1. Daniel O’Connell, PhD Seattle, WA 98119 danoconn@uw.edu 206 282-1007

2. The Problem: Behaviors such as condescension (verbal, tone, body), disparaging, intimidating, patronizing, angry outbursts, reluctance or refusal to answer questions, unwillingness to cooperate/collaborate or provide reasonable help, threatening body language and physical contact, unwillingness to participate in resolution of an interpersonal problem The emotional impact of abusiveness demoralizes people who feel attacked, devalued, or humiliated as well as the witnesses.

3. Prevalence and Impact Verbal abuse reported by 80-97% of nurses by doctors or other nurses/staff. 16% of nursing turnover was found to be associated with verbal abuse. Physicians have been recognized as the primary perpetrators of verbal abuse; however they are not the only source. Patients, families, peers, supervisors and other colleagues have demonstrated abusive behaviors as well. “Relational aggression” a particular problem for women (cf Cheryl Dellasega 2005 Mean Girls Grown Up) Intimidating, abusive behaviors impact patient safety. (49%) of all 2000 respondents reported that their experiences with intimidation had altered the way they handle clarifications or questions about medication orders increasing the risk of incorrect interpretation and occurrences of medication errors. Only 39% felt that their organization dealt effectively with intimidating behavior. (Intimidation. Institute for Safe Medication Practices March, 2004) Multiple studies have shown that the negative effect of abuse on productivity, morale, nursing care delivery, workload and errors. Research confirms evidence-based prevention strategies as well as enforceable zero-tolerance policies can significantly reduce the occurrence

4. Code of Conduct Treat all persons with respect, courtesy, caring, dignity and a sense of fairness Communicate openly, respectfully and directly with team members… to promote mutual trust and understanding Encourage, support and respect the right and responsibility of al individuals to assert themselves to ensure patient safety and the quality of care

5. BMC Medical Dental Staff Policy Regarding Unprofessional Relationships Boston Medical Center (“BMC”) is committed to having a work environment that is professional, collegial, supportive of all personnel, and conducive to providing optimum patient care

6. BMC Policy All members of the Medical and Dental Staff (“Medical Staff”) are expected to treat one another and all other individuals of the BMC community with respect and dignity. 2. BMC is committed to assuring that the workplace environment at the BMC is a positive and supportive one and without disruptive, intimidating, or abusive behavior. Harassment of any kind, conduct that is disrespectful and/or abusive, and unprofessional relationships are not acceptable behavior at BMC. 3. BMC takes seriously any and all allegations of unprofessional relationships and disrespectful and/or abusive conduct seriously, and will respond promptly to complaints. When an allegation has been made that undesirable behavior has occurred, BMC will act promptly to investigate the alleged conduct and address behaviors that are found to be unprofessional or disrespectful. Moreover, retaliation of any kind will not be tolerated against an individual who has made a complaint or allegation under this policy or who has participated in an investigation of said complaint or allegation

7. Courageous Conversations by Colleagues and Supervisors Courage of convictions We need to do better than this Courage of role It is my role to raise these concerns Courage in the face of conflict I/we are not so fragile that we cannot tolerate some conflict if we are skillful in how we approach it Courage of persistence I can come back again and again if needed until we get this right I can/we can ask for help to get this resolved

8. Having the Courageous Conversation Good resources: Crucial Conversations by K. Patterson et al 2002 Crucial Confrontations by K. Patterson et al 2004 Difficult Conversations by D. Stone et al Fierce Conversations by Susan Scott 2004

9. Key perspectives in promoting civility and collegiality Teamwork requires investment, civility and collegiality “Both/and” replaces “Either/or” Empathy is essential for real civility and collegiality “Contribution” replaces blame Separate the people from the problem The “reasonable person” test Describe behavior and impact, not theorized intentions Yet consider psych/sa contribution in light of behavior People are pre-disposed to certain kinds of problems So monitor and maintain to prevent or manage relapse Zero tolerance does not always mean discipline “Bully effect” means help is reasonable often necessary

10. Bully Effect Bullying behavior is usually directed at someone towards whom one feels dome impunity. Someone for whom respect is already diminished and from whom one does not fear retaliation. That means that the receiver of bullying will often not have the clout to confront the bully effectively enough to end the behavior. So… be quick to often assistance through coaching, facilitation, mediation

11. Empathy with Clarity I want to help you be successful You are a valuable member of the department and I want to help you have the constructive impact you intend and not the destructive impact that your behavior sometimes causes

12. Zero tolerance does not require capital punishment Create pathways to recovery whenever possible Be creative about how recovery could occur. 4 Steps of Apology Acknowledge wrong and its impact Express remorse/regret Explain how it occurred and steps to prevent recurrence Offer restitution

13. Reasonable Person Test Ultimately, one must make a judgment Was this behavior such that a “reasonable person” would have it offensive, disrespectful, disruptive to the safe and effective conduct of teaching, research, clinical work and collegiality

14. Focus on Behavior and Its Impact Avoid getting stuck in Intentions Most your people will defend their intentions (because it reflects on their identity) Focus on impact When you behave like this_______________, I am hearing/observing/learning that is has these unwanted impacts.____________________. Because I do not think that is your intention, I want to help you have the constructive impact you are intending. Let’s talk about how that could be achieved.

15. Contribution replaces Blame The way in which you______________ contributes to others feeling__________which unfortunately has the consequence at times of ______________.

16. Separate the People form the Problem You are not the problem. He/She/They are not the problem. The Problem is the problem. So let’s talk about the problem that we are seeing.

17. Both/And replaces Either/Or Both high quality clinical direction, teaching and research rigor AND doing it in a way, in a demeanor with a clear intention of building and maintaining respect, collegiately, and attention to the emotional impact on others

18. Progressive Intensity/Discipline “Diagnosis and Treatment” progresses through levels of increasing intensity appropriate to resolving the problem Encourage conversation by individuals involved “Supervisor” to clarify/investigate, affirm expectations, facilitate and/or obtain resources Supervisor takes on issue directly within progressive discipline structure focusing on promoting resolution Process is aimed at getting and maintaining individual’s attention on problem resolution, creating/offering plans to understand and resolve problem and clarifying consequences of unwillingness or inability to behavior appropriately

19. Expect Slips and be Ready for Relapse Behavior issues often emerge from underlying vulnerabilities that predispose their happening in the first place and recurring in the future. That means that slips into misbehavior need not be seen as total failures. They may not call for draconian action. They do call for intervention. So… put in place a “treatment and monitoring plan” that lasts longer (1+ years), continue to gather data about behavior, have regular feedback meetings and do all this transparently