Kelly Gooch and Alexis Kayser – Updated Friday, December 15th, 2023
Bullying, rudeness and violence have permeated headlines about the healthcare industry lately. In the post-pandemic era — one riddled with anxious patients and burnt-out providers, all still dealing with the consequences of prolonged isolation — it can be easy to assume that civility is dead.
But it’s not, Tammy Capretta, RN, chief transformation and risk officer at Los Angeles-based Keck Medicine of USC, told Becker’s.
“Professionals want to be professional,” Ms. Capretta said. It’s part of the reason nurses and physicians spent years in school to serve their chosen field. But no human is immune to frustration and overwhelm, which often present as unprofessional behaviors: raised voices, harsh tones, refusal to abide by the rules.
When left unaddressed, unprofessional behavior can derail an organization’s culture. About seven years ago, Keck Medicine realized it had space for improvement and employed the Vanderbilt Health Center for Patient and Professional Advocacy, an organization that partners with more than 200 health systems, hospitals, and practices to facilitate interventions based on data and analysis from patient and co-worker concerns about professionalism.
The importance of professionalism
When it comes to healthcare, there are various teams in medicine where professionalism can come into play. Nursing professionals, pharmacists, physical therapists, and other workers have honed special skills, which they then expect to use in certain ways as members of the team to provide the best possible care to patients.
“In that sense, it is this notion of why teamwork is so important. Why professionalism in medicine is so important,” Gerald Hickson, MD, founding director of the Vanderbilt Health Center for Patient and Professional Advocacy, told Becker’s.
There is also an abundance of literature noting potential consequences of disrespectful behaviors in the workplace for patient safety. For example, a study published in JAMA Surgery in 2019 found that patients whose surgeons had higher numbers of reports from co-workers about unprofessional behavior in the three years before the patient’s operation appeared to be at higher risk of surgical and medical complications.
“We know from our research that acts of disrespect, unprofessional behavior, are not random in distribution,” Dr. Hickson said. “A small subset of team members, whether physicians or nurses, will model disrespectful behavior, aggressive behavior, passive aggressive behavior, or just passive behavior. But in all of those cases, they threaten outcomes of care. And one of the ways they do it is by negatively impacting team performance.”
Although a small number of team members may dole out the majority of unprofessional behavior, the implications are widespread. A survey the Institute for Safe Medication Practices conducted in late 2021 among 1,047 healthcare workers found that 79% had personally experienced disrespectful behaviors in the past year. A majority of respondents were nurses (42%) and pharmacists (37%), though some physicians, pharmacy technicians, quality experts and other leaders were also polled.
Patients have a responsibility to be respectful to healthcare professionals, too, according to Dr. Hickson; this topic of respect from patients to healthcare workers has been particularly prevalent in recent years amid a nationwide push for healthcare worker safety. But he doesn’t view professionalism from healthcare workers to each other and to patients in the same way as expectations regarding respect from patients and families to healthcare workers.
“Here’s a variant. My notion is that given the stress, the sensitivity, the fear, all of the other things that may occur when [a patient is] seeking care, I don’t want to say [the healthcare worker] tolerates disrespect, but gives a fair measure of tolerance to individuals who are often in suffering circumstances where they don’t fully understand what’s happening and may be fearful of the consequences,” he said. “So, the professional will cut the family a little slack, and we, [as healthcare professionals], also pause and self-reflect to be sure that we are meeting the expectations of the profession toward the patient.”
At Keck Medicine, physicians initially led the “cultural transformation” around professionalism, as Ms. Capretta calls it; although soon after the nursing organization wanted to be active participants and drivers of change as well. Vanderbilt’s literature demonstrated a direct correlation between professionalism, working relationships and high-quality patient care — which resonated with physicians and nurses aiming to effectively collaborate on complex cases.
When Dr. Hickson and the center’s president, William Cooper, MD, assessed Keck Medicine, they found highly committed leaders, physicians, nurses and faculty. What they didn’t find was a clear statement of professional standards.
Defining professionalism became Keck Medicine’s first assignment.
A widely accepted definition of a profession is the one handed down by the late U.S. Supreme Court Justice Louis Brandeis: “A profession is an occupation requiring extensive preliminary intellectual training pursued primarily for others, and not merely for oneself and accepting as a measure of achievement one’s contributions to society rather than financial advancement.”
Mr. Brandeis’s definition does not specifically refer to medicine. However, Dr. Hickson often points to it when healthcare professionals ask him about a definition for professionalism, as he sees it as applicable to the medical field.
“We all recognize or hope to recognize that there’s this body of knowledge that is owned by the [medical] profession,” he said. “And using technical and cognitive skills, we put that body of knowledge to work.”
The definition “is important because it distinguishes this from more than skills alone. So skills, ability, knowledge, and then how you use them to deliver effective high-quality, safe care, too.”
Dr. Hickson said he also views the definition as important in that it differentiates professionalism among professionals, such as those in the medical field, from the performance of the everyday citizen seeking services.
“We, [in healthcare], have an obligation for self-regulation, and that means that I pause and self-reflect how my behavior and performance affects yours and your ability to do your job,” he said. “And then it also means not only should I be self-reflective, we need to come together as professionals to establish best pathways, best practices and provide feedback when we’re doing good work and [also] missed opportunities.”
But professionalism presents differently at every organization, so Keck Medicine’s physicians rolled art boards into their hospital lobbies and invited their colleagues — including other physicians, nurses, technicians and therapists — to write, in their own words, what professionalism in healthcare looked like to them. They received 1,800 responses, and a team of nurses and physicians compiled those responses into the system’s first “rallying cry” for professionalism in the environment, Ms. Capretta said.
What resulted was the Keck Commitment, shared with Becker’s in an 18-page document.
The commitment includes a statement of professional standards: “We commit to delivering high quality care with kindness and consideration. We will do this by exhibiting excellence in all we do, incorporating sound judgment in our decisions, practicing civility in our interactions, and communicating with respect to patients, families and coworkers.” It also specifies how to create a supportive and collaborative environment (such as by actively listening and generously sharing knowledge); how to commit to respectful interactions (such as by acknowledging others’ presence and being mindful of tone of voice); how to adhere to applicable regulations (such as by taking ownership of problems until they are resolved); and how to recognize professionalism in others (such as by sharing positive observations with a colleague or their supervisor).
Keck Medicine has seen a number of positive outcomes since clearly defining and promoting professionalism, including “extraordinary” quality results and record-low nurse turnover, according to Ms. Capretta.
How the code is broken
“Any behavior or performance that adversely affects the ability of the team to achieve its intended outcome” could be classified as unprofessional, by the Vanderbilt Health Center for Patient and Professional Advocacy’s definition.
Those carrying out medical procedures also have a unique responsibility to uphold professional standards, as their failure to do so can have dangerous implications.
One example Dr. Hickson gave of unprofessional behavior could occur during a knee replacement surgery, such as the one his wife had, specifically when individuals don’t follow proper hand-washing and other protocols to minimize the risk of a surgical site infection. The implication would be that standard practices don’t apply to the person.
“That’s actually an unprofessional act, because the team member understands that even though the risk is miniscule in one sense, when my wife gets infected, it’s not minuscule for her, and frankly, the insurance company that pays for it,” Dr. Hickson said.
He also gave the example of a situation where a nursing professional offers a pair of gloves to a team member who needs them during a procedure, and the colleague takes the gloves and drops them into the trash can and then proceeds with the procedure. Another example was a situation where a physician would not mark a site prior to surgery, and a colleague mentions this in the moment because they want to ensure the correct site is marked as part of universal protocols. The physician’s response is, “I’m not in kindergarten anymore.”
Dr. Hickson noted that the professionalism piece comes in when a colleague provides feedback about the incident to the individual who exhibited unprofessional conduct.
For instance, after his wife’s knee replacement surgery, the health system identified ways to make hand-washing easier and more accessible to team members. This included adding more dispensers.
“We need to provide feedback and elevate everybody’s performance,” Dr. Hickson said.
But providing feedback can be uncomfortable, especially when there is a power imbalance at play; for example, when a supervisor with the ability to take disciplinary action confronts an entry-level employee.
That’s why Vanderbilt piloted the “coffee conversation.”
The value of a ‘coffee conversation’
Under Vanderbilt’s model, peers handle reports of unprofessional behavior over casual cups of coffee. More than 100 clinicians have been trained as peer messengers at Keck Medicine and are paired up to discuss concerns brought against colleagues one-on-one. Every Thursday night, Keck Medicine leaders come together to review complaints filed through the incident reporting system and assign a peer messenger to address each one.
It can be uncomfortable for both parties, Ms. Capretta said, but it gives people the opportunity to reflect on their behavior and deliberately choose a new course of action. More than 90% of the time, Keck Medicine clinicians who have a coffee conversation will self-correct their unprofessional behavior.
“[Peer messengers] approach [their] colleague with no judgment, with no ‘he said, she said, you’re wrong, they’re right.’ There’s no determination of right or wrong, only that a concern was raised that you may not be aware of, and receiving this information might give you an opportunity to think about how that conversation went down, and how it might go differently the next time,” Ms. Capretta said. “The premise is that allowing someone to have information about how they were perceived in an interaction empowers them, upon self-reflection, to change how they approach it next time.”
Physicians and nurses who have been approached for a coffee chat tend to appreciate the opportunity to pivot, leaders said in statements shared with Becker’s.
“I have witnessed how the simple reminder that a perception of unprofessional behavior exists, even when truly a perception, leads to dramatic durable behavior alterations. No one is immune from the occasional slip in our professional behavior, and most of us are easily capable of self-correction,” said Steven Giannotta, MD, Keck Medicine’s chair of neurological surgery.
Alison Wilcox, MD, section chief for cardiothoracic imaging, said, “From a personal perspective, I found it helpful and very benign to have that cup of coffee.”
Sometimes, providers open up in this more conversational setting, alerting the health system to problems at home that might catalyze their actions: for example, a sick child or spouse. This allows the organization to help alleviate some of their burden — in this case, by making scheduled accommodations — and reinforces the concept of psychological safety.
As psychological safety grows, people will naturally be more comfortable addressing unprofessional behavior on the floor, and receiving those critiques in the moment, according to Ms. Capretta.
There are other ways to address unprofessional behaviors, too. In a March 2022 report, the Institute for Safe Medication Practices outlined 13 ways organizations can address disrespectful behaviors in healthcare. These included creating an organizational culture that sets the foundation for a healthy workplace; establishing a steering committee of employees from across the organization to create an action plan for addressing disrespectful behaviors; and creating a “no retribution” policy for people who report disrespectful behaviors.
“Disrespectful behaviors in healthcare are not too complex to reverse, but it requires deliberate, intentional and persistent actions to start the process,” ISMP said.
A generational divide?
Some companies have noted a generational divide when it comes to professionalism, saying Gen Z employees — who are entering the workforce after spending formative periods of their education online — are less professional than their predecessors.
Ms. Capretta has had quite the opposite experience at Keck Medicine, she said. In fact, clearly defining professionalism has been so useful in developing a cross-generational standard that the system’s residents are looking to fully implement it throughout their training program.
“Professionalism has really emerged as something common amongst us,” Ms. Capretta said. “You may have certain individuals of a certain generation who see behaviors, boundaries in a certain way, and you see others that see it in a different way. But by commonly defining what is and isn’t acceptable, we’re able to draw people to the same commitment, to the same interpretation.”