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ing with coworkers, also negatively affect laboratories’ day-to-day operations. These disruptive behaviors are relatively common and have a significant impact on medical errors, according to oncology nurse and author, Theresa Brown. In a recent New York Times article, she explained how such inappropriate workplace conduct adversely affects patient safety (2). For example, out of fear, a nurse being bullied by a doctor would be less likely to question the doctor’s orders, despite suspecting an error. Brown contended that a healthcare worker being abused or intimated by a co-worker often avoids communicating with the perpetrator, thereby increasing the probability of a medical error. In addition, she observed that any type of disruptive behavior negatively affects patient safety because it distracts and upsets the people involved. When staff members are not able to concentrate on their assigned Confronting Conflict in the Lab How Lab Managers Can Curb the Effects of Disruptive Behavior By JaMes s. heRnanDez, MD, Ms We all probably have known one: the lab staff member whose disruptive behavior affects not only her own performance, but also keeps her co-workers from doing their best. Disruptive behavior can include verbal abuse, sexual harassment, yelling, profanity, vulgarity, and threatening words or actions, according to Gerald B. Hickson, MD, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn. He says disruptive behavior can negatively affect both lab operations and the level of respect and camaraderie among lab staff (1). Why is it so important to stop disruptive behavior? Because such conduct not only can lead to medical errors, but failure to curb it also can cause team members to adopt the disruptive person’s negative behavior, which in turn can reduce the level of trust and respect among co-workers, says Hickson. Inappropriate attitudes and actions also reduce productivity in the lab sources of conflict in the Workplace ® goals and/or values conflict ® ambiguous jurisdictions; role ambiguity ® Competitively fueled reward systems yielding divisiveness ® weak communication capabilities ® perceived power imbalances ® personality style differences ® difficult behavior patterns Adapted from reference 3. 16 CliniCal laboratory news July 2011 tasks, they are more likely to commit noncognitive errors, meaning they make mistakes in a process that is normally automatic. Bad Behavior Leads to Lab Errors How serious is the disruptive behavior problem in healthcare systems today? Rosenstein and O’Daniel recently described the scope of the problem based on a survey involving more than 100 Veteran’s Health Administration Hospitals (3). In their study, approximately 4,500 physicians, nurses, and other healthcare workers responded to questions about the frequency of disruptive behavior and its effect on patient safety. More than three-quarters of participants reported witnessing disruptive behavior by physicians, while two-thirds had observed disruptive behavior by nurses. Furthermore, 71% said they believed there is a link between disruptive behaviors because staff are distracted by the perpetrator’s behavior. As this environment affects how efficiently a lab operates and has negative repercussions for all involved, lab managers should continuously monitor the offender’s disruptive behavior (2). Multiple sources of conflict in the workplace exist, according to management expert Louellen Essex, president of Louellen Essex & Associates (See “Sources of Conflict,” below). Essex has worked extensively with healthcare organizations, including laboratories. When Conflict is Good Not all conflict is dysfunctional, according to management guru Charles Dwyer, PhD, academic director for the Aresty Institute’s Leading and Managing People Program at the University of Pennsylvania Wharton School of Business. Although some people actually enjoy conflict, the lab director’s goal should be to manage, rather than squelch, conflict. (4). In fact, getting to the Tips for confronting disruptive behavior ® prepare by writing down and practicing what you are going to say. ® Make sure you are in the right mindset. ® document and stay calm at all times. ® be objective, not judgmental. ® get help when you need it. Adapted from reference 5. and medical errors, and 18% indicated that they were aware of specific adverse events related to disruptive behavior. Policies and Procedures Given the possible dire consequences of medical errors, clinical laboratories should not hesitate to take action against employees who display disruptive behaviors (See Table, p. 15). The first step is to develop and enforce policies and procedures based on a professional code of conduct (4). These policies and procedures must include a protocol for reporting and managing disruptive behavior without fear of retaliation. A successful workplace environment depends on encouraging lab workers to confront these behaviors at all levels of the organization. Removing intimidators and disruptors from the laboratory not only boosts productivity but also helps ensure patient safety. disruptive behaviors, such as sexual harassment, create tension in the laboratory and threaten its safe operation. root of the conflict has several benefits for laboratories, including raising important and unresolved issues, resolving deep-seated problems, and helping the lab to evolve better group cohesion. Overall, such resolution can lead to productive changes in lab culture and output. Managing Conflict As unsettling as disruptive behavior can be, some individuals thrive on conflict. Today, it seems that conflict among co-workers is rooted in American culture, which often times rewards and encourages bad behavior. In fact, some co-workers may even instigate or encourage conflict. It takes courage, discipline, and practice for lab managers to learn how to de-escalate conflict in a healthy way. What should lab managers do when they observe conflict in the laboratory? Barbara Linney, vice president of career development at the American College of Physician Executives in Tampa, Fla., offers a few pointers (5). First, avoid teasing REFERENCES 1. Behaviors that undermine a culture of safety. The Joint Commission Sentinel Event Alert. Issue 40. July 9, 2008. Available at: www.jointcommission.org/assets/1/18/ SEA_40.PDF, accessed May 26, 2011. 2. Brown T. Physician, Heel Thyself. New York Times. May 7, 2011. Available at: www.nytimes.com/2011/05/08/, accessed May 26, 2011. 3. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008:34;464– 71. 4. Saxton RS, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: A review of the literature. J Patient Saf 2009;5:180–183. subordinates about the behavior. This only makes the lab manager an equal with the disruptive staff member. Second, avoid big shows of emotions, such as angry outbursts or crying. This merely escalates the problem. Linney also advises lab professionals to be mindful of their body language, since 55% of what we communicate is through body language, 38% is from the tone of our voice, and only 7% is due to the words we are speaking (6) (See “Tips,” left). Listening skills are essential to resolving conflict, according to Essex (3). Lab managers should listen and avoid being defensive when managing conflict. It helps to paraphrase the concerns of the other person or team members and to ask questions to clarify your understanding. If you are at fault, don’t be afraid to admit it, and if you’re not at fault, explain your point of view to clear up the misunderstanding. Finally, thank the person or team for bringing the matter to your attention.
Being Prepared Hickson urges laboratories to have an infrastructure in place for addressing unprofessional behavior (7). Key components of such a system include commitment from the organization’s leadership, supportive institutional policies, surveillance tools to capture complaints, a model to guide graduated interventions, and a process for reviewing allegations. It also may help to institute a training program for employees and develop resources to aid both those being disruptive and the The Slippery Slope of Errors Steps Labs Can Take to Avoid the Normalization of Deviance By KaRen appolD anD MiChael astion, MD, phD People who prefer to sleep in are often in the habit of rushing to get to work on time. In their rush, they may multitask to make up for the lack of time by combing their hair and using their mobile devices while driving. Obviously, these behaviors increase the chances of a serious accident. But late sleepers who have never been in a wreck gradually adopt these risky actions as part of their normal routine to compensate for sleeping in. They may even rationalize that more sleep improves their work performance. Despite that little voice telling them they should go to bed earlier instead of risking an accident, their unsafe morning routine has become acceptable to them. This is an example of the normalization of deviance. In the workplace, the normalization of deviance refers to the gradual acceptance of incidents or activities that were initially defined as deviant and unacceptable. Typically this occurs because organizations fail to deploy their mission, vision, and goals at the ground level with employees. Factors that favor the normalization of deviance include inadequate or incompetent supervision, time pressure, and resource scarcity. Lessons Learned from The Challenger Diane Vaughan, PhD, coined the term “normalization of deviance” in her book, “The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.” Vaughan is a professor in the Departments of International and Public Affairs and Sociology at Columbia University in New York. She concluded that the Space Shuttle Challenger disaster on January 28, 1986, which killed all seven crew members, occurred due to normalization of deviance, rather than misconduct. The events leading up to this tragic accident are a good exam- looking for The joint commission standards? the Joint Commission standards are available in print and electronic formats and can be purchased from Joint Commission resources. www.jointcommission.org/ standards_information/standards. aspx staff members affected by the behavior. Even with limited resources, by taking tips from other areas in healthcare to guide policies and procedures, laboratorians can confront and combat disruptive behavior. In the end, experts agree that the ultimate goal is to eliminate poor behavior in the clinical laboratory in order to ensure patient safety. REFERENCES 1. Hickson G. Dealing with Disruptive Behavior among Health Care Professionals, ple of how normalization of deviance transpires. Organizations typically accept an initial deviant occurrence or two because it was unintended and little or no harm occurred. However, the initial incidents establish a precedent for accepting more and more deviance. In the case of the Challenger, when the first deviation from the expected performance happened involving O-ring pressure seals during flight, the problem was fixed. Overtime, more damage took place on subsequent flights. Eventually, more serious damage became acceptable to NASA. “Because failure did not occur and the causes of the problem continued to change, the pattern continued,” Vaughan explained. “It became normal to fly with the flawed design.” Eventually though, problems with the O-rings caused the Challenger disaster. The normalization of deviance often results from patterns of information that disguise the seriousness of the problem. For example, as NASA moved forward with launches, each decision seemed rational. “Technical deviations indicating something was wrong were interspersed with information that all was well,” Vaughan said. “What in retrospect seemed like strong warning signals of danger prior to the accident did not have the same meaning to insiders at the time events were occurring. Signals were mixed, weak, and routine.” Don’t Let Deviance Become the Norm In the laboratory, normalization of deviance tends to occur when employees become less sensitive to slight changes or take small shortcuts to improve work performance, according to Mark R. Chassin, MD, president of The Joint Commission in Oak Brook Terrace, Ill. The problem is that laboratory professionals don’t realize this behavior can cause unsafe situations that eventually can harm patients. Chassin believes they fall into this behavior when strong safety systems aren’t in place and the lab doesn’t have a clear commitment to follow safety protocols without fail. As a former commissioner of the New York State Department of Health, Chassin oversaw medical institutions’ quality programs and had the opportunity to observe normalization of deviance events in clinical laboratories. He recalled one instance in which patient and specimen identification CLMA audioconference, Gerald B. Hickson, MD, director, Center for Patient and Professional Advocacy, Vanderbilt University Medical Center. 2. Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Res Organ Behav 2006;27:175–222. 3. Louellen Essex and Associates, www. louellenessex.com/contact.html, accessed May 12, 2011. 4. Dwyer C. The Shifting Source of Power and Influence, ACPE Publication, 1991 labels were slightly cut off as they were dispensed from the label maker. As the problem worsened, some letters and numbers were omitted. “That small abnormality went unreported until it caused several patient misidentifications,” Chassin said. “If people would have been more attentive to that slight change earlier and called it to the attention of the right individuals sooner, then it wouldn’t have led to the misidentifications of patients and specimens.” Another example involved reporting of highly abnormal test results. A technologist had difficulty reaching clinicians when reporting critical lab values. He became satisfied with leaving the information with a clerk or non-clinician, even though the protocol called for leaving it with a nurse or doctor. Since nothing bad resulted from the technologist’s actions, this deviation continued. He eventually developed a habit of being less careful about adhering to the critical value policy, even though this increased the likelihood of an adverse event. Taking Action The Joint Commission has put in place several standards to help labs combat the normalization of deviance, and it has es- Patient safety focus editorial board chair michael astion, md, Phd seattle Children’s Hospital seattle, wash. members Peggy a. ahlin, bs, mT(ascP) Consultant salf lake City, utah 5. Linney, Barbara, Conflict and Cooperation, American College of Physician Executive course, 2008. 6. Malandro, LA, Barker, LL, Barker, DA Nonverbal Communication, 2nd Edition, New York, Random House (1989). 7. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Acad Med. 2007; 82: 1040–48. lab examples of the normalization of deviance ® repeating quality control until it is in range ® allowing relabeling of mislabeled specimens that are replaceable ® allowing physicians to opt out of a critical value policy ® accepting outdated specimens ® labeling specimens in batch at the nurses’ station ® accepting a culture of rudeness on the phone ® ordering a CbC, tsH, and basic metabolic panel on all ambulatory patients tablished safety guidelines, which identify situations that increase the likelihood of patient harm. “If there is a problem, no one should feel intimidated about identifying it, regardless of how junior an individual may be,” Chassin said. “For example, a lab technologist asks a doctor, ‘Are you sure you want to order this test?’ The doctor replies, ‘That’s a really stupid question; it is on the ordering sheet.’ This kind of intimidating behavior, although subtle, is likely to result in the technologist not questioning the doctor again, even if he or she feels that the doctor is creating an unsafe situation for patients. Behavior that diminishes communication needs to be eliminated when building a safety culture. Otherwise, such behavior promotes the normalization of deviance.” SuGGESTED READING Vaughan, D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, Ill: University of Chicago Press 1996. Karen Appold is an editorial consultant for the clinical laboratory industry. Email: karenappold@comcast.net corrine fantz, Phd emory university atlanta, ga. james s. hernandez, md, ms Mayo Clinic arizona scottsdale and phoenix, ariz. brian r. jackson, md, ms arup laboratories salt lake City, utah CliniCal laboratory news July 2011 17
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