3ObjectivesRecognize professional conduct as a foundation for achieving organizational mission, vision, valuesDefine professional and unprofessional conductUse two approaches to unprofessional conduct: Enforcement & EngagementRespond to unprofessional conduct using connect and correctRecognize the high conflict personality and seek guidance from human resources when needed
4Interprofessional Professionalism “Consistent demonstration of core values evidenced by professionals working together, aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability to achieve optimal health and wellness in individuals and communities” (Interprofessional Professionalism Collaborative, 2010).Professionalism is behaving in a way that is consistent with your organization’s core values.Interprofessional Professionalism Collaborative. Definition ofInterprofessional Professionalism. Retrieved Feb. 14, 2015 from
5The Science Effectiveness Team Leadership Orientation Mutual PerformanceMonitoringBack-upBehaviorAdaptabilityShared MentalModelsTrustEffectivenessClosed LoopCommunication(Salas, Sims, Burke; 2005)Big 5Coord.MechanismUnprofessional conduct undermines the trust and team orientation required to support team effectiveness.Teams provide organizations with a greater ability to adapt and learn than do individuals. However, just because groups of people call themselves a team doesn’t mean that they are truly a team. Based on an extensive review of the literature, Eduardo Salas and colleagues published this framework/model —called the big 5 of teamwork—in The purpose of the model is to identify the core concepts that enable groups of people to work together, to collaborate, to adapt to changing circumstances, and effectively work toward a common goal. The diagram illustrates that when team leaders direct and coordinate the activities of other team members by clarifying roles, establishing goals & expectations, and organizing meetings for planning and feedback, they provide the opportunity for team members to communicate, collaborate, and cooperate. It is during these meetings—in TS we learned to call them briefs, huddles, and debrief—that team members communicate what they have learned by monitoring others, a new shared mental model of how to reach a goal emerges, and team members offer back up or mutual support to achieve that goal. When team members trust each other, value team goals above individual goals, and use closed loop communication, they have the ability to be adapt, manage complex systems & patients and learn from experience.
6Professional Conduct and High-Performing Teams Professional conduct contributes to safe patient care and is a key component of high performing teams.Reinforcing professional conduct expectations within the team:Is a form of self-correctionProvides mutual supportReinforces trustProvides needed feedbackIs a key component of care coordinationProfessional conduct contributes to safe patient care and is a key component of high-performing teams.High performing teams have members who are able to selfcorrect.Reinforcing professional conduct expectations within the team is a form of self-correction.Addressing lapses in professional behavior also:• Provides mutual support• Reinforces trust• Provides needed feedback• Is a key component of care coordinationAddressing lapses in professional behavior requires courage, practice, and support.
7Defining Unprofessional Conduct Unprofessional conduct includes disruptive and intimidating behaviors that interrupt teamwork and undermine safe care.Overt behaviors:Verbal abuseShaming in front of othersScapegoatingBelittlingPhysical threats/ throwing objectsPassive behaviors:Refusing to answer questions or return callsBackstabbingWithholding informationRecruiting others to take a sideUnderminingRetaliationTEACHING POINTS:Unprofessional conduct includes disruptive and intimidating behaviors that interrupt teamwork and undermine safe care.Intimidating and disruptive behaviors include overt actions as well as more indirect or passive behaviors.Examples of overt behaviors include:– Verbal abuse– Shaming in front of others– Scapegoating– Belittling– Physical threats/ throwing objectsExamples of indirect or passive behaviors include:– Refusing to answer questions or return calls– Backstabbing– Withholding information– Recruiting others to take a side– Undermining– RetaliationThese behaviors are often exhibited by health professionals in positions of power. This may include people with greater authority or rank, or people with greater seniority.Disruptive and intimidating behaviors occur across all professions and within all levels of an organization. A majority of health professionals have witnessed or been subjected to disruptive and intimidating behaviors from colleagues.
8Impact of Unprofessional Conduct According to Joint Commission Sentinel Event Alert #40 —Behaviors that Undermine Safe Patient Care:Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.TEACHING POINTS:Disruptive and intimidating behaviors undermine team effectiveness, compromise the safety of patients, and contribute to unhealthy work environments.According to the Joint Commission Sentinel Event Alert #40 –Behaviors that Undermine Safe Patient Care (July 2008): Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.Source:Some ways in which unprofessional conduct impacts patient care include:• Breakdowns in information sharing• Loss of trust among team members• Keeping quiet when shortcuts or poor care are observed• Hesitancy in asking questions or clarifying information• Absenteeism and turnover resulting from stress in the work environment• Fear of asking for help• Loss of trust by patients and their families in the clinical care they are receivingEveryone has a bad day from time to time, and there are times when the pressures in the work environment contribute to isolated incidents of bad behavior.Repeated events, or patterns of unprofessional behavior must be addressed as a part of culture of safety.
9Patterns of Unprofessional Conduct A 2008 statement by the Center for American Nurses defines:Horizontal (lateral) violence as “the physical, verbal, or emotional abuse of a fellow employee”Bullying as “an offensive abusive, intimidating, malicious or insulting behavior, or abuse of power conducted by an individual or group against others, which makes the recipient feel upset, threatened, humiliated or vulnerable, which undermines their self-confidence and which may cause them to suffer stress.”
10Two Approaches: Enforcement & Engagement Actions to promote professional conduct occur at both the individual and system levels.Two approaches for promoting professional conduct are:Enforcement (power based)Engagement (collaborative)TEACHING POINTS:Actions to promote professional conduct occur at both the individual and system levels.There are two approaches for promoting professional conduct:• Enforcement (power-based)• Engagement (collaborative)Enforcement is the use of power to address lapses in professional conduct through discipline and other authority interventions.Enforcement includes options such as:• Use of chain of command• Use of investigations• Use of peer review• Use of progressive disciplinary processes such as reprimands, warnings, suspension, and terminationEnforcement relies on an established code of conduct and written policies for responding to infractions of that code.Organizations are required by The Joint Commission to have a code of conduct that outlines acceptable and unacceptable behaviors. Organizations must also have a process for addressing lapses in professional conduct.Engagement is a collaborative approach that seeks to correct the behavior while preserving or restoring trust among team members. It provides an opportunity for the team to resolve the issues directly and provides an opportunity for improving engagement skills. Engagement provides an opportunity for the team to resolve theissues directly and provides an opportunity for improving engagement skills.Engagement happens when the issues are dealt with directly by those involved in the incident rather than merely reporting the incident to someone else.Engagement involves a conversation rather than an investigation. Engagement is an approach that balances assertiveness and cooperativeness and makes use of constructive conflict behaviors.Knowing when to engage is a core conflict competency. It requires that you reflect on and become aware of your own conflict skills and hot buttons.Effective teams find ways of integrating both engagement and enforcement options. Developing an ability to engage effectively is a core competency for health professionals. Supporting engagement is a key role for leaders within the organization.
11Tiered Interventions Disciplinary action / termination NochangeDisciplinary action / terminationPatternpersistsAuthority intervention/ PI planApparent patternAwareness interventionSingle unprofessional eventInformal conversation—“cup of coffee”TEACHING POINTS:Effective organizational procedures will outline tiered interventions that incorporate collaborative strategies before making use of progressive discipline or formal dispute resolution processes.Generally, initial responses to lapses in professional conduct should be non-adversarial and focus on building trust, accountable performance, and an opportunity to self-correct and make amends.The Hickson pyramid demonstrates a model for using a tiered approach to unprofessional conduct.The vast majority of health professionals have no behavior problems or only an occasional event that is typically related to fatigue or other environmental stressors. For rare events, it is best to have an informal “cup of coffee” conversation to provide feedback to the person. This conversation can be between peers, with a supervisor or with a mentor. Using the Connect & Correct techniques can be useful during these types of conversations.If there is a repeated pattern of disruptive behavior, it is necessary to have an “awareness intervention” conversation. The emphasis of this level of engagement is to bring to the person’s awareness the pattern of behavior and the impact it is having on the team and on patient care.Majority of professionals—no issuesHickson, 2007
12Tiered InterventionsVery often individuals are not aware of their behavior or the effect it is having on others.Receiving feedback from team members is a form of mutual support.Informal feedback from a trusted colleague is a good first step.Very often individuals are not aware of their behavior or the effect it is having on others and such a conversation is enough to bring about improvement. Documenting the conversation with a memo that indicates the conversation occurred and sharing it with the individual is a good idea.If behavior does not improve after an awareness intervention, the next level of engagement is an authority intervention and implementation of a performance improvement (PI) plan. This level of intervention is more formal and should be documented in detail. If the individual is not able to make progress on the PI plan, it may be necessary to move toward progressive discipline including suspension, termination or removal of privileges.
13Four Steps for Responding to Unprofessional Conduct Addressing instances of unprofessional behavior in order to improve patient safety is the job of all team members.Four Steps for Responding to Unprofessional Conduct:AssessAdopt a stanceConnect & CorrectEvaluateAssess the situation:What is the difficult situation? What are the risks to me and others? Do I need to be assertive, cooperative, or both?Adopt a stance: When to be assertive and when to be cooperative? What type of response are you getting from the other person?Connect and Correct: How do we connect with the person and correct the situation? Will focus on tools to do so for the rest of our time.Evaluate: Evaluate progress in your skills and abilities in responding, the outcome of your conversations—what changed?, next steps if any are required, and identify your support system
14Adopting a Stance: Examples Assertive, competitive: Imminent riskCUS—I’m concerned. I’m uncomfortable. This is a safety issue.Two-Challenge Rule—Assertively voicing a concern at least two times to ensure that it has been heard.Assertive, collaborative: Resistance, non-imminent situationConnect and correctConnect with PEARLACorrect with DESCCompetitive: Does the situation require a very immediate assertive approach? (crisis situations, imminent risk). In these situations the immediate outcome must be prioritized over individual relationships. Use the following tools:CUS—I’m concerned. I’m uncomfortable. This is a safety issue.Two-Challenge Rule—Assertively voicing a concern at least two times to ensure that it has been heard.These are good techniques to use to ensure that your concern is heard when there is an imminent risk to patient care. If you get resistance or if the situation is not emergent, you should consider using a more collaborative approach.Collaborative: Engaging effectively requires that you are both assertive and cooperative. Navigating levels of assertiveness and cooperativeness is a key skill that requires you pay attention to the type of response you are getting from the other person. If the situation allows you be assertive and cooperative, consider using the “yes, and” approach to invite the other person to work with you and acknowledge what they might need to do so. This reflects a concern for a solution and a concern for the ongoing relationship, and requires an open mindset in which you inquire about and acknowledge what is important to the other person before making recommendations or offering solutions.Making a Conscious Choice:Consciously choosing how to engage rather than defaulting to a habitual style takes practice and self reflection. If you tend to be assertive, you may need to work on how to be more open to other’s perceptions. If you tend to be very cooperative, you may need to work on how to be more direct and clear about what you need or want.
15Connect & CorrectUsing the two-stage collaborative process Connect & Correct:Improves the likelihood that the feedback will be receivedDoes not compromise the work relationshipSets the stage for productive problem solving.Have copies of the connect and correct tip sheet available to hand outUsing the two-stage collaborative process, Connect & Correct, improves the odds that the feedback will be received without compromising the relationship and it sets the stage for productive problem solving. Adding Connect to what they already know about using DESC for Correction…increases likelyMutual support is a key component of effective teams. Providing mutual support includes fair and respectful feedback that is directed toward improvement and that is considerate of the feelings of other team members. Connecting provides a space for the emotions to dissipate so that there can be a rational problem-solving conversation. It lessens defensiveness and creates trust.NOTE: See the Connect & Correct Tip Sheet
16Stage 1 Connect: PEARLA Understand first, explain later… To connect, use the following algorithm:PEARLAPresenceEmpathyAcknowledgementReflect/reframeListen openlyAsk questionsReference the PEARLA Tip sheet on the back of the connect and correct pageThe first stage, Connect, focuses on creating a connection with the other person and building trust. By creating a connection first you de-escalate the situation, develop trust with the person, gain deeper understanding of the situation, and demonstrate respect. Attempting to problem solve before creating a connection can result in resistance, defensiveness, or escalated behavior.Presence: To create connection, you must first focus on the situation that is occurring between you and the other person. Presence helps you let go of distractions and be ready to listen openly.Empathy: Putting yourself in another’s shoes and imagining what might be going on for them is a key element in creating connection. Setting aside your own concerns long enough to see what may be underlying the behaviors or words of another allows you to better understand their positions and also demonstrates respect.Acknowledging what is going on for the other person is a crucial step in helping them to calm down and helping them to hear what you have to say.Acknowledging what matters, particularly when someone is upset, takes practice but is a crucial step in helping them to calm down and helping them to hear what you have to say.Reflect: Reflecting back what you heard using neutral language is a good way to both check that you heard correctly and de-escalate the situation.Reframe: Reframing means to take a concept, idea, or statement and say it in a way that helps the person view the situation differently. It is a way of refocusing the conversation toward the issues and what matters to the person—and away from blame or rigid positions.Listening openly requires that you listen to the facts, listen to the emotions, notice the body language, and listen for the meaning behind the words. Listening openly gives you insight into what may be driving the disruptive behavior. It requires that you suspend judgment and postpone solutions until you have clearly heard the other person’s story. It takes practice to listen openly when someone is making accusations or exhibiting strong emotions that you are uncomfortable with. By listening more effectively, you can gain good information in a shorter period of time. Listening below the surface for what theperson is trying to communicate helps you to know what to say next!Ask clarifying questions to clarify the situation and show you are interested in what matters to the person speaking. Using questions to better understand the situation provides a framework for developing effective solutions. Clarifying questions are also a good way to help the person become aware of how they are behaving. Asking clarifying questions takes practice. They should focus onthe other person rather than focus on fact-gathering or solutions.NOTE: See the PEARLA Tip Sheet
17Acknowledgment: Example 1 Nurse 1: Are you kidding me? I can’t believe this is the assignment you gave me! How am I supposed to take care of this guy who is bleeding and get my other patient ready for OR? How might Nurse 2 respond? Nurse 2: It seems overwhelming. What would help you right now so you can feel more comfortable caring for these two patients?
18Acknowledgment: Example 2 Nurse 1: I can’t believe you went ahead and left the clinic early yesterday! You really left us in a bind trying to get all of the patients prepared before the provider saw them. How might Nurse 2 respond?Nurse 2: I can see that my absence caused some difficulty.
19Reflect and Reframe: Example Person 1: It figures that the new person was involved in this medication error. It seems like every time something bad happens, he’s had something to do with it. How might Person 2 respond?Person 2:Rarely is one person to blame for everything that goes wrong. What do you think contributed to this particular situation?OR—So you’re saying you’re concerned about medication safety on this unit. What concerns you most?It’s hard to say what happened since he’s not here. Have you spoken to him directly about your concerns?
20Sample Clarifying Questions Tell me—what would help you right now?Where would be a better place to have this conversation?What does respect look like to you?What is going on that has you so upset?What do you think is the impact of your behavior?What do you hope to accomplish by talking this way?How is this helping you get what you need?
21Acknowledgement and Clarifying: Example 2 Nurse 1: I can’t believe you went ahead and left the clinic early yesterday! You really left us in a bind trying to get all of the patients prepared before the provider saw them. How might Nurse 2 respond?Nurse 2: I can see that my absence caused some difficulty (acknowledgement). We had discussed that I needed to leave early. How could we better prepare for a staff absence the next time (clarifying question)?
22Stage 2: CorrectUsing the TeamSTEPPS® DESC script is one way to seek correction of unprofessional behaviors.DESC:Describe the specific behaviorExpress how it makes you feel and what your concerns areSuggest alternatives and seek agreementClarify the consequences in terms of the impact on goals of the teamHave copies of the connect and correct tip sheet available to hand outHow does connecting first increase likelihood of success with correction?In Stage 2, you seek correction of the behavior by describing it, describing the impact, suggesting an alternative, and seeking agreement.To address lapses in professional conduct, it is important to remember that you are solving two problems:1. Restoring trust among team members2. Problem solving to correct the behaviorYou may decide to Correct without using the Connect techniques. This could work if there is a high level of trust between you and the individual or if it is a one-time incident and not a pattern of unprofessional conduct.There are important things to consider when using the DESC script:• Timing matters—choose the right time and location for your conversation• Keep in mind that the goal is to improve patient care, not to prove who is right and who is wrong• Speak from your personal experience rather than blame the other person• Focus on what you want to be different• Be specific and focus only on the current event, don’t overstate your concerns or use language like, “You always…” or “Everybody thinks you…”• Be attentive, respectful and open to what the other person has to say during your conversation. Model the type of behavior you hope to see in them.
23Stage 2: DESC Script Sample Describe: When you don’t answer pages or return phone calls …Explain: I am worried that I won’t be able to give safe care to the patient.Seek alternatives and agreement: I need for you to respond or have someone call for you if you are busy. Is that something you could try?Clarify Consequences: If not, it is going to have an impact on patient care and how much I can trust you.
24Practice Exercise: Using Connect & Correct You will be assigned one of the video scenarios to work withUsing the Connect (PEARLA) and Correct (DESC) techniques, develop a response to one of the individuals who is behaving unprofessionallyIn pairs, practice your response with a partnerThree scenarios are:Consider starting at 4:03 with the last two scenariosRetaliation scenario (00:01 to 4:02)Queen is Jobe’s supervisorJobe is the nurse requesting a transferHow should Jobe handle this situation with Queen?Bullying scenario (4:03 to 5:40)Melanie is the frustrated nurseMelissa is Melanie’s and Donna’s supervisorDonna is the problem nurseHow should Melissa handle this situation with Donna?Exclusion of new nurse scenario (5:40 to STOP at 6:57)New nurse (didn’t give a name)Michelle is problem nurse on rightJudy is problem nurse on leftHow should the new nurse handle this situation with Michelle and Judy?
25Exercise DebriefWhich of the two stages, Connect or Correct, feels easier?What makes it easier for you?Which of the skills would you like to be better at?What steps could you take to improve your skills?What could help you feel more comfortable using these in your daily work?
26Practice Exercise: Using Connect & Correct Think of a conflict scenario you have recently or commonly face at work, or one you need to address. In pairs, practice your response with a partner:Connect first using PEARLADebrief with groupCorrect using DESCGoal: develop a response to one of the individuals who is behaving unprofessionallyAsk providers to consider scenarios in urgent care, triage, and the floor.Connect/listen with staff to avoid conflict …Connect first, debrief, then correct
27High-Conflict Personalities High-conflict people are those individuals who have a life-long pattern of high-conflict behavior and who typically exhibit long- term traits of those with personality disorders and who engage in ongoing high-conflict thinking.Eddy, W. It’s All Your Fault: 12 Tips for Managing People Who Blame Others for Everything. (2008). Janis Publications.Because addressing disruptive behavior is uncomfortable, it is easy to think that all disruptive people have personality disorders. They do not. The majority of individuals who exhibit disruptive behavior are simply behaving inappropriately and do not have personality disorders. A small percentage of individuals, however, have ongoing conflict patterns that have been present throughout their life and that will not be amenable to feedback or corrective actions.High-conflict people create a great deal of stress for others in the work environment and take a great deal of energy to manage. Leaders must evaluate whether the effort to constantly address unprofessional behaviors and set limits with these individuals is worth the value that the individual provides to the team or organization.High conflict personalities often exhibit the following characteristics:• Are high achievers• Seek positions of power or authority• Misinterpret the actions of others• Are unable to accept negative feedback or corrective action• Are highly emotional or fearful• Are unable to see their contribution to a situation and seek to blame others for everything• Exhibit self-sabotaging behaviors• Have trouble empathizing with others• Expend significant energy defending themselves or obtaining advocates for their point of view• Are rigid with fixed mindsets about their beliefs and positions
28Destructive Conflict Behaviors For high-conflict people, the ability to self-reflect and self-correct is limited or nonexistent.They default to destructive conflict behaviors and they seem unable to make different choices.Destructive conflict behaviors are those behaviors that escalate or perpetuate conflict. Decreasing the use of destructive conflict behaviors through self-awareness and self-correction is a natural part of developing conflict competency.Destructive conflict behaviors include:• All or nothing thinking (black and white)• Defensive responses to feedback• Simplifying complex situations• Failure to take into account the perspectives of others• Attributing mal-intent to others and feeling victimized by their actions• With me or against me thinking• Retaliation and targeting of individuals• Projection• Narrow understanding of the situation• Desire to prove they are right at all costs• Splitting behaviors- getting others to take sidesInitial reactions by most people who are stressed, such as when receiving negative feedback, are seldom the same as their final response. It requires several attempts and sometimes multiple conversations to break through defensive postures. With high conflict people, their initial reaction seldom changes except to become more rigid and fearful.
29Tips for Managing High-Conflict People Use empathy and create connection repeatedly.Acknowledge their fears and emotions as real to them without agreeing with their conclusions or beliefs.Listen openly to their concerns without being taken in by misinformation or inaccurate conclusions.Consistently set clear limits on behavior and create structures to contain their impact on others.Managing lapses in professional conduct with high-conflict personalities takes advanced skills and persistent effort.Due to the inability of high-conflict people to receive feedback or recognize their contribution to a situation, the Connect & Correct technique outlined in Module 2 is only a beginning approach for dealing with them. It is likely you will need help from experts to assist you in managing these individuals.
30Tips for Managing High-Conflict People Don’t fall for the drama and don’t adopt high-conflict behavior yourselfRecognize that a single intervention will not be sufficient—they will require continued interventions and limit settingDo not take their attacks personally or feel you are to blame for the situationIt is essential that leaders find ways of supporting those who are impacted by high-conflict people, particularly those with less power or authority.The impact of high-conflict people in the work environment can be devastating, particularly for those who are the target of their dysfunctional behavior. In already stressful environments, the stress of a high-conflict colleague can be overwhelming for many people.Supporting Others is critical. Address the impact by letting others know that it is not their fault and that supervisors are aware of the issue—demonstrate receptivity to their concerns or requests. These are important steps leaders must take.Providing referral options for those who have been targeted by high-conflict people is an important form of mutual support. Sometimes the process for remediating or removing high-conflict individuals takes a period of time, and this can be demoralizing and occasionally harmful to those who are subject to the behaviors. Leaders may need to make interim changes to protect the individual who may be targeted and protect others from retaliatory behavior by the high-conflict individual.
31SummaryProfessional conduct is consistent with your organization’s mission, vision, valuesKnow when to enforce and when to engage using connect and correctManage the high conflict personality; DON’T let them manage you