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Published in CenterView on August 27, 2012

UMMC leadership promotes respectful culture of professionalism

By Matt Westerfield

Dr. Jan Cooper remembers starting her career as a nurse many years ago at a Florida hospital and how the staff was instructed to stand whenever a physician came to the nurses’ station.

“You gave them your chairs; you served them, essentially,” she said.

But she also remembers a well-respected surgeon who implored the nurses to sit when he would come by. She said the nurses couldn’t help but return the respect he showed them.

 “I’ll never forget how I felt when he behaved like that,” said Cooper, associate professor of nursing and director of the Clinical Simulation Center. “It made you want to be a better person.”

“Because I’ve had my share of physicians yelling at me and carrying on, throwing things and everything else. I’ve been on both sides of it,” Cooper said.

Disruptive and disrespectful behavior, as well as outright bullying, has long been endemic to health-care environments. But in recent years the phenomenon has attracted increasing attention as mounting evidence reveals its impact on patient care.

Administrators, faculty and staff at the University of Mississippi Medical Center have worked to stay ahead of the issue by promoting a culture of professionalism and mutual respect among all groups.

“Across the board, it’s recognized as an important issue based on a growing literature of disruptive physician behavior impacting nurse retention and patient outcomes,” said Dr. Ralph Didlake, professor of surgery and medicine. He explained that in the past decade, medical education accrediting agencies have adopted professionalism as a core standard.

“On the clinical side, the Joint Commission in 2009 imposed new standards explicitly designed to control unprofessional or disruptive physician behavior,” he said.

Experts say unprofessional behavior manifests in different forms in the workplace, such as emotional outbursts, the demeaning treatment of subordinates and harassment. Didlake says conflicts that most often impact patients are those between physicians and nurses.

Anita East, nurse manager in the Eli Manning Children’s Clinics, says she has seen a major culture change in her 10 years as a nurse.

“When I first started, it was not uncommon to see certain physicians come in and jump up and down in the middle of the ICU because they were upset about something, just cursing and ranting and raving,” she said. “And nobody did anything about it.

“Within the last few years, it’s really changed to the point where it’s just not tolerated.”

“Most of the time, these situations occur over disagreements about how to treat a patient,” said Dr. Rishi Roy, general surgery resident. “I’ve seen disagreements that were handled unprofessionally, but that’s going to happen in a health-care setting. But the people in charge have done a good job of addressing those situations effectively to correct that behavior.”

Within the nursing profession, an adage warns: “nurses eat their young.” Bullying among nurses has been acknowledged for decades, but its acceptance is dwindling.

Janet Harris, interim CEO of University Hospitals, along with other nurses, points to an outdated mindset where young nurses had to “earn their stripes.”

“I think we do still have some residual thought that you have to pay your dues,” Harris said. “Over time, I believe that this has improved significantly.

“Over the past several years we have developed a zero-tolerance policy on this type of behavior.” Reporting such behavior is a key, she said.

“Fear of retaliation still exists,” Harris said. “My hope would be that every person felt comfortable in reporting such in a timely manner.”

Cooper, who has been a faculty member for 13 years, completed her Ph.D. dissertation five years ago, which investigated nurse bullying. She surveyed 660 senior nursing students to see whether they experienced mistreatment during their clinical training.

“I expected to see some bullying from physicians,” she said. “However, the students weren’t really having contact with physicians, so they didn’t really see them as a threat.”

Instead, she found bullying behavior was attributed to other nursing students.

“One of my questions was, does bullying start in nursing school? My answer was no. Those are behaviors students bring with them — it was already a part of their behavior.”

Medical students are not immune from bullying behavior or intimidation, either. For instance, last year an AAMC medical student graduation questionnaire showed 17 percent of students who responded said they had been mistreated.

“That’s an interesting dynamic, because the faculty member plays two roles as an educator and as a physician, so there are two sets of ethical obligations, Didlake said. “Sometimes those obligations conflict. But in any complex dynamic, it comes down to communication.”

Two years ago, Didlake developed a Quality Enhancement Plan (QEP) for the campus, emphasizing ethics and professionalism.

“UMMC has made a significant commitment through the QEP to imbed these ethical standards into the curricula of all the schools,” he said.

As the Medical Center moves toward a team-based approach to patient care, Didlake says interprofessional training for future professionals will help cultivate an earlier foundation for professional values. In fact, the Schools of Medicine and Nursing have already initiated joint simulation training exercises.

Next month, Cooper will host the second interprofessional education session, combining M2s and junior nursing students in a clinical simulation to practice communicating across disciplines. She said feedback from the first pilot session last fall was extremely positive.

Michael Estes, chief human resources officer, said professionalism and mutual respect are central to the organization’s espoused values, mission and vision statements.

“Being respectful doesn’t mean that you can’t disagree,” he said. “To the contrary, respectful and professional debate of issues oftentimes leads to the best answers.”

When legitimate disagreements do occur, Estes said employees should first discuss concerns with their immediate supervisor.

“The vast majority of issues are typically resolved at that level,” he said. “But in those instances where they can’t be, the HR employee relations team stands ready to assist.”