Daniel O’Connell, PhD
Seattle, WA 98119
danoconn@uw.edu
206 282-1007
The Problem:
 Behaviors such as condescension (verbal, tone, body),
disparaging, intimidating, patronizing, angry
outbursts, reluctance or refusal to answer questions,
unwillingness to cooperate/collaborate or provide
reasonable help, threatening body language and
physical contact, unwillingness to participate in
resolution of an interpersonal problem
 The emotional impact of abusiveness demoralizes
people who feel attacked, devalued, or humiliated as
well as the witnesses.
Prevalence and Impact
 Verbal abuse reported by 80-97% of nurses by doctors or other nurses/staff.
 16% of nursing turnover was found to be associated with verbal abuse.
 Physicians have been recognized as the primary perpetrators of verbal abuse;
however they are not the only source. Patients, families, peers, supervisors and
other colleagues have demonstrated abusive behaviors as well.
 “Relational aggression” a particular problem for women (cf Cheryl Dellasega
2005 Mean Girls Grown Up)
 Intimidating, abusive behaviors impact patient safety. (49%) of all 2000
respondents reported that their experiences with intimidation had altered the
way they handle clarifications or questions about medication orders increasing
the risk of incorrect interpretation and occurrences of medication errors. Only
39% felt that their organization dealt effectively with intimidating behavior.
(Intimidation. Institute for Safe Medication Practices March, 2004)
 Multiple studies have shown that the negative effect of abuse on productivity,
morale, nursing care delivery, workload and errors.
 Research confirms evidence-based prevention strategies as well as enforceable
zero-tolerance policies can significantly reduce the occurrence
Code of Conduct
 Treat all persons with respect, courtesy, caring, dignity
and a sense of fairness
 Communicate openly, respectfully and directly with
team members… to promote mutual trust and
understanding
 Encourage, support and respect the right and
responsibility of al individuals to assert themselves to
ensure patient safety and the quality of care
BMC Medical Dental Staff Policy
Regarding Unprofessional
Relationships
 Boston Medical Center (“BMC”) is committed to
having a work environment that is professional,
collegial, supportive of all personnel, and conducive to
providing optimum patient care
BMC Policy
 All members of the Medical and Dental Staff (“Medical Staff”) are
expected to treat one another and all other individuals of the BMC
community with respect and dignity.
 2. BMC is committed to assuring that the workplace environment at the
BMC is a positive and supportive one and without disruptive,
intimidating, or abusive behavior. Harassment of any kind, conduct
that is disrespectful and/or abusive, and unprofessional relationships
are not acceptable behavior at BMC.
 3. BMC takes seriously any and all allegations of unprofessional
relationships and disrespectful and/or abusive conduct seriously, and
will respond promptly to complaints. When an allegation has been
made that undesirable behavior has occurred, BMC will act promptly to
investigate the alleged conduct and address behaviors that are found to
be unprofessional or disrespectful. Moreover, retaliation of any kind
will not be tolerated against an individual who has made a complaint or
allegation under this policy or who has participated in an investigation
of said complaint or allegation
Courageous Conversations by
Colleagues and Supervisors
 Courage of convictions
 We need to do better than this
 Courage of role
 It is my role to raise these concerns
 Courage in the face of conflict
 I/we are not so fragile that we cannot tolerate some conflict if we are
skillful in how we approach it
 Courage of persistence
 I can come back again and again if needed until we get this right
 I can/we can ask for help to get this resolved
Having the Courageous
Conversation
Good resources:
 Crucial Conversations by K. Patterson et al 2002
 Crucial Confrontations by K. Patterson et al 2004
 Difficult Conversations by D. Stone et al
 Fierce Conversations by Susan Scott 2004
Key perspectives in promoting
civility and collegiality







Teamwork requires investment, civility and collegiality
“Both/and” replaces “Either/or”
Empathy is essential for real civility and collegiality
“Contribution” replaces blame
Separate the people from the problem
The “reasonable person” test
Describe behavior and impact, not theorized intentions
 Yet consider psych/sa contribution in light of behavior
 People are pre-disposed to certain kinds of problems
 So monitor and maintain to prevent or manage relapse
 Zero tolerance does not always mean discipline
 “Bully effect” means help is reasonable often necessary
Bully Effect
 Bullying behavior is usually directed at someone
towards whom one feels dome impunity. Someone for
whom respect is already diminished and from whom
one does not fear retaliation.
 That means that the receiver of bullying will often not
have the clout to confront the bully effectively enough
to end the behavior.
 So… be quick to often assistance through coaching,
facilitation, mediation
Empathy with Clarity
 I want to help you be successful
 You are a valuable member of the department and I
want to help you have the constructive impact you
intend and not the destructive impact that your
behavior sometimes causes
Zero tolerance does not require
capital punishment
 Create pathways to recovery whenever possible
 Be creative about how recovery could occur.
 4 Steps of Apology
 Acknowledge wrong and its impact
 Express remorse/regret
 Explain how it occurred and steps to prevent recurrence
 Offer restitution
Reasonable Person Test
 Ultimately, one must make a judgment
 Was this behavior such that a “reasonable person”
would have it offensive, disrespectful, disruptive to the
safe and effective conduct of teaching, research,
clinical work and collegiality
Focus on Behavior and Its Impact
Avoid getting stuck in Intentions
 Most your people will defend their intentions
(because it reflects on their identity)
 Focus on impact
 When you behave like this_______________, I am
hearing/observing/learning that is has these unwanted
impacts.____________________. Because I do not think
that is your intention, I want to help you have the
constructive impact you are intending. Let’s talk about
how that could be achieved.
Contribution replaces Blame
 The way in which you______________ contributes to
others feeling__________which unfortunately has the
consequence at times of ______________.
Separate the People form the
Problem
 You are not the problem. He/She/They are not the
problem. The Problem is the problem. So let’s talk
about the problem that we are seeing.
Both/And replaces Either/Or
 Both high quality clinical direction, teaching and
research rigor AND doing it in a way, in a demeanor
with a clear intention of building and maintaining
respect, collegiately, and attention to the emotional
impact on others
Progressive Intensity/Discipline
“Diagnosis and Treatment” progresses through levels of
increasing intensity appropriate to resolving the problem
 Encourage conversation by individuals involved
 “Supervisor” to clarify/investigate, affirm expectations,
facilitate and/or obtain resources
 Supervisor takes on issue directly within progressive
discipline structure focusing on promoting resolution
 Process is aimed at getting and maintaining individual’s
attention on problem resolution, creating/offering plans to
understand and resolve problem and clarifying consequences
of unwillingness or inability to behavior appropriately
Expect Slips and be Ready for
Relapse
 Behavior issues often emerge from underlying
vulnerabilities that predispose their happening in the
first place and recurring in the future.
 That means that slips into misbehavior need not be
seen as total failures. They may not call for draconian
action. They do call for intervention.
 So… put in place a “treatment and monitoring plan”
that lasts longer (1+ years), continue to gather data
about behavior, have regular feedback meetings and
do all this transparently