Cora is a trauma nurse. One Friday morning, her patient had an adverse reaction to a medication that caused his temperature to stabilise at 104 degrees. She was convinced he was headed toward acute renal failure. The chief resident agreed that continuous renal replacement therapy should be started immediately but asked her to first consult a nephrologist – which she did.
The nephrologist was dismissive and curt. He rolled his eyes as she pressed her point. When she asked if she could share some research indicating the best treatment option for the patient he cut her off mid-sentence, pointed his finger in her face and yelled, "We will not be starting dialysis. Period." With that, he walked away.
The Joint Commission announced this year that Cora and her fellow nurses should not have to face situations like this again and for good reason. The Silence Kills study, conducted by VitalSmarts and the American Association of Critical-Care Nurses, reveals that more than three quarters of caregivers regularly work with doctors or nurses who are condescending, insulting or rude.
A third of study participants say the behaviour is even worse and includes name-calling, yelling and swearing.
But while these disruptive and disrespectful behaviours can be hurtful, what prompted The Joint Commission to address them as a condition of accreditation is the mounting evidence that they are also harmful. The Silence Kills study found that more than 20% of healthcare professionals have seen actual harm come to patients as a result of such behaviour.
For example, one nurse tearfully told us of a diabetic patient who had a colon resection with a large surgical wound. He was complaining of nausea and his stitches were coming loose. The surgeon on call had a reputation for being rude and hostile when awakened, but when the patient continued to deteriorate she made the call.
The surgeon refused to come and check the patient and demanded that she simply reinforce the dressing on the wound. Ultimately the patient vomited, popped his stitches and died from complications of his open wound.
Silence Kills found countless examples of caregivers who delayed action, withheld feedback or went along with erroneous diagnoses rather than face potential abuse from a colleague.
The data in Table 1 shows that three quarters of the healthcare workers surveyed experience some level of disrespect. For many, the treatment is frequent and longstanding. The correlations show that the more frequent the behaviour and the longer it has gone on, the greater the workers' intent to quit their jobs.
In fact, these correlations are so strong (correlations where r > .1 are meaningful; here we find r = .424, which is impressive) that disrespectful behaviour is suggested to be a primary cause of people's desire to quit. Discussing their concerns with the person who is responsible for the abuse is almost out of the question.
Even more startling than the pervasiveness of disrespect is that more than half of participants reported that the disrespectful behaviour had persisted for a year or longer. A surprising 20% said the problems had continued for five years or more.
It's not the conduct but the silence
The Joint Commission has taken an important step by requiring hospitals to create a clear code of conduct demonstrating the unacceptability of disruptive behaviour and laying the groundwork for holding caregivers accountable for their behaviour.
While this is an important element of influencing behaviour change, the research shows that there is something far more immediate and powerful individuals and leaders can do to drive change: they need to break the code of silence. Until they do so, they will fail to mobilise social pressure to drive change.
The most powerful force over human behaviour is social influence. People will do almost anything to gain acceptance or avoid rejection. Unfortunately, the vast majority of healthcare workers fail to exercise the enormous social influence they have in the face of disruptive behaviour.
The study showed that when doctors or nurses see disrespectful or abusive behaviour, there is a less than 7% chance that they or anyone will effectively confront the person who has behaved badly, as demonstrated in Table 2. Why don't people speak up and share their full concerns?
The obvious reason is that confronting people is difficult. In fact, the majority of respondents indicated it was between difficult and impossible to confront people in these crucial situations. People's lack of ability, belief that it is "not their job" and low confidence that it will do any good to have the conversation are the three primary obstacles to direct communication.
As a result of people's decision to choose silence over speaking up, disruptive behaviour has lingered for years awaiting social disapproval, yet receiving none.
If healthcare leaders want to not only secure the well-being of patients, but also increase employee retention and engagement, the most immediate and effective thing they can do is change this culture of silence. They need to substantially increase caregivers' skill and will to step up to crucial conversations immediately and directly when inappropriate behaviour emerges.
Cora was an exception to the rule of silence. She was one of the rare caregivers we found who was capable of confronting disrespectful behaviour head on. As the nephrologist walked away, she politely asked for another moment of his time.
Though he was clearly aggravated, she calmed things by explaining, "I am not trying to challenge your expertise. I know you are well trained for this decision. I apologise if it sounded as though I was being insubordinate. I know we both want to do the right thing for this patient. May I please explain why I have additional concerns in this case?"
With that small change in approach, the entire conversation shifted. The nephrologist listened to her concerns and ultimately agreed to order dialysis – saving the patient's life.
But Cora's conversation didn't stop there. Had she walked away at that point, she would have done right by the patient, but would have failed to exercise social influence on the nephrologist's bad behaviour. Having reached agreement, she asked him for two more minutes.
"Doctor, I suspect you found my approach to you a moment ago disrespectful. If so, I apologise. I recognise your expertise and will work harder in the future to address you as you deserve." The nephrologist's eyes widened.
She continued, "And doctor, I must ask the same of you. When I shared my concerns about the patient, you raised your voice, you rolled your eyes and you spoke to me harshly. That doesn't work for me, either. May I have your word that you will not address me that way again?" He apologised and never addressed Cora disrespectfully again.
Social influence – if wielded skilfully – is incredibly potent. The problem is it is rarely used. While the code of conduct may be an essential element to influence change in disruptive behaviour, the conversations around it will ultimately determine the pace and pervasiveness of change in any hospital.
Can you teach people to talk?
Not surprisingly, the Silence Kills study found that the small number of 'Coras' who speak up produce far better outcomes for their patients, their colleagues and themselves. These skillful 7% enjoy their jobs more, intend to stay longer, are far more productive and see better patient outcomes.
So we've studied what it takes to clone the Coras of the world. We've found that there are recognisable, repeatable and learnable skills for dealing with crucial conversations.
One hospital, MaineGeneral Health, spent two years teaching these skills to its employees. The caregivers learned to speak up about issues and concerns they had formerly ignored. For example, those who acquired greater skills were:
- 88% more likely to speak up when they saw someone take a dangerous shortcut
- 83% more likely to speak up when they had concerns about someone's competence
- 167% more likely to speak up when they saw someone demonstrate poor teamwork
- 167% more likely to speak up when they saw someone be disrespectful.
A poignant example came from the heart of the operating room. In one OR, some of the staff had felt unappreciated by a feisty surgeon for a long time. After participating in Crucial Conversations Training, two members of the staff independently approached the surgeon and shared their concerns.
Humbled, the surgeon started to make small but significant changes in his approach, including, for the first time in a decade, thanking staff when they did a good job. The result was a more unified and potentially safer team.
Four crucial conversations
Healthcare leaders who want to engage social influence to eliminate disruptive behaviour will have to break the code of silence in four crucial conversations:
Administrations must go public about the pervasiveness of concerns.
Most hospitals attempt to put a good face on disruptive behaviour by dismissing it as a problem with 'a few bad apples'. The truth, according to the Silence Kills study, is that it happens every day in most hospitals. It is not just a few bad apples. In order to influence change, leaders need to begin by acknowledging the frequency of concerns.
Caregivers must directly confront disruptive behaviour.
Next, leaders need to invest substantially in increasing the will and skill of every employee to speak up when they see problems. The focus needs to be not just on confronting disruptive behaviour, but on speaking up when people see mistakes, incompetence, violations of safety standards and more. The Silence Kills study identifies seven kinds of problems; fewer than one in ten people address these problems effectively, which can lead to burnout, disengagement, errors and worse.
Medical directors and nurse managers must respond appropriately to escalations.
The research also shows that the problem is not just upward, it's sideways and downward. Nurses fail to speak up to their peers when they have concerns. Managers fail to confront direct reports. Medical directors give their underlings a 'pass' rather than make waves. The silence is deafening in every direction and lower-level employees will not feel the expectation to address concerns if their leaders don't lead the way.
Administration must back up sanctions when they occur.
The most common reason people fail to speak up in hospitals is because they adopt the attitude of "it's not my job". The second most common reason is the belief that "others won't back me up if I do". For example, nurse managers worry that if they confront a disruptive doctor who brings a lot of money into a hospital, no one in administration will back them up. Administration must make it clear that if code-of-conduct violations occur, they will back up those who take appropriate action.
As the saying goes, "silence betokens consent". The pervasive and risky problems with disruptive behaviour in hospitals today will not be eradicated by codes of conduct – although these are a worthwhile step in the right direction.
The real change will occur when we substantially increase skills in conversation – especially the emotionally and politically risky conversations we so consistently avoid. When this vast potential of social pressure is finally tapped, our hospitals will become healthier for patients and caregivers alike.