How to Address Unprofessionalism in Healthcare Settings

Healthcare leaders such as chief medical officers need to model professionalism themselves.

Editor's note: This article appears in the October-December 2023 edition of HealthLeaders magazine.

Healthcare organizations need to develop a plan to promote professionalism among their staff members, according to an expert at Vanderbilt University School of Medicine.

About 3% to 5% of physicians, nurses, and other healthcare workers have a pattern of unprofessional conduct, says Gerald Hickson, MD, Joseph C. Ross chair of medical education and administration as well as professor of pediatrics at Vanderbilt University School of Medicine, and founding director of the Vanderbilt Health Center for Patient and Professional Advocacy (CPPA). Unprofessionalism is any behavior that "gets in the way" of healthcare teams or effective care for patients, he says.

Unprofessionalism in the healthcare setting can come in many forms, Hickson says. "Traditionally in medicine when we have thought about unprofessional or disrespectful behavior, it has been the notion of aggressive behavior. In our research, it is clear that passive and passive-aggressive behaviors are more common and can be just as interfering with our intent for good outcomes."

Examples of unprofessional behavior include throwing equipment, yelling at colleagues, and willful disregard of hand hygiene, he says. "These behaviors get in the way, and 3% to 5% of physicians, nurses, and other medical professionals have patterns of these behaviors that can have an extraordinary impact on healthcare teams and the patients we serve."

Unprofessional behavior has several negative impacts on healthcare teams and their patients, Hickson says. "We know that if physicians or nurses are disrespectful of the patients they are serving, it decreases the willingness of the patient to come back for care, to share their concerns, and to follow care plans. As you escalate unprofessionalism into a larger health system or a hospital, physicians, nursing professionals at the bedside, pharmacists, and other professionals need to play as a team. If a healthcare professional is disrespectful of colleagues, if they belittle questions from colleagues, or if they fail to perform a professional duty, it decreases the willingness to ask the healthcare professional for help and it decreases willingness to share information about a patient, so team function falls, and bad outcomes occur."

For surgeons who engage in unprofessional conduct, research has shown that patient outcomes are impacted, he says. "If you see one of those surgeons and you have a surgical procedure, you are 20% to 30% more likely to get a surgical site infection, you are 20% to 30% more likely to have to be readmitted to an intensive care unit, and you are more likely to experience a host of avoidable complications because the team is not functioning well."

Unprofessionalism can drive healthcare workers from the field, Hickson says. "When we interview nurses who leave their positions, 20% to 40% of them cite having to work with a problematic physician as the reason they leave. When you look at the cost of replacing a nurse, that is a problem. Unprofessionalism is a huge driver of the retention problem we are seeing in medicine now."

Rising to the unprofessionalism challenge

Healthcare organizations can effectively address unprofessionalism, Hickson says. "No. 1, leaders such as chief medical officers need to model professionalism themselves. If leaders are committed as professionals, the first thing they do is look at and self-assess their own performance."

Health systems, hospitals, and physician practices need to have a plan that promotes professionalism, he says. "The plan is built on the observations of patients, families, and healthcare team members. They see and experience unprofessional conduct, and individuals need to be able to address those behaviors in the moment. Reports and stories of unprofessionalism can be funneled into an office of patient relations or reported in a safety event system by coworkers. If those reports are mined or looked at routinely, you can identify at-risk individuals."

Plans to promote professionalism have several elements, Hickson says. "The plan for promoting professionalism begins with the onboarding of new hires to be sure they understand their roles and their importance in the organization. It involves wellness resources because some of the individuals who get identified as unprofessional have personal, family, or illness-related issues that need to be addressed. You need to have mental health and physical health resources because you just can't tell someone, 'Go get better.' There also needs to be a commitment to terminate the rare number of employees who refuse to respond."

To address instances of unprofessional conduct, healthcare organizations should provide feedback to problematic employees early and often, Hickson says. "In organizations that are committed to professionalism, they have trained peers who take the stories and reports that have come in, and they address the problematic professionals within a day. They sit down with their colleagues, and say, 'Here at this institution, we are committed to do everything we can to maximize outcomes for patients. We have a story of an event, and we want you to review this event, and if there is anything you can think of to do differently, we know you will do the right thing in the future.'"

Healthcare organizations need to promulgate standards for professionalism, he says. "You must have general communication, so people know the expectations for professionalism. Everyone in the organization must know that issues of professionalism are taken seriously."

The best practice for addressing unprofessionalism in individual healthcare workers is direct communication, Hickson says. "There is no more effective way educate and share professional standards than one-on-one communication in a private setting. When a peer comes and knocks on your door, you are not being called to the principal's office. The peer comes in and shares an observation. The peer shares all of the events that have arisen. The peer is not going to diagnose the situation, they are going to say, 'I know there are two sides to the story, and I just want you to reflect on the events.' The other issue in engaging people who have been unprofessional is letting them know that they are trusted to do the right thing. If there are ongoing reports of unprofessionalism, the problematic employee must be told that they are going to get another knock on their door. The good news is that in the majority of cases, the unprofessionalism does not happen again."

Among physicians, healthcare organizations can address unprofessionalism whether physicians are employed or practicing independently, he says. "Every physician who walks into a hospital must have privileges. You may be employed or a physician in your own practice; but in both circumstances, you must have privileges to practice care. If you have a health system, hospital, or physician practice where everyone is employed, all physicians operate under the same rules. If on the other hand, a physician has a separate practice, to work with patients that physician has to agree to certain standards and be held to those standards."

CMOs must work collaboratively with organizational partners to address unprofessionalism among physicians, Hickson says. "We have learned that HR is a critical partner in delivering safe care. CMOs need to recognize and understand that they have an important role in moving a health system, hospital, or medical group forward. To do that successfully, they must understand and respect the roles of HR, legal departments, safety departments, and risk management. They need to see them as partners."

The Vanderbilt Health CPPA is holding a two-day course on addressing unprofessionalism in December. To register, click on this link.

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