Study: Infighting among doctors and nurses is frequent and harms patients

Disruptive behavior directly threatens patient safety; what you can do

Arguments, nasty comments, and demeaning behavior — what health care professional can’t tell stories of how some co-worker or colleague made life miserable for people just trying to do their jobs? Disruptive behavior is all too common in health care, but now experts are warning that the harmful effects fall on more than just the health care professionals.

New research conducted by VHA Inc. has found that disruptive behavior between physicians and nurses occurs frequently and affects patient outcomes. As a result of this behavior, these providers report that patients are experiencing pain or prolonged pain, receiving medications or antibiotics late, being mistreated or misdiagnosed, or dying.

Can a lawsuit be far behind? Something along the lines of, "The doctors and nurses were so busy arguing with each other that they missed the patient’s obvious signs of distress until it was too late." That scenario definitely can happen, researchers say, and it probably already has.

More than three-quarters (86%) of nurses who participated in the survey and nearly half (49%) of physicians said they have witnessed disruptive behavior.1 Research also revealed disruptive behavior between nurses is prevalent. Sixty-eight percent of nurses and 47% of physicians who responded said they have witnessed disruptive behavior between nurses and from nurses aimed at other hospital staff.

Direct effect on patient safety found

Previous studies have shown the harmful effects of disruptive behavior on staff and health care operations, but the recent study is the first to decisively show that patient safety is undermined. The latest research comes from Alan H. Rosenstein, MD, vice president and medical director at VHA in Irving, TX, and Michelle O’Daniel, director of member relations for VHA. The study was initiated to assess perceptions of the impact of disruptive behavior on nurse-physician relationships and to determine what physicians, nurses and hospital administrators believe to be its effects on patient care.

Surveys were distributed to 50 VHA member hospitals in more than 12 states and results from more than 1,500 participants were evaluated.

The survey found that most respondents (94%) believe disruptive behavior impacts adverse events, medical errors, patient safety, patient mortality, quality of care, and patient satisfaction. Sixty percent of the respondents were aware of potential adverse events that may have occurred from disruptive behavior.

For the purposes of the study, disruptive behavior refers to any inappropriate behavior, confrontation or conflict, ranging from verbal abuse to physical and sexual harassment.

Direct patient harm from personal conflicts

In perhaps the most disturbing finding, 17% of the respondents reported that they knew of a specific adverse event that occurred as a result of disruptive behavior and 78% of those respondents felt the adverse event could have been prevented. "The survey suggests a serious problem within and across disciplines," Rosenstein says. "It’s not just disruptive physician behavior either. That’s a common myth. It’s disruptive nurse behavior also and disruptive staff behavior across the board."

In the VHA study, the respondents confidentially reported incidents in which disruptive behavior among coworkers resulted in actual harm to patients and plenty of near-miss incidents as well. Comments included incidents such as a nurse making a medication error because a confrontation with a doctor had upset her.

Throwing placentas and scalpels at nurses

The survey also found that disruptive behavior affects nurses’ and physicians’ stress levels (94%), frustration levels (94%), concentration (83%), communication (92%), collaboration (90%), information transfer (87%), and workplace relationships (91%). Each of those psychological and behavioral variables can directly affect patient safety, Rosenstein notes.

O’Daniel says part of the problem can be traced to generational differences in the expectations of health care professionals. Nurses, for instance, used to put up with far more outlandish behavior than would be tolerated today. O’Daniel recalls speaking to one older, very accomplished OB/GYN who read the study results and said he could be one of the unidentified physicians cited in the confidential reports.

"He said, We used to throw placentas and scalpels at the nurses,’" she recalls. "He went on to say that the doctors learned not to do such overtly physical and violent things, but that they still might not think of some of these other verbal confrontations as being so hurtful and disruptive."

Yelling and condescending comments might not be seen by some as disruptive behavior, O’Daniel says, but they should be. Such behavior often is tolerated as part of the tradition in the medical community, particularly when it comes to doctors yelling at nurses.

Risk managers and other leaders may be hesitant to confront physicians who bring business to the hospital, but other demands are changing that, Rosenstein says. The severe staffing shortage in some areas means that no one wants a good nurse driven away because she can’t stand the verbal abuse. And there is the question of secondary liability from any harassment lawsuits, plus the very real possibility of a malpractice lawsuit stemming from disruptive behavior.

But remember, the bad guy is not always the doctor. "Nursing disruptive behavior is as prevalent as physician disruptive behavior," Rosenstein says.

Might not be easy to address

William Lynagh, MD, is a former practicing physician and health care administrator who moved into consulting and now is the founder of the Center for Holistic Leadership in Greensboro, NC. Lynagh has helped health care organizations resolve disruptive behavior problem and he says he encountered plenty in his own medical career as well. He advises risk managers to make sure they have a "culture of openness" because otherwise you’ll never even hear about a lot of disruptive behavior.

"You need to have clearly stated values, be open to listening, and then have the strength and courage to act on that value system," he says. "Health care still has very much a mentality in which doctors give orders and expect nurses to carry them out without question. Good communication and respect is not always valued as highly as it should be, so this is not always easy for a forward-thinking risk manager to address."

When you try to address disruptive behavior, the person accused of acting improperly may be genuinely shocked and not understand what he or she did wrong, Lynagh says. Don’t underestimate the wide variation in how people can interpret the same behavior or the way certain comments can come across far differently than the speaker intended.

"People often can have a certain behavior — a tone of voice or a habit of speaking loudly — and have no idea how it affects other people," he says. "Sometimes you have to acknowledge that they don’t mean any harm from that behavior, but you have to convince them that they still need to manage the way people react to it. If you’re not really so angry, OK, but how can you manage the fact that people think you are?"

Allow people a graceful way to improve

That can be less threatening to the personality of the person in question and encourage a more productive response. Allow the person to be part of the solution and allow them a face-saving way out. If the person can say, "Gee, I didn’t know people thought I was so angry. I guess my loud tone comes from growing up in a big family where we were all loud," he or she can act on that realization.

And whether it is completely true or not, that is much easier than simply admitting you’re an unpleasant person to work with. "You’re not trying to beat them into submission and get them to say how terrible they are," Lynagh explains. "You’re trying to change the behavior, and that works best when they can do it without having to feel terrible about themselves."


1. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses & physicians. Am J Nurs 2005; 105:52-62.