Background

 Many years ago I wrote a series of articles highlighting the negative impact of disruptive physician behaviors on nurse satisfaction, morale, and clinical performance. Disruptive behaviors include harassment, verbal abuse, bullying, physical intimidation, disrespect, and non- compliance with performance expectations, one of the key messages was the deleterious impact these types of behaviors can have on communication efficiency adversely affecting staff performance and its potential for compromising patient outcomes of care. Since that time there have been a number of new reports on workplace incivility and the negative consequences of bullying and harassment on nurse attitudes and performance. In addition to disruptive nurse-physician relationships there are a number of other forces that can have a detrimental effect on nurse well-being [1-6]. One is the growing recognition of the ill effects of disruptive nurse to nurse interactions. Some have described this condition as “horizontal hostility” to highlight the confrontational relationships between staff nurses and their supervisors. These problems are further intensified by the increasing complexities and pressures in today’s health care environment which have added a new level of stress and burnout affecting all health care providers which is taking its toll on staff morale and performance. It is crucial for us to recognize the importance of a well-functioning, engaged, collaborative health care team and its role in providing best patient care. Compassionate nursing care is a key part of this process. In this regard it is essential that the organizations in which our nurses, physicians, and other staff members are affiliated with recognize the significance of how individual feelings, attitudes, and behaviors can affect health care delivery and take pro-active measures to help staff thrive and succeed in their jobs [7-10].

Factors Affecting Attitudes and Behaviors

 Before addressing strategies to enhance positive attitudes and behaviors in health care personnel it is important to recognize the key underlying factors that influence an individual’s thoughts and reactions attitudes of individuals are affected by a number of different factors which I’ll classify as either Internal or External influencers (Table 1).

 Internal forces include age (generation), gender, sexual orientation, culture and ethnicity, religious beliefs, geography, and life experiences all of which mold an individual’s personality that shapes their values, beliefs, subconscious biases, thoughts, and behaviors. These are deep seated factors and require a significant change in mind set and a willingness to modify. Specific strategies will be discussed in the next section. External forces include the training environment, the healthcare environment, the work environment, and other relevant adult life experiences that influence one’s state of mind (mood) and reactions. The externals factors are somewhat easier to modify than the more ingrained internal factors and will be discussed in more detail in the following sections.

Table 1: Factors Affecting Attitudes and Behaviors.

 Consequences of Inappropriate Attitudes and Behaviors

 We need to recognize the downstream effect of disruptive care. Healthcare is a complex system that requires effective commitment, communication, and collaboration between all involved healthcare providers to assure best patient outcomes across the entire spectrum of care. Significant changes in today’s health care environment have dramatically affected the way we provide patient care. Medical breakthroughs, the introduction of new technologies, Health Care Reform, and a growing emphasis on performance accountability and cost/care efficiency have added a new level of intensity to health care delivery that has had a significant impact on changing the roles, responsibilities, and incentives for health care providers.

 The current Coronavirus epidemic has taken an additional toll as front-line nurses are concerned about access, availability, safety, and organizational support. More than ever is the importance of effective teamwork, communication, and collaboration as essential ingredients to get the job done and prevent any gaps in health care delivery. Many studies have documented the poor results of dysfunctional care Most of these inefficiencies are a result of inappropriate human interactions and not system failure. On the other side, there are many studies that have documented the positive results of well-coordinated care. These studies demonstrate a direct correlation between a happy, satisfied, engaged health care team and positive patient outcomes. Maintaining the well-being of our health care workforce needs to be a major priority [10-15].

Recommendations

Table 2 lists a number of different strategies for improvement. While the major focus will be on addressing the importance of attitudes and behaviors of individuals, it is equally important to address the underlying organizational factors that impact the healthcare work environment. The first essential is to raise awareness as to the importance of staff morale and its impact on patient care. These feelings can be assessed through a number of different survey tools and/ or by gaining insight through either formal or informal staff input. Listen, be sensitive, react, and respond to what they have to say. There is a direct link between staff attitudes and behaviors and organizational culture. Those organizations that have a strong leadership commitment to staff well-being and developing a positive work environment do the best in fostering high staff satisfaction and engagement. As part of this process there needs to be a policy in place that defines and supports appropriate behaviors with specific criteria that outlines how non-professional disruptive behaviors will be addressed to protect staff well-being [16-18].  The next area is to provide appropriate education and training. In regard to the internal factors there are many different types of training that can be offered which can be tapered to meet the organization’s primary needs. One of the best courses is training in Emotional Intelligence. These courses are designed to give individuals a better understanding of who they are, what molds their thoughts, perceptions, and subconscious biases, and provide insight as how they can more effectively interact with other individuals in an effort to improve overall work relationships. Other training programs to consider are Diversity training, Cultural competency training, Sensitivity training, Conflict/ anger management training, and training to improve overall communication, team collaboration, and customer satisfaction skills. In regard to the external factors, we can address some of the training issues. For physicians, training programs are often compared to a high stress fraternity hazing process which leads to low self- esteem and the development a strong, independent, autonomous behaviors as a way of survival [19].  The focus is on building knowledge and developing technical expertise and not developing personal skills that enhance collaborative team relationships. Many medical schools are now recognizing the importance of developing personal relationship skills and have added communication and team collaboration courses to their core curriculum. In regard to the healthcare environment, we can’t stop the introduction of new technologies or the impact of Health Care Reform, but we can provide support and empathy for our providers by helping them adjust to the pressures of today’s health care environment. One strategy is to provide logistical support. Be sensitive to staff concerns about time, capacity, and non-clinical responsibilities. Be open to readjusting their schedules and productivity demands. Provide additional clerical support to help with non-clinical duties. Use dedicated data specialists or scribes to help with electronic medical record entry and documentation. From a clinical perspective utilize paramedical support staff to handle some of the more routine medical matters to free up nurses and physicians to concentrate on more complex medical matters [20].

Table 2: Recommendations.

 From a work environment perspective I already addressed the importance of addressing disruptive nurse and physician unprofessional behaviors. As an extension of this problem is the more global issue of workplace incivility [5,6,21]. Forms of incivility include rude, abusive, harassing, passive- aggressive, disrespectful behaviors that can jeopardize patient care. Organizations need to address these types of issues in an effort to maintain a positive workplace environment. Staff well-being needs to be set as a major priority. One of the most important strategies is to provide programs that can help our providers better adjust to the pressures of clinical practice. Recent studies have documented that more than 50% of providers suffer from high stress and burnout which has adversely affected their thoughts about clinical practice. Organizations need to recognize the impact of stress and burnout and provide the necessary assistance to help our providers succeed. One generic approach is to offer courses in stress management, mindfulness, and resiliency training which provide tools to help individuals better cope with their ordeal [22-24]. On a more individualized level, approaches might include encouraging informal one on one or peer group discussions, providing dedicated mentors or coaches, enhancing the role of Wellness Committees, and/or utilizing the services of available Employee Assistance Programs. Some individuals may require more formal behavioral counseling. In addition to providing tools to better deal with the stress of practice, we also need to encourage our providers to take better care of themselves through appropriate lifestyle modifications that support a healthy work- life balance. The focus is on the value of maintaining healthy habits and prioritizing the importance of rest and relaxation. In their chaotic over extended world we need to remind our providers about how important the work is that they do. We need to re-establish the pride and joy of patient care as an inspiration and motivation to continue to move forward. When providers are happy we see improved staff and patient satisfaction which leads to better outcomes of care [25-29]. We need to keep our providers engaged. One of the consequences of a stressful or hostile work environment is cynicism and withdrawal. Detachment leads to ineffective care. To keep our providers engaged we need to allow them input as to what they’re feeling, involve them in the resolution process, and apply standards to support a positive productive work environment. As a final recommendation we need to make an extra effort to show respect for our health care providers. Make an extra effort to recognize and thank them for what they do [30-32].

 Conclusions

Health care is a complex enterprise that requires efficient coordination and collaboration between all members of the health care team. When healthcare providers become overextended, overly stressed, or otherwise demoralized, it can affect attitudes and behaviors that can adversely impact the process and outcomes of care. Healthcare providers are a precious limited resource and we need to do everything that we can to help them succeed. We need to listen to their concerns and provide the appropriate resources to help them adapt to the pressures of clinical practice. One of the key issues is to keep them happy and motivated so they can remain engaged.

 Part of the solution rides on the shoulders of the organization to maintain a supportive culture and positive workplace environment which assures reinforcing appropriate behaviors and setting policies and procedures to address unprofessional behaviors. This is particularly important for nurses who play a pivotal role in the time they spend in care coordination and direct patient care. At the same time all members of the team need to recognize the importance of and take accountability for their own behaviors. They need to do their own self- assessment and be open and willing to accept advice on how they can adjust their behaviors accordingly in an effort to maximize positive outcomes of patient care. We need to cultivate internal champions to push this effort forward. Show staff the value of their efforts and thank them for what they do.

References

1.  Rosenstein AH. The impact of nurse-physician relationships on nurse satisfaction and retention (2002) American J Nurs 102: 26-34. https://doi.org/10.1097/00000446-200206000-00040 

2.  Rosenstein AH and Daniel OM. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians (2005) American J Nurs 105: 54-64. https://doi.org/10.1097/00000446-200501000-00025 

3.  Rosenstein AH and Daniel OM. Negative behavior and clinical outcomes (2005) Nurs Manage 36: 18-28.

4.  Rosenstein AH and Daniel OM. A survey of the impact of disruptive behaviors and communication defects on patient safety strategies for creating, sustaining, and improving a Culture of Safety Second Edition Joint Commission Resources 2017 The             Joint Commission Oak Brook, IL p.21-28

5.  Layne D, Anderson E and Henderson S. Examining the presence and sources of incivility within nursing (2019) J Nurs Management 27: 1505-1511. https://doi.org/10.1111/jonm.12836 

6.  https://www.beckershospitalreview.com/quality/nurses-work-environments-affect-patient-outcomes-study-finds.html 

7. Zhang X and Xiung L. Impact of nurse horizontal violence and coping strategies: a review (2019) Yanktze Med 3: 289-300. https://doi.org/10.4236/ym.2019.34028

8.  Backbamis L, Paul D, Smith H and Coustasse A. The burnout syndrome in hospital nurses (2019) Health Care Manage 38: 3-10. https://doi.org/10.1097/HCM.0000000000000243 

9.  Wan W. Health-care system causing rampant burnout among doctors, nurses (2019) The Washington Post 

10. Lai J, Simeng M, Wang Y and Zhongxiang C. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 (2020) JAMA 3: e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976 

11. Dang D, Bae SH, Karkwicz K and Kim M. Do clinician disruptive behaviors make an unsafe environment for patients? (2016) J Nurs Care Qual 31: 115-123.

      https://doi.org/10.1097/NCQ.0000000000000150 

12. Layne D, Nemeth L, Mueller M and Martin M. Negative behaviors among healthcare professionals: relationship with patient safety culture (2019) Health Care 7: 23 

     https://doi.org/10.3390/healthcare7010023 

13. https://www.aha.org/news/blog/2017-03-15-focusing-teamwork-and-communication-improve-patient-safety 

14. Guck T, Potthoff M, Walters R, Doll J, Michael A, et al. Improved outcomes associated with interprofessional collaborative practice (2019) Annals Fam Med 17: 82. 

     https://doi.org/10.1370/afm.2428 

15. Shanafelt T, Gorringe G, Menaker R, Storz K, Reeves D, et al. Impact of organizational leadership on physician burnout and satisfaction (2015) Mayo Clin Proc 90: 432-440. 

     https://doi.org/10.1016/j.mayocp.2015.01.012 

16. https://catalyst.nejm.org/organizational-culture-better-health-care/ 

17. Rosenstein A. Hospital administration response to physician stress and burnout (2019) Hospital Practice 47: 217-220. http://dx.doi.org/10.1080/21548331.2019.1688596 

18. Rosenstein A and Daniel OM. Addressing disruptive nurse- physician behaviors: developing programs and policies to improve relationships that improve outcomes of care (2005) Harvard Health Policy Rev 7: 86-97.

19. Rosenstein A and Stark D. Emotional intelligence: a critical tool to understand and improve behaviors that impact patient care (2015) J Psychol Clin Psyc 2: 1-4 

     http://dx.doi.org/10.15406/jpcpy.2015.02.00066 

20. Rosenstein, A. Addressing physician stress and burnout: impact, implications, and what we need to do (2017) J Psychol Clin Pssyc 7: 1-3. https://doi.org/10.15406/jpcpy.2017.07.00446 

21. https://www.nursingcenter.com/getattachment/Clinical-Resources/nursing-pocket-cards/Workplace-Incivility/Workplace-Incivility.pdf.aspx 

22. Shanafelt T, West C, Sinsky C, Trockel M, Tutty M, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017 (2019) Mayo Clin Proc 94: 1681-1694.

     https://doi.org/10.1016/j.mayocp.2018.10.023 

23. https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#3 

24. Bakhamis L, Paul D, Smith H and Coustasse A. Still an epidemic: the burnout syndrome in hospital registered nurses (2019) Health Care Manager 38: 3-10.

     https://doi.org/10.1097/hcm.0000000000000243 

25. Shanafelt T, Trockel M, Ripp J, Murphy LM, Sandborg C, et al. Building a program on well-being: key design considerations to meet the unique needs of each organization (2019) Acad Med 94: 156-151.                                                      

      https://doi.org/10.1097/ACM.0000000000002415 

26. Dugal L. Re-enchanting medicine (2017) JAMA Intern Med 177: 1075-1076. https://doi.org/10.1001/jamainternmed.2017.2413 

27. Linzer L, Sinsky C, Poplau S, Brown R, Williams E, et al. Joy in medical practice: clinician satisfaction in the healthy workplace trial (2017) Health Affairs 36: 1808-1814. 

     https://doi.org/10.1377/hlthaff.2017.0790 

28.  https://hbr.org/2019/07/making-joy-a-priority-at-work 

29.  https://nurse.org/articles/nursing-satisfaction-patient-results/ 

30.  https://americannursetoday.com/physician-nurse-engagement-concept-collaboration/ 

31.  Sokol-Hessner L, Folcarelli P, Annas C, Brown S, Leonor Fernandez, et al. A roadmap for advancing the practice of respect in healthcare: the results of an interdisciplinary modified delphi consensus survey (2018) The Joint Commission J Quality Safety 44: 463-476. https://doi.org/10.1016/j.jcjq.2018.02.003 

32.  https://hbr.org/2020/05/in-times-of-crisis-a-little-thanks-goes-a-long-way 

^*Corresponding author

Keywords

Patient care, Nursing, Behavior