only the health workers but also of the entire institution, including management, is necessary¹¹. By communicating effectively, the health workers can better understand their relationship with the team and manage the care they provide to users and with the other professional categories¹⁸.

In this way, effective communication is essential to teamwork. In relation to avoidable errors, effective communication serves as the foundation for safe and quality care¹¹.

All the persons involved must interact and this is only possible through communication. Understanding the process of communication, its forming elements, and its consequences can help tackle the challenges of effectively communicating at work¹⁸ and meetings, as mentioned, can provide the people involved with this understanding.

Another critical element is authentic leaders who conduct the team ethically and respectfully and who are able to align organizational processes so information is transmitted correctly and optimally(11).

It is also important to learn about body language since it can transmit negative messages in the same way as words¹⁹. The ability to recognize communication patterns can enable cultural and behavioral changes⁴ and stimulating a review of body language can help develop this skill.

Another strategy is to include education that focuses on teaching health workers to communicate assertively, especially in the case of people with an authoritarian and hostile personality and in the case of difficult situations⁷. Continuing education must include participatory and significant approaches, such as realistic simulations that help workers identify their errors in communication, and involve the entire multidisciplinary team^11,20.

Moreover, workers should individually or collectively identify the conflicting situations and/or disruptive behaviors, which requires listening to the team and stimulating constructive dialogue, as observed in the statements.

Listen to each specific class [...]. (E2)

It’s the conversation, the dialogue, and identifying the error, if there is one, and we have to fix the error [...] find out what's going on, if it's true, it's a lie [...]. (TE6)

Talking to their head of staff [surgeons], summon them to the room and talk, show him the whole situation, watching from the outside, and the damage caused ... asking him to see it as an outsider, as a non-participant, and as a person... so he can see it as a spectator, measure the entire situation, and make a critical judgment, as his own self-criticism. (E3)

Call them to talk, guide them, explain, try to show them we're adults, we have to behave like adults. Show them that it’s senseless to cause friction at work. (TE10)

[...] nothing like a good chat, a good conversation, someone talking and providing guidance. So let's solve our situation between us so that we can provide quality work and a good service to patients. (E10)

The statements suggest that a good strategy would be open dialogue that enables the workers to identify conflicts and ways of solving them, and thus provide quality care and prevent harm to patients.

Effective communication to ensure quality care is primarily achieved with direct eye contact, well-informed listening, the capacity to understand the message, developed leadership, the union of all team members, and the exchanging of information¹¹.

The participants stressed the importance of active and reflective listening to minimize the occurrence of disruptive behavior. When addressing unprofessional behavior, it is important to hear not only the persons involved but also the other team members since they witness the situations and can help identify the triggers. Moreover, they can add other situations in which this pattern of behavior is constantly adopted and poorly managed. Thus, listening to others is important to understand their history and elucidate facts¹⁹.

Facts must be effectively investigated so the appropriate measures can be taken to prevent harm to workers, the team, and patients; therefore, any flaws in communication can hinder the effective resolution of problems.

Effective communication must be established from the moment risk or a critical incident is identified to prevent an adverse event and the damage it causes. It is not only necessary to stimulate the notification of serious adverse events, but also of their risks, causes, and any strategies for their resolution¹⁶.

In this sense, creating and implementing a system of communication and/or information may help improve communication⁷, either electronically, in which workers observe and report unprofessional behavior to the responsible sectors⁹ or in the form of a patient safety unit.

Opening a channel of communication can ensure workers feel free to report conflicting situations. Moreover, a notification system can allow professionals with disruptive behavior to respond to complaints and the persons responsible to monitor improvements after intervention⁹.

Health institutions need to adopt a standardized approach to incident notification in order to avoid inconsistencies in the responses. This uniformity makes the notification system safe and acceptable for workers to report incidents and address them in a timely fashion with effective follow-up and communication^7,17.

When the nursing team has a cohesive, effective, and well-established communication process, the relationship between professionals can encourage them to be at work and provide comprehensive and quality care to users¹⁸.

Open communication channels between health professionals enable problem identification, the establishment of effective communication tools and mechanisms, and event notification. In addition to the positive effects of effective communication on patient safety, it also has positive consequences in the professional and personal lives of these workers.

Leadership with an emphasis on individual support, training, recognition, and mutual respect

This category contains the strategies suggested to establish authentic leadership and worker guidance through training, organizational support, and the valorization of mutual respect.

Include these people that have this kind of behavior in receptive all-inclusive training sessions. (E5)

Lectures on interpersonal skills, teamwork, would be very helpful! (NT4)

Start from both medical and nursing coordination with the issue of mutual respect between in the team. (N1)

I think there has to be a leader and here in our unit, we have this figure. We have two people for this. They work in every sense, with the structure, personnel, medical and non-medical, and notifications. So I think that [a strategy would be] the fact that we notify behavior that is inappropriate. I think they have an estimate of what needs improving, and they have regular meetings with doctors and medical professionals so we can provide great care to patients. (P4)

Try to enforce that we are all in the same boat and we have to help each other. Not drift apart, because no one manages to work better alone. Together we can do this. For the greater good, which is the good of the people! (NT10)

Since the workplace is permeated by the grouping of several relational and interpersonal skills, leadership and communication are essential for an effective work process(11).

Evidently, however, disruptive behavior at work threatens this harmony because it affects teamwork and communication by destroying trust, mutual respect, and collegiality. Therefore, the interdisciplinary environment must allow all professionals, regardless of category, to work according to the organization´s goals and inappropriate conditions¹².

Corroborating the participants’ statements, effective communication enables two parties to solve their problems and reduces role-related and power-related conflicts. Inpatient care is complex and must be provided with quality without harming patients¹⁶.

Consequently, organizational silence and the difficulties workers have in expressing their views in front of co-workers must be eliminated and should not be barriers to communication and teamwork²⁰.

An organizational culture with a mission based on effective communication methods and authentic leadership will have a positive effect on care, quality, and patient safety²⁰. Along these lines, Ordinance MS/GM No. 529/2013 defines a patient safety culture as one in which all professionals involved in care, either directly or as managers, assume the responsibility of their own safety and that of their co-workers, patients, and their families and should, therefore, encourage the identification, notification and resolution of security-related issues, among others¹⁵.

For an organizational culture to function accordingly, the effective communication between different occupational categories must be a priority, especially in relations between the medical staff and nursing staff since they can substantially increase the risk of harm through disruptive behavior in the workplace.

International research on disruptive behavior in health care shows that unprofessional behavior can be minimized when the communication of professionals who are not good communicators is improved⁷.

The crisis of disruptive behaviors and the cases of horizontal violence in health services demand creative solutions and appropriate answers that start with a vision of care communities and environments and promote respectful relationships and communication¹⁰.

The different strategies of leadership and training that focus on interpersonal skills can improve communication and reduce disruptive behaviors in health care since communication is essential in any discussions and approaches to this unprofessional behavior¹⁷.

Final Considerations

We identified several strategies related to effective interprofessional communication that can facilitate the management of disruptive behavior in health care and promote patient safety. The most commonly suggested strategies by participants are team recognition of the disruptive behaviors; open channels for dialogue; meetings between all team members; authentic leadership with a focus on performance assessments and feedback; and promoting mutual respect among professionals.

A limitation of this study was the non-inclusion of other categories of health workers who are also part of the multidisciplinary team and could express other strategies. Moreover, the study was conducted at a single hospital and, therefore, only provides insight into the reality of one location.

However, this study contributes to clinical teaching and practice by shedding light on the subject and positively impacting the education of better professionals. It also contributes to research by providing a more profound perspective on the subject and disseminates strategies to manage disruptive behaviors in health care. Furthermore, our study addresses effective communication among health professionals as a fundamental skill that enables quality care and favors a work setting with pleasant and respectful human relationships.

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Publication Dates

• Publication in this collection
  29 Apr 2019
• Date of issue
  2019

History

• Received
  31 Aug 2018
• Accepted
  16 Nov 2018