Implementation of Peer Messengers to Deliver Feedback: An Observational Study to Promote Professionalism in Nursing.

BACKGROUND: The Co-Worker Observation System (CORS) is a tool and a process to address disrespectful behavior through feedback from trained peer messengers. First used by physicians and advanced practice providers (APPs), CORS has been shown to decrease instances of unprofessional behaviors among physicians and APPs. The research team assessed the feasibility and fidelity of implementing CORS for staff nurses. METHODS: CORS was implemented at three academic medical centers using a project bundle with 10 essential implementation elements. Reports of unprofessional behavior among staff nurses that were submitted through the institution's electronic reporting system were screened through natural language processing software, coded by trained CORS coders using the Martinez taxonomy, and referred to a trained peer messenger to share the observations with the nurse. A mixed methods, observational design assessed feasibility and fidelity. RESULTS: A total of 590 reports from three sites were identified by the Center for Patient and Professional Advocacy from September 1, 2019, through August 31, 2021. Most reports included more than one problematic behavior, each of which was coded. Of the peer messages, 76.5% were successfully documented using the debriefing survey as complete, 2.2% as awaiting messenger feedback, and 0.2% as awaiting messenger assignments (total of 78.9 % considered delivered). A total of 21.1% were not shared; 4.7% of reports were intentionally not shared because the issue stemmed from a new system or policy implementation (4.0%) or because of known factors affecting the nurse (0.7%). CONCLUSION: CORS can be implemented with staff nurses efficiently when nursing infrastructure is adequate.

Teaching the Skill of Shared Decision Making Utilizing a Novel Online Module: A Pilot Randomized Controlled Study.

OBJECTIVES: In this pilot study, we developed and tested an online educational module for the purpose of teaching optimal shared decision making (SDM) behaviors for physicians in training. We hypothesized that those who received this intervention would show significant improvement in SDM behaviors afterward as compared with those who had not received the intervention. METHODS: Pediatric subspecialty fellows (pediatric critical care medicine, neonatology, hematology and oncology, and pulmonology) at the Monroe Carell Jr Children's Hospital at Vanderbilt were eligible to participate, if approved by their respective program directors. Design was a randomized crossover trial of an online educational module to promote behaviors essential to SDM. Participants were randomized by subspecialty. Experts in clinical communication blinded to participants' study arms evaluated SDM behaviors in video-taped clinical simulations with standardized parent dyads. The study protocol was approved by the Vanderbilt University Institutional Review Board. RESULTS: Participants receiving the intervention were approximately 40 times more likely to improve their subsequent total score when compared with simply repeating the simulation alone (95% confidence interval, 1.72-919.29; P = .022). CONCLUSIONS: This pilot study demonstrates that an online, interactive module can be an effective way of teaching the skill of SDM to pediatric subspecialty trainees. Tools like this one could help overcome the limitations inherent in currently published SDM resources and meet the need for interventions with demonstrated effectiveness, helping to increase the utilization of SDM skills by providing primary or supplemental education at institutions across the resource spectrum.

Qualitative Content Analysis of Coworkers' Safety Reports of Unprofessional Behavior by Physicians and Advanced Practice Professionals.

OBJECTIVES: The aims of the study were to develop a valid and reliable taxonomy of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals and determine the prevalence of reports describing particular types of unprofessional conduct. METHODS: We conducted qualitative content analysis of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals to create a standardized taxonomy. We conducted a focus group of experts in medical professionalism to assess the taxonomy's face validity. We randomly selected 120 reports (20%) of the 590 total reports submitted through the medical center's safety event reporting system between June 2015 and September 2016 to measure interrater reliability of taxonomy codes and estimate the prevalence of reports describing particular types of conduct. RESULTS: The initial taxonomy contained 22 codes organized into the following four domains: competent medical care, clear and respectful communication, integrity, and responsibility. All 10 experts agreed that the four domains reflected essential elements of medical professionalism. Interrater reliabilities for all codes and domains had a κ value greater than the 0.60 threshold for good reliability. Most reports (60%, 95% confidence interval = 51%-69%) described disrespectful or offensive communication. Nine codes had a prevalence of less than 1% and were folded into their respective domains resulting in a final taxonomy composed of 13 codes. CONCLUSIONS: The final taxonomy represents a useful tool with demonstrated validity and reliability, opening the door for reliable analysis and systems to promote accountability and behavior change. Given the safety implications of unprofessional behavior, understanding the typology of coworker observations of unprofessional behavior may inform organization strategies to address this threat to patient safety.

Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients.

Importance: For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. Objective: To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports. Design, Setting, and Participants: This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019. Exposures: Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation. Results: Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05). Conclusions and Relevance: Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

Unsolicited Patient Complaints Identify Physicians with Evidence of Neurocognitive Disorders.

OBJECTIVES: Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD). METHODS: We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups. RESULTS: Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p < 0.001 using Pearson's χ2 test, χ2 = 30.21, df = 1) and site/complaint matched comparisons (18%, p < 0.001 using Pearson's χ2 test, χ2 = 17.51, df = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 [95% confidence interval 4.9-81.7]). CONCLUSIONS: Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications.

Importance: Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective: To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants: This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures: Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results: Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance: Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

Using Coworker Observations to Promote Accountability for Disrespectful and Unsafe Behaviors by Physicians and Advanced Practice Professionals.

BACKGROUND: Health care team members are well positioned to observe disrespectful and unsafe conduct-behaviors known to undermine team function. Based on experience in sharing patient complaints with physicians who subsequently achieved decreased complaints and malpractice risk, Vanderbilt University Medical Center developed and assessed the feasibility of the Co-Worker Observation Reporting System(SM) (CORS (SM)) for addressing coworkers' reported concerns. METHODS: VUMC leaders used a "Project Bundle" readiness assessment, which entailed identification and development of key people, organizational supports, and systems. Methods involved gaining leadership buy-in, recruiting and training key individuals, aligning the project with organizational values and policies, promoting reporting, monitoring reports, and employing a tiered intervention process to address reported coworker concerns. RESULTS: Peer messengers shared coworker reports with the physicians and advanced practice professionals associated with at least one report 84% of the time. Since CORS inception, 3% of the medical staff was associated with a pattern of CORS reports, and 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period. CONCLUSIONS: Systematic monitoring of documented co-worker observations about unprofessional conduct and sharing that information with involved professionals are feasible. Feasibility requires organizationwide implementation; co-workers willing and able to share respectful, nonjudgmental, timely feedback designed initially to encourage self-reflection; and leadership committed to be more directive if needed. Follow-up surveillance indicates that the majority of professionals "self-regulate" after receiving CORS data.

Communication training improves patient-centered provider behavior and screening for soldiers' mental health concerns.

OBJECTIVE: To evaluate the effectiveness of patient-centered communication training for military providers who conduct post-deployment health screening. The half-day interactive workshop included simulated Soldier patients using video technology. METHODS: Using a quasi-experimental design, all health care providers at four military treatment facilities were recruited for data collection during a four- to nine-day site visit (23 trained providers, 28 providers in the control group, and one provider declined to participate). All Soldiers were eligible to participate and were blinded to provider training status. Immediately after screening encounters, providers reported on their identification of mental health concerns and Soldiers reported on provider communication behaviors resulting in 1,400 matched pairs. Electronic health records were also available for 26,005 Soldiers. RESULTS: The workshop was found to increase (1) providers' patient-centered communication behaviors as evaluated by Soldiers; (2) provider identification of Soldier mental health concerns; and (3), related health outcomes including provision of education and referral to a confidential counseling resource. CONCLUSION: Results are promising, but with small effect sizes and study limitations, further research is warranted. PRACTICE IMPLICATIONS: A brief intensive workshop on patient-centered communication tailored to the military screening context is feasible and may improve key outcomes.

Association between performance on Neurology In-Training and Certification Examinations.

OBJECTIVE: This study analyzed the relationship between performance on the American Academy of Neurology Residency In-Service Training Examination (RITE) and subsequent performance on the American Board of Psychiatry and Neurology (ABPN) Certification Examination. METHODS: Pearson correlation coefficients were used to examine the relationship between performance on the RITE and the Certification Examination for 2 cohorts of adult neurologists and 2 cohorts of child neurologists. The 2 cohorts represented test takers for 2008 and 2009. RESULTS: For adult neurologists, the correlation between the total RITE and the Certification Examination scores was 0.77 (p < 0.01) in 2008 and 0.65 (p < 0.01) in 2009. For child neurologists, it was 0.74 (p < 0.01) in 2008 and 0.56 (p < 0.01) in 2009. DISCUSSION: For 2 consecutive years, there was a significant correlation between performance on the RITE and performance on the ABPN Certification Examination for both adult and child neurologists. The RITE is a self-assessment examination, and performance on the test is a positive predictor of future performance on the ABPN Certification Examination.

Burnout in medical school deans: an uncommon problem.

PURPOSE: To assess the burnout level among U.S. and Canadian medical school deans and to study how burnout relates to certain characteristics including hours worked, effectiveness, and support from family and colleagues. METHOD: Questionnaires were sent in September 2006 to 100 deans who had served at least one year. The questionnaire included 13 questions from the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures three subcomponents of burnout: emotional exhaustion, depersonalization, and personal accomplishment. RESULTS: The response rate was 90%. The median age of participants was 60; the median length of service at the current institution was four years; the median number of hours worked per week was 70.0. Deans most frequently identified school budget deficits, loss of funding, and departure of key faculty as stressors. Whereas only 11% reported being dissatisfied with their positions, 33% reported it was likely they would step down within the next two years. The predominant pattern of MBI-HSS subscale scores in participating deans was moderate emotional exhaustion, moderate depersonalization, and high personal accomplishment. Only 2% of respondents satisfied all three subscale scores for high burnout. Emotional exhaustion was significantly directly associated with work week length and number of weekend days worked and was inversely associated with spousal support, length of service, and age. CONCLUSIONS: Despite having an "extreme" job, only 2% of deans exhibited high levels of burnout. A high sense of control and self-efficacy, a supportive family, increasing length of service, and increasing age may be factors which reduce burnout in deans.

Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology: results from a prospective, randomized pilot study.

OBJECTIVE: This study assessed burnout in new chairs of obstetrics and gynecology and whether mentoring by experienced chairs would prevent or reduce burnout. STUDY DESIGN: We performed a year-long prospective, randomized trial. Questionnaires were sent to new chairs to obtain demographic information and to identify need for mentoring and level of burnout. Fourteen chairs in the intervention group selected a mentor; 13 chairs served as controls. After 1 year, questionnaires were completed to determine stress and burnout and the impact of mentoring. RESULTS: Financial issues were the major stressors. New chairs identified human resources, finances, and relationships with school leaders as areas of greatest need for mentoring. Few chairs exhibited burnout. No differences were observed in burnout at the start of the study or after 1 year in the study groups. Mentors and new chairs found the mentoring relationship difficult to establish and maintain. CONCLUSION: Long-distance mentoring by experienced chairs did not alter burnout in new chairs of obstetrics and gynecology. Local mentors appear to be more effective.

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.

Vanderbilt University School of Medicine (VUSM) employs several strategies for teaching professionalism. This article, however, reviews VUSM's alternative, complementary approach: identifying, measuring, and addressing unprofessional behaviors. The key to this alternative approach is a supportive infrastructure that includes VUSM leadership's commitment to addressing unprofessional/disruptive behaviors, a model to guide intervention, supportive institutional policies, surveillance tools for capturing patients' and staff members' allegations, review processes, multilevel training, and resources for addressing disruptive behavior.Our model for addressing disruptive behavior focuses on four graduated interventions: informal conversations for single incidents, nonpunitive "awareness" interventions when data reveal patterns, leader-developed action plans if patterns persist, and imposition of disciplinary processes if the plans fail. Every physician needs skills for conducting informal interventions with peers; therefore, these are taught throughout VUSM's curriculum. Physician leaders receive skills training for conducting higher-level interventions. No single strategy fits every situation, so we teach a balance beam approach to understanding and weighing the pros and cons of alternative intervention-related communications. Understanding common excuses, rationalizations, denials, and barriers to change prepares physicians to appropriately, consistently, and professionally address the real issues. Failing to address unprofessional behavior simply promotes more of it. Besides being the right thing to do, addressing unprofessional behavior can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments.

Comedy workshop: an enjoyable way to develop multiple-choice questions.

PURPOSE: To describe an innovative method of developing multiple-choice items for a board certification examination. SUMMARY: The development of appropriate multiple-choice items is definitely more of an art, rather than a science. The comedy workshop format for developing questions for a certification examination is similar to the process used by comedy writers composing scripts for television shows. This group format dramatically diminishes the frustrations faced by an individual question writer attempting to create items. The vast majority of our comedy workshop participants enjoy and prefer the comedy workshop format. It provides an ideal environment in which to teach and blend the talents of inexperienced and experienced question writers. CONCLUSION: This is a descriptive article, in which we suggest an innovative process in the art of creating multiple-choice items for a high-stakes examination.