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Difficult interactions with colleagues

During Medical Protection Society’s recent Ethics For All conference, Dr Julia Ambler gave a presentation on handling difficult interactions with colleagues. Here she outlines some of her advice.

With increasing subspecialisation and patient’s freedom to choose providers, there may be numerous healthcare practitioners involved in an individual’s care. The World Health Organization (WHO) has defined transitions of care as being “the various points where a patient moves to, or returns from, a particular physical location or makes contact with a health care professional for the purposes of receiving health care”. (1)

With each transition of care there is a risk of communication failure and this may have significant impacts.

First and foremost is the impact on patient safety. For example, when referrals are lacking key medical information or there is an assumption that another provider will check and follow up abnormal results, diagnosis of serious disease may be delayed or completely missed. Further this kind of poor communication can lead to poor clinical outcomes, increased medical error, additional visits and increased costs and potential suffering for the patient.

Healthcare institutions can also be affected; undermined patient confidence, reputational damage, duplication of work and increased financial burden.

Healthcare practitioners must acknowledge these impacts and reflect on how we are personally affected. It is well understood that “poor teamwork, poorly defined roles, and hierarchical issues make medical care less efficient and increase frustration in the workplace”. (2) This in turn can lead to decreased morale and job satisfaction and ultimately even burnout.

The threat of medico-legal action is a constant concern in today’s clinical environment and poor interprofessional communication raises this risk for each practitioner involved.

Healthcare workplaces are full of strong personalities that may not always use respectful language when communicating with each other. Bradley and colleagues surveyed more than 600 doctors of mixed career stage in the UK, and their study identified that 31% of those surveyed experienced rude or aggressive behaviour at least once a week and 40% of them felt that this behaviour was having a negative impact on their work. (3)

For an area of practice that is so very important in patient care and safety, it is alarming how frequently communication is poor. It is therefore imperative that we understand the many barriers to excellent and timely communication to be able to move past them. Time pressures are very real in the working environment and it can be difficult to access colleagues. Healthcare practitioners do not receive extra remuneration for the time it takes to communicate effectively, so must do so because it is the correct and safe way to practice.

Organisational hierarchy is still commonplace, with a blame and shame culture that inhibits speaking up. Healthcare practitioners may be reluctant to communicate with a colleague perceived to be difficult or where they have a history of a tricky relationship.

To improve communication, a few things should be considered.

First, you must make sure those involved are on the same page, using the same language. Strategies to do this include using standardised communication tools such as SBAR (4) for handovers, checklists, protocols and templates.

It is also important to consider the people and setting. A highly stressed, tired and hungry clinician working in a noisy casualty is likely to have a difficult time concentrating on the message they are trying to receive.

A further point is the mode of communication. Does the situation call for a face-to-face discussion, telephone call, or will an email suffice?

Last, ensuring the message sent is actually the message that has been received is imperative; this can only be achieved by the message sender checking what the receiver has heard and understood. This may feel awkward to begin with, but as it becomes common practice, this approach can dramatically reduce communication failures.

Disagreements between healthcare practitioners are common, but to achieve the best result for the patient, these conflicts must be resolved respectfully. The first step is to raise your concerns, framing this conversation as being in the patient’s best interest, avoiding any language that can come across as accusatory or disrespectful (5). In particular, the importance of negotiating an agreed way forward that both parties are comfortable with should be highlighted. This could include options such as seeking a third opinion, presenting the case for a group discussion with peers, meeting with the patient and/or their family, or delaying non-urgent treatment or investigation until a clearer clinical picture emerges (if this is appropriate).

When a person feels very strongly about a patient it can be all too easy to slip into using tone and language that are aggressive and rude. This is unlikely to result in a good outcome. Similarly, if you are not clear and assertive about your concern for the patient, it is possible the response will be dismissive. Finding the balance between respect for your colleague and concern for the patient is key in achieving a satisfactory response.

If, after raising your concerns with a colleague, you fail to find a way forward with which you are both comfortable and you are feel the patient’s best interests are not being served, you should continue to take action until you are satisfied that the patient’s best is being served.

In summary, effective inter-professional interactions are essential to minimise risk for patients and healthcare practitioners. Healthcare practitioners are at risk if inter-professional communication is incomplete or not timely or if there is significant unresolved disagreement with a colleague. Standardised communication checklists and tools can be helpful. Poor inter-professional communication requires action.

Dr Julia Ambler is a Paediatric Palliative Care Specialist, co-founder of Umduduzi – Hospice Care for Children, Board of PALPRAC, and Medical Protection Risk Prevention Faculty Presenter. Her presentation was delivered during the Healthcare Practitioner’s Conference at Medical Protection’s Ethics For All 2021.

View full presentation at www.medicalprotection.org/southafrica/events-e-learning/events/ethics-for-all#HP%20Prog

References

1. WHO, Transitions of Care, https://apps.who.int › handle › 9789241511599-eng (accessed 12/11/2021)

2. Harolds, Jay A. MD Quality and Safety in Healthcare, Part LVII, Clinical Nuclear Medicine: April 2020 – Volume 45 – Issue 4 – p 299-300
doi: 10.1097/RLU.0000000000002728 (accessed 12/11/2021)

3. Bradley V, Liddle S, Shaw R, Savage E, Rabbitts R, Trim C, Lasoye TA, Whitelaw BC. Sticks and stones: investigating rude, dismissive and aggressive communication between doctors. Clin Med (Lond). 2015 Dec;15(6):541-5. doi: 10.7861/clinmedicine.15-6-541. PMID: 26621942; PMCID: PMC4953255.

4. Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W.E. and Stock, S., 2018. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ open, 8(8), p.e022202.

5. Gallagher, T, Mello M,, Levinson W., Wynia, M.K., Sachdeva A., Sulmasy A.S., Truog R.D., Conway J., Mazor K, Lembitz A., Bell S.K and Sokol-Hessner L.; Talking with Patients about Other Clinicians' Errors; N Engl J Med 2013; 369:1752-1757, DOI: 10.1056/NEJMsb1303119

 

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