Drawing Lines in the Sand

In every clinical setting, there exists a line that is never to be crossed. We often refer to drawing lines in the sand; however, I’m not talking about the sometimes “moveable” lines but rather the hard ones that are etched in stone.

When we work with our patients, a variety of situations have to be taken into account. Someone is ill that day and may feel worse than usual. Perhaps a staff member was just served divorce papers as she left for the office or maybe a student just found out they did not get accepted into the college of their choice. In each case, the person may be off or even uncharacteristically rude. And in most cases they apologize for their behaviors that day or shortly after.

But what happens when someone calls your staff or co-workers names repeatedly? And what if your staff and or waiting patients feel threatened by the behaviors? Or worse?

This was a recent situation in our office where someone crossed the line etched in stone. Fortunately we had written policies already in place to address the situation. Because of this, we were able to address the situation and manage it quickly and effectively. Both patients and staff felt reassured that their well-being was being attended to.

In your business, or your place of employment, do you have policies and procedures in place that address the “sticky” situations that can occur when working with people?

Are theses policies and procedures followed or are the rules bent and skewed for each situation?

While there is an argument for addressing each situation separately, there is also stability, reassurance and trust that comes from standing on a firm foundation.

If you don’t have strong policies in place, the time to create such a policy is before you need one. Here are a few tips:

1. Identify behaviors: What behavioral situations might make your low and zero tolerance list? Consider behaviors for staff as well as patients and other visitors to your practice. Some examples might include:
– Belligerent or threatening behaviors
– Acute/chronic intoxication/impairment
– Dishonesty
– Substance use in the office
– A show of weapons in the office
– Severe lack of personal hygiene
– Overuse of fragrance.
– Verbal or physical abuse

2. What are some possible responses to low tolerance behaviors?
– Coaching individuals and offering a plan for corrective actions?
– Giving a warning regarding subsequent behaviors?
– Perhaps consider probationary notices?
– When to include law enforcement?

3. What are some possible responses for zero tolerance behaviors?
– Dismissal from the practice? Perhaps a referral to another provider or another practice might be more   appropriate for the patient.
– If it’s a staff member, dismissal from employment might be appropriate.
– Or perhaps there is another response you may want to take.

4. When might you be flexible in your responses (if ever)?

5. Who should be involved in the decisions? Counselors? Your lawyer? Patients? Families? Staff? Your board?

6. How will you communicate these policies with appropriate staff, patients and visitors?

7. What will be your communication with staff, patients and visitors?

I believe I can say without a doubt that these situations are ones we all dislike and try to avoid if possible. However, a little “disaster” preparedness will go a long way.

How do you manage “sticky” situations in your practice?


Barbara C. Phillips, NP, FAANP is a professional speaker, author, clinician and business owner who provides business education, resources and support to Nurse Practitioners, Physician Assistants and other Advance Practice Clinicians — both for the employed and self-employed clinician. Additional information about Ms. Phillips is available at www.BarbaraCPhillips.com.

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  1. Barbara,
    This is a really great article, filled with awesome ideas and reminders. I think the more clear we can be with our boundaries, the better off we are when there is a breech. If we are vague then the results we allow will also be vague. Thank you for such wonderful suggestions!

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