Describe tiers of disruptive behaviors and actions to address them
Discuss how disruptive behavior negatively affects patient care
Rude interactions, unpleasant language, hostile attitudes, and other bad behaviors not only create an unpleasant environment, but are detrimental to patient safety and quality of care, according to The Joint Commission's most recent Sentinel Event Alert targeting disruptive behavior by healthcare providers.
This alert ties into new Joint Commission (formerly JCAHO) standards going into effect January 1, 2009, which will require healthcare organizations to create a code of conduct defining acceptable and unacceptable behaviors, as well as crafting a process for handling poor behavior, which may include:
- Sexual misconduct
- Conduct endangering the safety of others
- Possession of a weapon
- Property damage
- Distribution of intoxicants on the property
- Patient abuse
- Breech of patient confidentiality
- Inability to get along with others
- Refusal to perform an assigned task
The Sentinel Event Alert provides 11 steps to curb disruptive behavior, which include providing education and training for healthcare providers about professional behavior and appropriate interactions with coworkers, creating accountability for maintaining appropriate behavior, establishing a zero tolerance policy for disruptive behaviors and a means for enforcing this policy, and crafting nonconfrontational methods for reporting and addressing inappropriate behavior. Read more about the 11 steps.
Tiered approach to bad behavior
Paula Stellman-Ashley, BSN, MBA, of Stellman-Ashley and Associates, LLC, in Racine, WI, was part of an initiative at Wheaton Franciscan Healthcare to implement a process to curb disruptive behavior. Backing a strong chief of staff made making the changes at the facility a much smoother process.
"Rules, standards, and bylaws are there for a reason," Stellman-Ashley says. "You have to look beyond the point of rules on paper. It's not a punishment; they're there for patient safety and quality."
The facility needed to enforce the rules. It had a system in place that included the creation of a red file any time a complication or bad behavior was reported, but there was little to no follow-through.
"At the time, we did have a very disruptive physician," Stellman-Ashley says. "Outbursts of rage, obscenities, condescending and intimidating language, and threats directed at people-all the behaviors listed in the Sentinel Event Alert."
Read about other barriers to reporting disruptive physician behavior.
Wheaton also identified knowledge deficits in future physician leaders and worked on educating them.
"The organization started a program called Executive Leadership Development," Stellman-Ashley says. Select staff members being groomed for leadership positions attended a yearlong program created to help physicians who were not trained in medical school to be in such positions (e.g., coaches and administrators).
The facility then implemented satisfaction surveys that addressed not only patients', but employees' and physicians' satisfaction as well.
Wheaton used a three-tiered system for behavior reporting, classifying severity by a Level I, II, or III behavior. Each level described varying degrees of behaviors and subsequent follow-up.
Given the severity level and potential for harm, the chief of staff or designee assumed responsibility and accountability for investigation. Level I, the most severe violation, required prompt intervention within 24 hours, Level II within five days, and Level III within 10 days.
Follow-up included documented one-on-one conversations, reprimands, warnings, continuing education, staff debriefings, written and verbal apologies to the medical executive committee, referrals, and corrective action pursuant to the medical staff bylaws, including temporary suspension or termination/relinquishment of privileges.
When something goes wrong
A number of studies measuring the effect of disruptive behavior in the healthcare setting have found it can negatively affect patient outcomes, therefore emphasizing the importance of facilities having a strong policy in place when a staff member engages in behavior that will require a response by management. A 2006 study focused specifically on the operating room, revealing that 68% of respondents felt disruptive behavior "needlessly contributes to impaired quality of care." Read more about the results.
Gayla Jackson, RN, BSN, nurse manager at Mount Auburn Hospital in Cambridge, MA, advises meeting with new staff members early in their employment to discuss established performance standards, conduct, and punctuality. If, after 90 days, they do not meet the required standards, corrective action should be taken.
Nurse managers may want to involve management, HR, and legal counsel when necessary.
"HR is instrumental in helping managers deal with this," Jackson says. "Our focus is clinical, and they are human resource specialists; they deal with this all the time. You need HR oversight. And HR confers with legal counsel. It's HR's job to protect [all involved parties]."
Curb negative behavior before it starts
"We don't dig down deep enough to understand what's causing the disruptive behavior," says Robert J. Latino, CEO of the Reliability Center, Inc., in Hopewell, VA. "They don't go to work thinking, 'I'm going to hurt patients today.' If you take at face value that people are good, then there is a reason why they're doing what they do."
Typically, bad behaviors are identified that we were always aware of but simply did not address at the time. "The common denominator is that we're human," says Latino.
The problem is unique in healthcare because so much communication is human to human. The most reliable operation, says Latino, is where machines talk to machines, followed by man-machine interfaces. Finally and least reliable are organizations highly dependent upon human-to-human communications.
Tips for lowering occurrences of bad behavior include:
- Training, coaching, and mentoring for those who struggle with parameters.
- Monitoring for a culture of violations. Try doing anonymous culture of safety surveys in the beginning if staff are fearful to speak up.
- Early intervention for even mild violations.
- Progressive discipline for repeated violations.
- Consistent response and enforcement.
- Systematic solutions to contributing causes.
1. AllBusiness.com. (2006.) "Study: Disruptive behavior in the OR can affect patient outcomes." Available at http://www.allbusiness.com/health-care-social-assistance/1192832-1.html
2. Rosenstein, Alan H., et al. (2002). "Disruptive physician behavior contributes to nursing shortage: Study links bad behavior by doctors to nurses leaving the profession - Doctors, Nurses, and Disruptive Behavior." Physician Executive. Available at http://findarticles.com/p/articles/mi_m0843/is_6_28/ai_94590407
3. The Joint Commission. (2008). "Behaviors that undermine a culture of safety." Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm