Use social influence to fight disruptive behavior

By Joseph Grenny, Consultant, VitalSmarts

With The Joint Commission's recent announcement that rude language and hostile behavior pose serious threats to patient safety and quality of care, risk managers are on high alert for disruptive behavior and searching for ways to combat it. And for good reason: The "Silence Kills" study, conducted by VitalSmarts and the American Association of Critical-Care Nurses, reveals that more than three-fourths of caregivers regularly work with doctors or nurses who are condescending, insulting, or rude.

But while these disruptive and disrespectful behaviors can be hurtful, what prompted The Joint Commission to address them as a condition of accreditation is the mounting evidence that these behaviors also are harmful. The Silence Kills study found that more than 20% of health care professionals have seen actual harm come to patients as a result of such behavior.

There are many ways that risk managers can combat disruptive behavior, but one of the most effective strategies also is one of the simplest: Get people to talk. Encourage them to have "crucial conversations" about disruptive behavior, so it can be stopped.

The Joint Commission has taken an important step by requiring hospitals to create a clear code of conduct demonstrating the unacceptability of disruptive behavior and laying the groundwork for holding caregivers accountable for their behavior. While this is an important element of influencing behavioral change, the research shows that there is something far more immediate and powerful individuals and leaders can do to drive change: They need to break the code of silence.

The most powerful force over human behavior is social influence. People will do almost anything to gain acceptance or avoid rejection. Unfortunately, the vast majority of health care workers fail to exercise the enormous social influence they have in the face of disruptive behavior.

As a result, disruptive behavior has lingered for years awaiting social disapproval, yet receiving none.

If health care leaders want to not only secure the well-being of patients, but also increase employee retention and engagement, the most immediate and effective thing they can do is change this culture of silence. They need to substantially increase caregivers' skill and will to step up to crucial conversations immediately and directly when inappropriate behavior emerges.

Health care risk managers who want to engage social influence to eliminate disruptive behavior will have to break the code of silence in these four crucial conversations:

1. Administrations must go public about the pervasiveness of concerns. Most hospitals attempt to put a good face on disruptive behavior by dismissing it as a problem with "a few bad apples." The truth, according to the Silence Kills study, is that it happens every day in most hospitals. It is not just a few bad apples. In order to influence change, leaders need to begin by acknowledging the frequency of concerns.

2. Caregivers must directly confront disruptive behavior. Next, leaders need to invest substantially in increasing the will and skill of every employee to speak up when he or she sees problems. The focus needs to be not just on confronting disruptive behavior, but on speaking up when people see mistakes, incompetence, violations of safety standards, and more. The Silence Kills study identifies seven kinds of problems; fewer than one in 10 people address those problems effectively, which can lead to burnout, disengagement, errors, and worse.

3. Medical directors and nurse managers must respond appropriately to escalations. The research also shows that the problem is not just upward; it's sideways and downward. Nurses fail to speak up to their peers when they have concerns. Managers fail to confront direct reports. Medical directors give their underlings a "pass" rather than make waves. The silence is deafening in every direction - and lower-level employees will not feel the expectation to address concerns if their leaders don't lead the way.

4. Administration must back up sanctions when they occur. The most common reason people fail to speak up in hospitals is that they adopt the attitude of "It's not my job." The second most common reason is the belief that "Others won't back me up if I do." For example, nurse managers worry if they confront a disruptive doctor who brings a lot of money into a hospital, no one in administration will back them up. Administration must make it clear that if code-of-conduct violations occur, they will back up those who take appropriate action.

Risk managers must take a lead role in speaking out against disruptive behavior. Start the conversation. State clearly and loudly that disruptive, abusive, potentially harmful speech and behavior by physicians and staff will not be tolerated. Simply saying it out loud, and with authority, goes a long way toward changing the culture. As the saying goes, "Silence betokens consent."

The pervasive and risky problems with disruptive behavior in hospitals today will not be eradicated by codes of conduct - although these are a worthwhile step in the right direction. The real change will occur when we substantially increase skills in conversation - especially the emotionally and politically risky conversations we so consistently avoid. When this vast potential of social pressure is finally tapped, our hospitals will become healthier for patients and caregivers alike.

(Editor's note: Joseph Grenny is the co-author of the books Influencer, Crucial Conversations, and Crucial Confrontations. He is a co-founder of VitalSmarts, a consulting group in Provo, UT, that offers advice on the role crucial conversations play in medical errors, employee retention, and patient satisfaction. For more information, go to