Disruptive Behavior is Bad for Patients on Louisiana Medical News

Disruptive Behavior is Bad for Patients

By: SHARON H. FITZGERALD

Survey Reveals Troubling Conduct in the Healthcare Environment

Being a good member of a team means playing well with others, but a recent survey by the American College of Physician Executives reveals that disruptive behavior by professional members of healthcare teams compromises patient safety, undermines cooperation and makes going to work a miserable experience.

“As healthcare moves toward high-performing teams of professionals with multidisciplinary backgrounds, we wanted to just see what was the state of the problem after years of talking about it. We were somewhat surprised to see that there continues to be a problem with this in the healthcare industry,” said Barry Silbaugh, MD, ACPE chief executive officer.

The electronic survey was e-mailed to about 13,000 doctors and nurses in hospitals, group practices, academic medical centers and other healthcare settings. Published in the November/December 2009 issue of Physician Executive Journal, the survey results disclose that an astounding 97.4 percent of respondents have experienced behavior problems with doctors and nurses in the past year. What’s more, 10 percent said they witness such problems daily. “When it’s threatening and intimidating, we know that it’s a threat to patient safety. That’s what’s really troubling about this,” Silbaugh said.

In response to one survey question, respondents shared troubling anecdotes: a physician who lay on the floor in the operating room – with the patient open on the surgical table – because an instrument didn’t work correctly; a nursing director who screamed at her nursing colleagues every day; nurses who colluded to get a physician fired; a physician who hit a nurse; cursing by physicians or nurses in front of other staff and even in front of patients; and a surgeon flinging the blood and fluids of an HIV-positive patient at a nurse.

Other survey results were:

That 85 percent of respondents experienced degrading comments and insults.
That 73 percent reported yelling.
That 2.8 percent reported that they had experienced or witnessed physical assault.
That a majority of respondents, 52.3 percent, said the number of problems between doctors and nurses has stayed consistent over the last three years.

Gerald B. Hickson, MD, a national authority on disruptive behavior in the healthcare workplace and the director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, said he defines disruptive behavior as “any behavior that adversely affects the ability of the team to achieve its intended outcomes.” And that team includes physicians, nurses, administrators, pharmacists, technicians and even the patient and his or her family and friends.

Hickson said 4 to 6 percent of healthcare professionals exhibit patterns of disruptive behavior. “When we model the attributes of a professional, we don’t have disruptive behavior, but all of us periodically will stub our toe,” he said. The occasional toe stub isn’t at issue here; the problem is consistent displays of unacceptable conduct that undermine teamwork. He divided this unfortunate behavior into three categories:

Aggression. “Unfortunately, most of the discussion, which I don’t think helps us, is about aggressive and bullying behavior. Yet we don’t see a lot of that,” Hickson said.
Passive-aggressive actions like sabotage and bad-mouthing a colleague.
Passive behavior like failing to complete an assigned task or simply not returning a phone call. Such behavior, Hickson said, can be “just as destructive as the aggressive.” He labeled as “enabling behavior” the actions of colleagues who complete tasks for these passive offenders.

Hickson said such behaviors “create lots and lots of inflammation within the environment, which creates barriers for us achieving what we want to do. … It contributes to the burnout of staff members who have to tolerate it, and it creates bad reputations within the community.” He added that there’s “no question” that it affects patient care.

The Joint Commission agrees. On Jan. 1, 2009, a Joint Commission “Sentinel Event Alert” took effect, requiring accredited facilities to create a code of conduct and establish a process for educating staff and identifying and managing unacceptable behaviors. The requirement is a zero-tolerance policy.

According to the alert, these “intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”

Promoting a dialogue among colleagues is the key to tackling the problem. “So often, people suffer in silence,” said Hickson, who conducts onsite CME seminars entitled “Taming Disruptive Behavior.” His frustration is when attendees know who the offenders are in their organization, yet they haven’t taken appropriate action. “The problem is, nobody’s done a dang thing except talk about each other instead of talk to each other about the challenge,” he said. Sometimes, letting offenders know they have a problem may be all that’s necessary, he noted. “The goal is restoration,” he said, and a system that’s “kinder and safer.”

Silbaugh pointed to the aviation industry as a model for how to create open communication lines in a workplace. Once plagued with miscommunication and an inflexible hierarchy that discouraged junior pilots from speaking up even if they recognized a problem, the aviation industry today encourages a more horizontal model. “One of the key factors for a safe environment is that the hierarchy needs to break down periodically when safety is at stake,” Silbaugh said. “In other words, the person with the most expertise, the most knowledge, best able to handle a certain problem should be given that right and that authority – and it’s not always the physician.”

Silbaugh encouraged what he called the ARCC approach, which he said is particularly useful when someone disagrees with a colleague who has more authority. First, he said, “using the lightest touch possible,” Ask a question. If that question falls on deaf ears, make a Request for change. Next, it’s time to voice a Concern. When all else fails, it’s time to turn to the Chain of command.

Finally, Silbaugh noted that managers and administrators must be proactive. One suggestion he had was to reduce inefficient processes that frustrate medical professionals. Without such frustrations, tempers remain in check.

For more information, visit www.acpe.org and click on Resources on Hot Topics. A “tool kit” is available.