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Disruptive behavior remains a common occurrence in health care; organizations may lack policies to identify, prevent, and address such behavior.
• Physicians can address disruptive behavior with peer-to-peer meetings.
• Bioethicists can ensure individuals who report such behavior are supported.
• Leaders can make it clear that disruptive behavior won’t be tolerated.
In 2008, The Joint Commission issued a Sentinel Event Alert on behaviors that undermine a culture of safety; its leadership standard requires all hospitals to have a process for managing disruptive and inappropriate behaviors.1 Seven years later, however, disruptive behavior remains a troubling problem in health care.
“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; they most frequently identified nurses as the source of disruption.2 Forty attending physicians were also 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. Owens says ethicists have an obligation to:
• help to create policies that prohibit disruptive behavior, and
• 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 1627 physician executives surveyed in a 2004 study reported regularly encountering disruptive physician behavior; nearly 80% said disruptive physician behavior is under-reported because of victim fear of reprisal or is only reported when a serious violation occurs.3 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, most commonly in the emergency department. “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 ER or operating room 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.”
Inclusion of ethicists during the process of developing policies on disruptive behavior, Kowdley says, “will allow the process itself to be inclusive of all parties and their wishes,” he says. “Ethicists do a great job of having individual opinions be respected and heard.”
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 amongst 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. “But how do we defuse these situations before a bioethicist is called in?”
Physicians may become defensive if approached by an ethicist 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. “But we need input from both physicians and non-physicians. We all have to work together on this.”
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 the 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.”
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 standards, Nelson expects that many organizations still lack formal policies or guidelines to address disruptive behavior. “Part of the work of an ethics program should be to at least review, if not draft, that policy,” he says. “Just as guidelines to withdrawing life-sustaining treatment are essential, so are guidelines to ensure appropriate behavior.”
Ethicists need to ensure that unacceptable behaviors are identified; 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 will vary depending on the organization’s resources. For instance, 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.”