Frontline health care workers — including nurses, doctors, residents, security guards, orderlies, and cleaning staff — have borne the brunt of a population made angrier and more frustrated by the pandemic. This should be disconcerting for everyone given the potential consequences. Research shows that exposure to rudeness has been shown to negatively impact medical teams’ diagnoses and procedural performance. The authors present six ways to reduce incivility and bad behavior in health care settings based on their experience and research. Safety and communication training, behavioral nudges, and trauma-informed care can all help align patients’ and their caregivers’ expectations and keep both groups safe.
Over the course of the pandemic, the outward, active support and gratitude for health care providers has waned and, in many cases, been replaced by distrust and increasing aggression. Refusals to wear masks, frustration with visitation policies, and racial profiling feel amplified in these times of crisis. Frontline staff, including nurses, doctors, residents, security guards, orderlies, and cleaning staff have been feeling the effects.
The American Psychiatric Association’s recent Stress in America report found that eight out of 10 Americans said the pandemic has created significant stress in their life. This stress and the growing emotional toll may fuel what our hospital and so many other health care providers are seeing. We’re bearing the brunt of a much angrier, more frustrated, and weary bunch. Patients, their families, and other caregivers have little patience or tolerance, and their short fuses can explode on the very people trying to care for them. For example, shortly after visitation was restricted in April 2020 for safety, Cleveland Clinic saw the frequency of threatening and violent behavior increase, and the complaint rate jumped from 1.19 to 2.63 complaints per 1,000 patients.
This should be disconcerting for everyone given the potential consequences. Christine’s research has shown that we falter when we witness rudeness and other bad behavior. It interferes with our working memory and decreases our performance. Disruptions can be catastrophic, as exposure to rudeness has been shown to negatively impact medical teams’ diagnoses and procedural performance. Physicians exposed to rudeness tend to get stuck on an initial incorrect diagnosis, leading to medical errors. All of this could ultimately increase mortality.
For example, a doctor from another health care system described to us how on one occasion, a supervising doctor belittled a medical team on duty. Soon after, the team accidentally administered the wrong treatment to a patient, having failed to read vital information that had been right there on the chart. As a result, the patient died.
Unfortunately, this wasn’t an isolated incident. In a study of more than 4,500 doctors and nurses, 71% saw a link between disruptive behavior (defined as “abusive personal conduct,” including condescending, insulting, or rude behavior) and medical errors, and 27% connected such behavior to actual deaths among their patients.
Health care workers may also be particularly vulnerable to the stress of the pandemic. According to a recent survey conducted by the nonprofit Mental Health America, 93% of health care workers were experiencing stress, 86% reported experiencing anxiety, 77% reported frustration, 76% reported exhaustion and burnout, and 75% said they were overwhelmed.
To protect both patients and frontline workers, health care leaders must do what they can to reduce incivility and bad behavior. We’ve arrived at the following steps based on our research.
Implement Safety Training
Health care workers are several times more likely to experience workplace violence than those in other sectors, and global violence against them has gotten worse in the pandemic. Cleveland Clinic has long made efforts in this space, led by its workplace violence committee, including launching online reporting of incidents, a Speak Up Award, visible signage on units indicating that violence will not be tolerated, and making programs like Non-Abusive Psychological and Physical Intervention (NAPPI) training available for all caregivers.
Widely used in health care, the NAPPI training program focuses on de-escalation, self-protection, and restraint training. After participating in the program, Michigan Medicine caregivers reported feeling more empowered and confident in their own abilities in identifying and handling agitated patients and family members.
At Cleveland Clinic, we also team with police — who confiscated 30,000 weapons in Northeast Ohio Cleveland Clinic facilities in 2018 alone — and do everything we can to mitigate potential violence. But training on how to handle behavior continues to be a crucial way to keep staff safe. Security teams run active shooter drills and walk caregivers through how they might exit, what they could use for protection, steps for patient safety, and mitigation strategies, as well as conducting alarm testing. Patients who threaten or hurt caregivers (or themselves) are identified in the electronic health record with suggested safety mechanisms.
Nudge Patients and Caregivers
Nudges — short, personalized recommendations with a clear call-to-action — have been useful in a variety of settings, including health care. Stefanie Tignor, head of Data Science and Insights at Humu, a company specializing in people science, told us that they’ve found that across industries, people who receive nudges are 53% more likely to take action.
Recently, some hospitals have tried to nudge patients’ and caregivers’ behavior. At the Indiana University Health system, visitors are greeted by a sign that reads, “Please take responsibility for the energy you bring into this space …your behaviors matter. Our patients and caregivers matter,” as a proactive reminder of expected behavior. The sign goes on to say, “Take a slow, deep breath and make sure your energy is in check before entering.”
Another trending intervention at Cleveland Clinic is the use of so-called behavioral contracts. After repeated attempts to manage a patient’s behavior through conversation, the ombudsman office drafts a formal agreement about expected language and behavior and outlines the associated consequences. This creates clarity for the patient and safety for the caregivers. At the Cleveland Clinic, we’ve gone from nine behavioral contracts in 2017 to 183 in 2020.
Reinforce Expectations with Training
Expectations set the tone, and through training and reinforcement, remind health care providers of what they need to do in volatile situations, how to respond respectfully, and how to hold people accountable.
“Do no harm” in health care is a timeless promise to patients, but it also applies to the emotional impact of the workplace on the people who work within it. The pandemic amplified racial tension in the forms of health disparity, systemic racism, and unconscious bias, and based on conversations we’ve had with people in health care, it seems some hospitals have seen rising volumes of discrimination complaints (directed at health care workers and patients alike) compared to prior years.
Cleveland Clinic augmented its already robust inclusion training by conducting listening tours on racism and bias, training local teams on how to create inclusive environments, and sharing skillsets for how to address racism directly. Notable was that, although many caregivers recognized the racial slurs coming at them or a colleague, often from patients, many did not know the right words to respond in the moment. Training specifically addressed this issue, and participants reported feeling moderately or extremely confident in responding effectively and fairly to others from various cultures and backgrounds. Appreciation of others’ cultures increased by nearly 25%.
In 2019, UMass Memorial Health Care committed to a massive civility campaign focused on six Standards of Respect (SOR). From 2019 to 2020, it trained more than 96% of employees and contractors in areas including defusing incivility and giving an effective apology. Stepping Up, a peer feedback program, identifies areas of improvement for physicians and leaders so that they’re better equipped to be role models and more consistent in holding people to their SOR. Dr. Eric Dickson, CEO of UMass Memorial, told us that “the Standards of Respect program is the linchpin that has led to a big increase in patient satisfaction, an increase in engagement, improved execution on projects, and in a way that people feel respect. There’s also been a palpable increase in performance.”
In 2011, Cleveland Clinic began formal training in communication aimed at fostering empathy and relationships while also increasing patient satisfaction and reducing employee burnout: the Communicate with H.E.A.R.T. and REDE to Communicate programs. These initially spread through grassroots efforts and were ultimately required for all clinicians and caregivers. Tens of thousands of caregivers have been trained, and it serves as the foundation of all other communication guidance. For example, when crafting communication about mask wearing for patients, we developed H.E.A.R.T. chats: quick, relevant scenarios with language examples of how to lead with empathy and set boundaries.
Although civility training based on evidence-based best practices is highly effective in general, training en masse during a pandemic is a challenge. Cleveland Clinic created communication guidance that could be distributed asynchronously in the form of pocket cards for clinicians and a placemat guide to empathically encourage masking and hold boundaries on visitation. In training on how to verbally respond to discrimination, the Agency for Healthcare Research and Quality’s Team STEPPSs safety training escalates language via the acronym “CUS” to express concern about behavior (“I’m concerned,” “I’m uncomfortable,” “safety is at risk”) and is a valuable, quick resource that can be adapted easily in new contexts.
Meet People Where They Are
Organizations can support caregivers’ growth and healing in part by simply recognizing that the pandemic has created trauma — not just medical trauma, but also devastating psychological trauma, physical injury, and emotional harm. The following tactics supplement trauma-informed care:
- Commit to no furloughs — you can’t support people if you let them go.
- Make sure people have what they need: Food, water, PPE, child care, groceries, etc.
- Conduct listening tours by walking the units or leader rounding (in person or virtual) to focus on caregiver and employee stress and demonstrate presence and willingness. When asked what’s one thing leadership can do, people often answer: “Show up.”
- At every meeting, tell stories of patients and caregivers that reinforce the values of the organization and a culture of compassion. Keep in mind, though, that reliving trauma through storytelling can hurt in unintended ways, so thoughtfulness and sensitivity are paramount.
- Create peer-support programs for people to simply talk to a peer without judgment or cost. This is not the same as professional mental health services.
- Honor those lost with remembrance ceremonies. This can help anchor in meaning, which is important for growth after grief and offers some protection from burnout.
- Recognize that in the midst of a pandemic, everyone is grieving someone or something — normalcy, lives lost, even vacations cancelled. Screen for distress and provide free grief support services like bereavement counseling and trauma-informed mental health services.
- Develop and share concrete policies, language, and training for how to respond to incivility of any kind. This should include caregiver support, and in extreme cases, behavioral contracts and patient termination.
Create Recovery Moments
Of course, the above organizational tactics won’t stop incivility altogether, so it’s also important that you and your people take care of yourselves in the face of uncivil behavior.
Encourage caregivers to take breaks when they can: a mindful moment, or even a breath. For example, a cardiologist pauses and stares at the door to his house for just a few moments before going in. Another health care provider describes stepping out of their home office when working at home and yelling, “Honey, I’m home!” Another recites a mantra when walking to her car: “Remember … I get to go home today, while others do not,” or, “Shift happens. Shift happens.”
Find Your Tribe
Our research shows the importance of positive relationships inside and outside of work. Encourage caregivers to identify and call on their energizers, the people in their lives who lift their spirits. Banding together in teams or a community provides a more potent effect and increases both theirs and others’ success — just like caring for patients.
Emotions are contagious: Our brains are wired to mirror the body language and emotion of others. Although that contagion makes incivility dangerous (bringing us to the brink of “uncivil war”), it also offers a way forward. Because happiness, peace, and empathy are also infectious, we can actually change ourselves, our teams, and the world — one gesture at a time.
Christine Porath is a professor of management at Georgetown University and the author of Mastering Community: The Surprising Ways We Move from Surviving to Thriving Together (forthcoming) and Mastering Civility: A Manifesto for the Workplace.
Adrienne Boissy is the chief experience officer for the Cleveland Clinic and a staff neurologist. She is co-editor of Communication the Cleveland Clinic Way: How to Drive a Relationship Centered Strategy for Exceptional Patient Experience.
Copyright 2021 Harvard Business School Publishing Corporation. Distributed by The New York Times Syndicate.