Professionalism
The CORD Remediation Task Force subcommittee on Professionalism and Interpersonal Communication Skills (ICS) acts as a resource for these core resident attributes and skills. Professionalism in particular applies to Milestones 16 and 17, Professional Values and Accountability. The importance of these core measures of resident proficiency cannot be overstated, as professional behavior is an absolute mandate for all practicing emergency physicians. A resident who graduates with basic deficiencies in professionalism (coming to work on time, appropriate meeting attendance, timely chart completion) will have a career filled with unhappy department chairs and unpleasant hospital staff meetings. One who misses more subtle and complex aspects of professionalism (lacking understanding of personal value impact on patient care, inability to reflect on patient care and overcome barriers to acting in the patients' best interest) will have unhappy patients and difficulty managing the stressful environment of the Emergency Department.
CORD Poster
The RTF Professionalism and ICS subcommittee developed a poster for 2014 CORD AA that nicely demonstrates examples for remediation of these important milestones. It is reproduced below.
Milestone Based Remediation Plans
Professionalism Disciplinary Action Example
JGME Article on Professionalism and ICS Remediation by RTF Members
JGME ICS and Professionalism Article
RTF Consults:
Consult 1:
“Any advice on remediation for a resident who likes to hit reply-all to emails and make disparaging comments about nursing?”
The replies:
The GOOD (G1-8)
G1
Sounds like it is time for a scheduled sit down 1:1 and written warning about professionalism. I just remediated someone for professionalism and had to be extra specific in the documentation.
G2
I handle these types of issues for our residency program and also do some of this institutionally here at Baylor as well. I’m sure you’ll get a couple of different types of responses and what I would recommend depends on if this is the first incident of problematic communication from the resident or a recurrence and if you have counseled him about this specific behavior before. My comments are focused to if you haven’t counseled him about this before. For a first time incident I think the “cup of coffee” approach pioneered by Gerry Hickson at Vanderbilt is a good option. Basically you just quickly meet with the resident, I think a neutral space is best but you can use your office. Go over that you’ve identified a type of behavior that isn’t consistent with your programs standards for communication by email and communication between physicians and nurses, that you know that this resident is a good doctor and a that this behavior doesn’t match up with the type of physician that they want to be, and tell them that you know they will do the right thing in the future. The key is to not get into debating something that is off topic (what they nurses are doing that he doesn’t like), to not debate whether or not the behavior itself is okay (define it as below standards for what you expect for residents in your program), and to keep it short.
G3
Wow.
I would start with a conversation with the resident and explaining how unprofessional it is. I would stress the importance of teamwork in EM, etc. etc. I would also be very clear with the resident that this can not happen again. I would then monitor it. If it happens again, I would move on to formal remediation.
Good luck! Sounds like a tough one.
G4
We've had to deal with a similar problem and I sat down with the resident and explained e-professionalism and the permanency of the written word.
Would discouraging him from responding to any messages if its a negative comment or have a mentor pre-screen his emails.
Again, these all need a cooperative resident.
G5
I am a fan of reflective writing— in this case you could make the resident write several confidential apology letters to you — only for reflection purposes and not for distribution.
G6
Formal apology at next nursing staff meeting
G7
Interesting set of responses, mostly folks are assuming that the nurses need an apology or the like. I am not even sure the nurse’s see these disparaging comments. Regardless, remediation depends on the reason behind these disparaging comments which could range from what is being assumed (an “ignorant” resident) to a resident in crisis to actual legitimate serious nursing issues perceived by this resident to which they are reacting in this manner. The resident for better or worse becomes part of your “family” once you put them on the match list and should be treated as such in my view. That means giving the benefit of doubt.
I think the answer depends heavily on what a sit down with the resident reveals. I would present the issue of these remarks as an atypical behavior and try to see what is behind that behavior. Is this a new thing or does it reflect ongoing behavior? Is the resident lashing out due to personal issues? Any number of things could be behind this besides just being a rude person. Is the resident depressed, going thru a personal family crisis, is there a substance abuse issue, etc.? This person did well enough in life to get into your residency, the odds of them being a true cad are low in my book while the odds of them being in a serious personal crisis are high.
G8
I agree with [G7] …Whenever I have a professionalism issue, I call the resident in first, tell them about the problem, and then ask, what's going on? …open-ended your side of the story.
If the resident is the problem, (anger management, depression, other stresses) I do find personal apologies go a long way with nurses and educating the resident that a good relationship with nursing will make or break their life in medicine now and forever. We can a wellness committee to address the above issues with residents and faculty.
If nursing is the problem, the resident still needs education about going through appropriate channels to affect change.
The BAD (B1-22)
B1
Honest feedback about what is happening and how it is being perceived. With the comment that perception (albeit sometimes not accurate) matters and will reflect how these people who should view you as a leader are actually viewing you.
I like to write a mock up letter of reference for what I would have to say about him/her to a future employer and then say, this is what I would have to write now and will write in the future if you don’t change your behavior. I would also take a recent eval form (with comments about nursing/peer relationships) and show it to them and let them know how it will be answered based on feedback you have.
I have had residents read books such as Dale Carnegie’s book how to win friends and influence people.
B2
I usually don’t chime in on the listserv, but this a particular pet peeve of mine. In brief, I would suggest the resident:
1. Apologize directly to the individual(s) he has commented on.
2. Have an Individualized Learning Plan designed and administered by you, specifically in the domain of Professionalism
3. Write a reflective piece on what he has learned from the experience
4. Present this case in an M&M (or MM&I, for Improvement) format to your weekly EM conference, hopefully with interprofessional member attendance. We can all learn from this.
B3
Assuming that the “this isn’t playing nice in the sandbox and don’t do it anymore” lecture didn’t work?
We’ve been trying to reshape some behaviors of one of my residents who likes to make snarky nursing comments to families. Some things we’ve tried (although jury is still out on success)
- Multisource evals with nursing feedback on their interactions with him – problem is that can become a feeding frenzy and quality of feedback often isn’t specific enough to be useful
- Very rapid and specific attending feedback on shifts whenever something is observed (good or bad)
- Sent him to a “how to play nicely in the sandbox with people you don’t like” course run by our HR department (he complained but it seemed to help)
Maybe a sitdown with RN leadership to learn how his behaviors are perceived? Is he just trying and failing to be funny? It’s also harder to be obnoxious to people that you work with closely and know as people – can you get him to engage with nursing on a committee or taskforce to improve something about the department?
B4
Start a paper trail. And have documented meetings with TWO people present and have him sign the paper that enters the file.
Assign a mentor, and track progress.
Nip in the bud.
B5
I'll assume you've already taken the direct tact of pulling him/her into the office (or behind the woodshed) and explicitly advised that "Reply All" is an administrative privilege not yet granted to this person and that disparaging the nurses is akin to disparaging the Chair, which is obviously also a no-no.
I'd say the key to all remediation is a clear plan, then following through on any consequences (and/or employing discipline prn).
Ie, give the speech about professional expectations. Give the resident an opportunity to explain what's driving the behavior or what they hope to gain by demonstrating that behavior/attitude. If it's weak, time to come up with a legit plan.
Then, in no uncertain terms, let that resident know that the next time they openly disparage a nurse (or demonstrate poor professional judgment or communication skills), the consequences will be a few of the options below (and maybe have the resident pick 2 (and you pick 1 or 2), so they can be part of their own plan, or they are welcome to come up with an alternative.
I love the tact: "Well pretend you're in charge. What would you do if one of your employees was amassing complaints like this? Should I fire you? Or should we instead come up with a plan to fix your reputation (which currently sucks)?"
Some ideas:
1) Note filed in the resident's file, and if behavior continues, formal professional remediation (show them on a blank senior LOR employment form where you intend to place the check mark of "below expectations")
2) Email an apology to the RN and they can cc you (you may decide to trade the note in the file (#1) for this)
3) Mandatory 4h shadow shift with a nurse clinical manager so they can understand the complexities of the job
4) Note to the CCC (and point out to the resident) where they fall below the mark for teamwork, professionalism, and communication within the Milestones
5) SDOT involving direct RN communications (ie, have their faculty mentor explicitly watch and evaluate how this person talks to RNs)
6) Lit search and or review of an article on communication skills and/or email etiquette. Then share it with all the residents so all can benefit.
7) Meeting with the Chiefs about professionalism, lessons learned, communication skills, etc. Then the resident can email you a summary of what was learned.
8) Something else equally painful for the resident but actually forces a good lesson on them (and could serve double duty to buddies who may be similarly inclined to run off at the mouth, who will otherwise think twice if they learn it comes with homework).
B6
My suggestion would be for him to have additional shifts to perform to enlighten him to the importance of nursing staff. Nursing could be present to perform those task that are not possible for him to do on his own secondary to hospital protocols, but all call bells, all blood draws, all family interactions, all vital sign documentation, all triage of his patients’ that he sees, have him do it on his own. One of the biggest fallacies of poor physicians is to not realize the asset we have in our nursing staff.
Along with that, perhaps research on nursing challenges and a second research report on the effect of a hostile working environment.
B7
In your case it sounds like you have two distinct behaviors to communicate that you have identified as below the goal level for your residents (using reply-all inappropriately and making disparaging comments about the nurses).
I’ve had these go one of 3 ways. 1. The person recognizes what they did as out of line and why and is apologetic and the meeting ends quickly 2. The person is very defensive and offers lots of excuses or context (outright denial here seems very unlikely since this was email). This is the hardest of the 3 and I try to keep the discussion short and say that while I appreciate that insight the purpose of this meeting isn’t to discuss the specifics but to identify a type of behavior that is not inline with your expectations of the residents and that you trust the resident to take this conversation to heart, end of meeting. 3. The person recognizes that this is poor behavior and asks for how they can help improve. In Hickson’s model you don’t offer them anything here, at the resident level I disagree with this and think that as educators we should be willing to provide some mentoring and resources. If that’s the case here you could offer a tip as simple as never using reply all, reminding them of the appropriate channels to use for addressing concerns, or recommend some outside reading on email etiquette ( I like the book Send by David Shipley for a simple description of what to do and not do in email).
B8
1: Counsel the resident on the inappropriateness of their behavior
2: Clarify acceptable and non-acceptable behavior
3: Review the employee handbook on acceptable communication and/or disruptive physicians (demonstrating that this can turn into a HR/staff issue thus
taking it out of your and GMEs control)
4: Place consequences on repeated behavior in an escalating manner (banning from list serve, remediation, etc.)
B9
A brief conversation indicating his behavior is unprofessional and if it recurs you will have no choice but to not renew his contract. And mean it. Once you have his attention, you can explain that once he has an actual job, should he get that far, he would already have been fired. He needs to believe that Changing his behavior is in his own best interest.
B10
Have him work a couple shifts without any nursing support?
Seriously though, we have a nurse resident council that works on relations between docs and nurses. It helps some residents to clue in to what it takes to be a nurse….no small feat. If his issue is ignorance of that issue, it might help.
If the issue is just having crappy judgment, hmmm… Wish I had good advice there.
B11
Individual letters of apology, hand written and hand delivered?
B12
When this happens and I am on the email trail, I hit reply all and write 'Mike (or whoever), call me'. That lets everyone know that you recognize the resident is being unprofessional. It also puts them on the hot seat and they have to call you right away. If you really want to make him squirm, don't answer the phone the first time they call.
If you think this is a really big problem, I say nip it in the bud and put them on a remediation plan for professionalism. that can entail meeting with the chief medical officer. It can be meeting with you and the chair. I have also resorted to making residents send me a copy of any email that they were about to send to other residents. It's a bit of a pain for you to do that, but it gets the job done.
B13
Put it in the nursing journal
The nurses will take care of the problem
B14
A nursing rotation where he must assist a nurse (not with drawing up meds but asking the docs for orders, cleaning up patients, assisting to patient needs etc) Not even sure it is legal but a day in their shoes can sure change perspective.
B15
Have that resident work as a nurse for the equivalent of one week of shifts.
B16
I can share with you how our school of medicine handled some analogous situations. One involved a student posting disparaging remarks regarding their classmates on social media and another incident which a student made deceitful comments to classmates. These were handled as a violation of the Code of Professional conduct and some of the steps taken included:
1) Placing on Academic Probation and the stipulation that another violation would result in dismissal. "Corrective Action" would be our residency equivalent.
2) Letter of Apology (as Vicken mentioned). In your situation, letters could be written not only to nursing leadership and any specific people disparaged in the e-mail but also to the entire residency - apologizing for not only how he/she represented themselves but the program itself.
3) Personal meetings. Have the resident meet with nursing leadership and offer to meet any specific individuals named in the e-mail. Affected individuals should not be forced to meet if not interested.
B17
I'm new to the list serve and not a big "reply all" kind of guy. When I was at my last program we had a few problem residents who especially liked to disparage nurses and maybe not via e-mail, but still rather publicly. They would often antagonize them on shift as well. Most of them were trying to exert their power as physicians and part of that was to step on the nurses. I had to mentor one of them through all of her issues with professionalism and I called and chatted with my aunt who is a nurse manager and got some good advice. With her thoughts and some of our creativeness, we came up with a plan.
The resident was given a counseling statement that outlined the issues with professionalism (couched in ACGME language of course). The resident was also put on a plan. That plan had several components. First was weekly meetings with the advisor (that was me). During those meetings I mostly chatted and listened. I also gave her some quick things I found on professionalism. A great resource was Chapter 8 of the book "Practical Teaching in Emergency Medicine" by Rob Rogers. Jim Adams wrote it and it has some fantastic ideas as well as a sample evaluation form used for professionalism. One of the key points was to get the resident to understand that whatever their goals were, the nurses were going to make their life harder until they learned to play ball. The resident also had to give the attending on shift a patient satisfaction card per shift that then the attending picked a patient to hand it to (she tended to yell at patients too). She also had to get 5 nursing evaluations (performed on her by the nurses). She got to pick 2 nurses to evaluate her and we got to pick 3. Gave her a sense of control and buy in. She also had to get 100% shift evaluations (so hounding attendings) for each shift that block. We got her to identify some personal relationship/conflict resolution classes (like dale carnegie stuff or "Crucial Coversations") but never had money to send her.
At the end we put it all together, and she turned around a bit. When the nurses suddenly had an element of control over her she sweetened up. Plus, it really helped her to sit down and realize that she can't treat nurses that way and expect to have easy working relationships. Her job got easier. She also only had a few more months of residency left when we got her turned around so we put her on a zero tolerance for complaints policy. She sailed the rest of the way.
Hope that helps. Sorry it was wordy.
B18
I think that this is a good opportunity for a face to face discussion and then ask for a written reflection regarding the issues involved here as well as an agreement to be more thoughtful in their communications.
While I also think that written letters of apology are also important, I think it's more critically important to know if there is ownership and understanding of the errors. I do believe that this could be an unfortunate situation of frontal lobe disinhibition after a long night shift or stress and it's important to know if this resident can acknowledge a mistake, own the mistake and have this be a good opportunity for learning (though an unfortunate one).
However, if a resident is unwilling to accept that this was an error and there is a pattern of behavior, there is a much more concerning situation here. That seems to require more hardline explanation of acceptable and unacceptable behavior and the ramifications that unacceptable behavior will have on this resident's career including not completing the program if it continues.
B19
Also, a sit down with the residency director to discuss what it means to be a ‘leader’ of the ED team, and how certain behavior can disrupt the team and thus compromise patient care. To continue along this vein, discuss an appropriate response if one has a problem with certain aspects or individuals in nursing.
B20
I'm sure you are probably doing this already, but keeping on-going and detailed documentation of the events, your discussions about what it means to be a leader of the team/good citizenship, attempts at remediation/redirection with the resident, and action plans are important. Follow-up after these meetings with an email to the resident summarizing the discussion and action plan (or in some other form of written communication as appropriate.) When he/she fails to meet the written/expressed expectations you will have strength behind further/escalating disciplinary action(s) if needed, and could withstand scrutiny or any grievance procedures that might be taken against your decision-making. This holds them accountable, illustrates to them the seriousness of what's going on (if they are smart, they'll recognize these emails as the 'start of a documentation file'), and hopefully keep you bullet-proof (figuratively of course) from a legal prospective should you ever decide to free up his/her future for another career.
They also have to understand that their behavior now may impact their futures. I tell our residents that I will not lie about documented on-going issues in their performance, interactions with staff, timeliness of documentation, etc while a resident when would-be employers ask. If your resident wants to keep a job (now, and in the future), now's the time to work through these behaviors while he/she has mentors and a modicum of 'protection' of residency-style due process. When they graduate, it's a dog-e-dog (?sp) world. This generation doesn't get that. I guess I'm getting old. I'm sounding like my parents.
B21
Excellent points from a sage wise man [IN REGARDS TO G7] who has seen all the angles from the standpoint of both a Program Director and Department Chair! (I endorse getting to the basis for the problem and always sit down with both parties separately to hear each side of the story before moving forward).
I would add just a couple of things.
We have a Nursing Relations Committee in the residency that works on developing ways to foster and maintain excellent nursing-resident interactions. This goes a long way to preventing problems.
Some residents just have trouble in the nursing relations area and we all know how critical this is to their success after graduation. At IU we have found it helpful to identify a “Nursing Champion” who can work one-on-one with the resident to observe them in the ED and identify problems and solutions. Clearly you need to pick the right nurses to fulfill this position. To tell you the truth, when we first implemented this approach, we were surprised how many nurses were interested in helping!
B22
I also agree with all the comments [In regards to B21 and U7] and advice made to assess and intervene on this particular individual. While this particular resident appears to be 1-2 standard deviations outside normal behavior, Kevin makes an excellent point below that problems with nursing, or other non-physician professions for that matter, are not new issues. While I was at IU, we recognized that issues with non-physician professions usually stemmed from a lack of appreciation of that profession…not necessarily the other individual. Assumptions and lack of appreciation of what the non-physician provider brings to the team has long been a nidus for conflict. This conflict gets magnified and results in poor communication, medical error, decreased safety, poor patient outcomes, workplace/ career dissatisfaction, etc, etc. We recognized that these interprofessional differences were due, in large part, because of how each profession trained. The respective health professions are essentially trained separately. This breeds profession-specific norms and assumptions about the other professions. We are then paradoxically placed into clinical situations where a health care "team" is caring for an individual patient. However, the team has limited to no training to appreciate the strengths or contributions possible from his/ her team members. As a result, negative outcomes, as mentioned above, are more likely to happen. We have excellent data to support how often this occurs.
In addition to the Nursing Relations Committee, we also began implementing interprofessional education and collaborative practice initiatives into our curriculum at IU. Our first event was a simulation event with a theme of interprofessional education focused on error disclosure. We involved our residents, nursing, EMS, pharmacy, and RT's for this event. We covered the basic interprofessional education collaborative (IPEC) competencies (Effective communication, Roles and responsibilities, Values and ethics, and Teams/ teamwork. We then mapped these to the EM milestones. The participants rapidly acquired an appreciation of the various professions. I hypothesize that they may not have fully appreciated this otherwise. I've continued this work at UAMS and have found similar results. IPE occurs when learners from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.
Would IPE focused initiatives have prevented this individual from hitting "reply all" and making disparaging comments about the nurses? Probably not? Maybe? The point I'm trying to make is that he may be far out on the spectrum compared to others, so he gets our attention, but many others are lower down on the spectrum and are operating with a lack of understanding of the value of the members of the team around them. This is the target population I wanted to draw attention to and suggest IPE as a preventative means to improve the outcomes of those we serve. This is not difficult to incorporate into an existing GME curriculum. Especially, since EM is the one true medical team sport.
The UGLY
U1
The only remediation for that is disruptive physician counseling, professionalism and leadership, emotional intelligence teaching and if it happens repeated despite that is the dismissal for disruptive physician behavior.
U2
I do not think corporal punishment is allowed anymore by the RRC (but thinking about it is likely OK).
I would put him in a room with you, his advisor, and your chairman and explain to him that there are literally hundreds of people who want his job, and that he will not get another shot at this career unless he changes.
You do not need to raise your voice, just put a lot of eyeballs on him and let him know it will all be over soon. Put it in writing. Create the paper trail now. Let your DIO know what is going on. Draw the line in the sand.
If he fails, document it and cut him loose.
U3
Sounds like he needs the gun test, courtesy of an ACEP executive long ago. His doctorate was in childhood special education – which he said was good training for dealing with E.P.s
1. Write down all the things he’s doing to make you crazy.
2. Call him into your office
3. Pull out a revolver and begin to load it
4. while you are loading, read the list to him
5. when loaded, point the gun at his head and tell them "stop doing this stuff!"
6. If he says "yes sir!", Everything's fine he was just testing your limits.
7. If he starts crying and says "I can’t do that.", Shoot him, he's worthless.
Specifically what Mike was trying to say is that there is no point in trying to remediate behavioral issues. The resident is an intelligent adult who knows what he's doing. This is not an academic issue.
I suggest you call him in, put him on probation, and tell him he must behave as a professional or you will fire him.
The Final Decision:
Dear Dr. XXX,
I have concerns that some emails you have sent are insensitive in nature. One email on college football player Jameis Winston was particularly insensitive to victims of sexual assault. Another email with off the cuff comments on nursing. Both of these emails are attached. Dr. XXX has requested a remediation plan for this behavior for which I and Dr. XXX agree.
The remediation plan is as follows:
1) Read the book
SEND: Why People Email So Badly and How to Do It Better
by David Shipley, Will Schwalbe
2) Provide 2-3 examples based on this book on how email can be harmful to your career
3) Read the following NEJM article:
Disciplinary action by medical boards and prior behavior in medical school.
N Engl J Med. 2005 Dec 22;353(25):2673-82.
4) Define the term “Disruptive physician”
I believe steps 1 and 2 in the remediation plan will immediately help unprofessional email conduct. Step 3 underscores the importance of dealing with professionalism early in your career. Step 4 is a term we do not want to see you become or be labeled as.
Please complete by May 1 and we can meet to assess your progress. Please sign below to acknowledge receipt of this letter.
Consult 2:
RTF CONSULT REQUEST: Professionalism issues: span from poor transitions of care, to openly discussing PHI in the hallways, to not answering calls when on trauma call, to consistently showing up late for shifts, to showing her midriff at the nurses station.
Bottom line - I think her issues are:
1. Poor communication/interpersonal skills - comes across as dismissive to everyone from patients to faculty, and can't see it. Lacks some insight and humility, can also be very defensive, which then spirals to worse IP communications.
2. Disorganization - doesn't keep an actual schedule (checks her schedule every day online to find out when the next shift is). As a result, is not paying attention to details and others perceive it, and it ultimately feeds back into IP skills (nurses think she's too scattered, so they give her a harder time, etc)
3. Some undiagnosed/unfixable personality disorder
(also thinks she has a sleep disorder preventing her from "being the best she can be")
Responses: See the JGME article on Remediation of Professionalism
Some more ideas embedded below…start by defining/labeling the problems:
General thoughts:
This resident is in need of professional coaching. Sounds like she isn't dumb, because dumb + unprofessional can't make it this far in life. She is able to compensate for all this bad behavior in some way, which must be via knowledge. Perhaps, and a guarded 'perhaps,' a professional coach can help. The problem is that the good ones are expensive and rare. And it's not your job to provide the exact referral and pay for it, though it might make for better care for patients, better staff (and PD) sanity, etc.
- this issue of professional coaching is complex. Central GME offices should be the resource for this, and the intake person should be savvy enough to recognize when the resident needs psych referral first. No one will guide her to seek such a service again until 10 years from now when she has been fired two or three times and comes to the decision of self-referral on her own.
One company who does this: "Perspectives" http://www.perspectives-counseling.com
Remediation Plan ideas:
Start with the fall back approach: "We are noticing that you are exhibiting these behaviors and we are concerned that there is something going on outside of the hospital that is effecting your performance. These behaviors include:
1. Lack of organization/focus—can't keep to a schedule
2. Other staff/nurses feeling that you are not focusing well in the clinical setting
3. Lateness for shifts
4. Difficulty with sleep/fatigue management
5. Not relating well to others
- tell her you are concerned that residency isn't the best place to grow one's professional brand once it is already broken. Perception = Reality 100% of the time. Hard to recover. But you will support her in the job search to come if she seeks outside professional coaching services and demonstrates some understanding of their work with her through improved residency assessments in her final year(s).
- you can create a special eval form for on survey monkey, give her the link, and encourage her to quietly share that link with nurses and attendings at the end of every shift. Whether you can document improvement or not, the professional thing to do is to always self improve, and the staff will recognize she is trying. That's the only way to fix the perception = reality issue. Is there something that you want to share with us so that we can help you to be a successful resident? We have resources that may be of use to you"
Then present the hard data (hopefully you have people who have sent emails or have documented her unprofessional behavior in the past.
"These behaviors are not acceptable and these are our expectations. How can we help you get there?"
You may be able to elevate the role of her advisor/mentor in this case to meet with her regularly for the remediation plan (recommendations via Linda's email/article). You can also ask her to identify a faculty member who may help her with this—this may allow her to feel empowered and feel like she has someone on her side.
I think that documentation is key and you can get this info:
1. Late for shift: have faculty/senior resident send you an email.
2. Inappropriate attire: refer to dress code; have nursing manager send email to you when this occurs.
3. Review her at an ad hoc CCC meeting and have it documented in the minutes: verbal comments in minutes count.
4. Document all meetings with her and set firm expectations with deadlines and consequences.