EXECUTIVE SUMMARY
Disruptive behavior remains a common occurrence in healthcare. Some organizations lack policies to identify, prevent, and address such behavior.
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Physicians can address disruptive behavior with peer-to-peer meetings.
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Managers can ensure individuals who report such behavior are supported.
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Leaders can make it clear that disruptive behavior won’t be tolerated.
Despite the fact that The Joint Commission issued a Sentinel Event Alert in 2008 on behaviors that undermine a culture of safety,1 disruptive behavior remains a troubling problem in healthcare.
“Some physicians have enormous hubris,” says William Doscher, MD, associate chair of ethics in the Department of Surgery at Hofstra North Shore — Long Island Jewish School of Medicine in Hempstead, NY, and an attending physician in the Department of Medicine’s Division of Medical Ethics. “They feel they are untouchable: ‘What are you going to do, fire me? I’m the only guy who can do the total knee.’”
Disruptive behavior was experienced by 93% of 394 interns surveyed at Partners HealthCare in Boston during the 2010 and 2011 academic years.2 They most frequently identified nurses as the source of disruption. Forty attending physicians also were surveyed and reported other physicians as the most frequent source of disruption. Donald P. Owens Jr., PhD, the James A. Knight, MD, Chair of Humanities and Ethics in Medicine at Tulane University School of Medicine, says in his experience, bullying is most often directed at medical students by residents and nurses. Sources say managers have an obligation to:
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help to create policies that prohibit disruptive behavior;
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explain the procedures for reporting disruptive behavior, and support individuals when it occurs. “This needs to be developed with the input of those who have been impacted by disruptive behavior,” says Owens.
Almost all (96%) of 1,627 physician executives surveyed in a 2004 study reported regularly encountering disruptive physician behavior.3 Nearly 80% said disruptive physician behavior is under-reported because of victim fear of reprisal or is only reported when a serious violation occurs. Gopal Kowdley, MD, PhD, associate program director in the Department of Surgery at Baltimore-based St. Agnes Hospital, recently surveyed practicing physicians and trainees about disruptive behaviors. About half of the physicians reported observing aggressive or intimidating behavior in the workplace.
“Places where a process was in place to deal with aggressive behavior tended to make physicians perceive themselves as happier,” says Kowdley, adding that the most common incidents involve interactions among physicians and ancillary staff in the operating room or emergency department settings. “As a program director, I run into this often,” he says. “Belittling, and sometimes elevation of voices, is common, especially when there is a delay in services.”
Are staff in denial?
Denial is one reason disruptive behavior continues at many organizations, even those with policies in place to address it.
Recently, Doscher expressed concern to a colleague over a physician who was observed speaking rudely. The colleague’s response was, “Don’t worry about him. He’s always like that. It’s nothing to be concerned about.” “But it is!” says Doscher. “Who can argue about the fact we should try to do something about it? But it doesn’t happen by magic. It really doesn’t.”
Doscher most often encounters disruptive behavior in surgeons. He says that ideally, physicians should resolve disruptive behavior among peers. “You don’t want this to go to administrators. That is exactly the worst way to deal with physicians. This is a professional problem,” he says.
Physicians might become defensive if approached by someone on staff without a clinical background. “There is a feeling that they are just sticking their noses in and quoting from a book they read,” says Doscher. However, the issue of disruptive behavior needs input from clinicians and administrators, he says. “We all have to work together on this,” Doscher says.
Doscher envisions using peer-to-peer meetings as a vehicle to address disruptive physicians. “We’ve talked about establishing a committee of physicians who can sit down and talk with the physician — not next week, but as soon after the incident as possible,” he says. Doscher helped to rewrite his organization’s bylaws addressing disruptive behavior, but acknowledges that even the best policies don’t ensure such behavior is eradicated. “It’s very easy to say, ‘Thou shalt not be a bully.’ But we are dealing with human beings who are under significant stress,” he says. “We are beginning to understand this. But it’s not going to happen overnight.”
Not in alignment
The problem of disruptive behavior reflects a misalignment between organizational values and the behavior of individual clinicians, according to William A. Nelson, PhD, associate professor at The Dartmouth Institute for Health Policy and Clinical Practice in Hanover, NH.
“As the organization establishes its values, it is really up to every person to be aligned with those values in their behaviors,” he says. “When inappropriate, abusive behavior is occurring, it really is the responsibility of everyone to call it out and address it.”
Despite The Joint Commission’s 2008 Alert, Nelson expects that many organizations still lack formal policies or guidelines to address disruptive behavior. “Just as guidelines to withdrawing life-sustaining treatment are essential, so are guidelines to ensure appropriate behavior,” he says.
Ensure that unacceptable behaviors are identified. Also, a structure must be in place to address incidents as they arise.
“There ought to be training about this, so that people understand what is expected of them as a professional,” says Nelson. “If people feel they have been treated inappropriately, they need to have a resource or mechanism to go to.”
This process will vary depending on the organization’s resources. For example, the chair of a department can make it clear that if disruptive behavior occurs within the department, anyone can go directly to him or her to report it. “If leaders are aware of inappropriate behavior, it needs to be called out one way or other. It cannot be ignored,” says Nelson.
When disruptive behavior is tolerated, it becomes part of the organizational culture. “You change it by having effective role models,” says Nelson. “If leaders don’t demonstrate the values that are captured in various policies, then you have a real problem.”
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The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert Issue No. 40. Oakbrook Terrace (IL): Joint Commission; 2008. Accessed at http://www.jointcommission.org/assets/1/18/SEA_40.pdf.
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Mullan CP, Shapiro J, McMahon GT. Interns’ experiences of disruptive behavior in an academic medical center. J Grad Med Educ 2013; 5(1):25-30.
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Weber DO. Poll results: Doctors’ disruptive behavior disturbs physician leaders. Physician Executive 2004; 6-14.
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