A matter of respect

Disruptive behavior is common in U.S. hospitals, according to a recent survey.

What may seem like appropriate work behavior to one person isn't always acceptable to others. Indeed, degrading remarks, yelling, swearing and inappropriate joke-telling are rampant among doctors and nurses at the nation's hospitals, a November/December 2009 survey by the American College of Physician Executives found. About 10% of survey participants said they witness these kinds of problems daily, and 30% said they see them at least weekly.

While both nurses and physicians are to blame, survey respondents said physicians are more likely to behave improperly.

Photo by Thinkstock
Photo by Thinkstock

Alan Rosenstein, MD, medical director and vice president at Physician Wellness Services, learned firsthand about the pervasiveness of disruptive behavior in health care when he conducted a survey to seek explanations for nursing shortages a few years ago. Physician Wellness Services helps physicians manage work/life issues, and healthcare organizations manage performance issues.

“It was like opening Pandora's box. People kept thanking me for bringing (unpleasant behavior) up, because no one wanted to deal with the problem that they knew was preventing them from doing their best work,” Dr. Rosenstein said.

Failure to address the issue contributes to nursing shortages, patient compliance and safety issues, liability problems, loss of profitability and possible failure to meet Joint Commission standards, he added. Those standards include having a code of conduct that defines disruptive and inappropriate behaviors, as well as having a formal process for managing them.

“The evidence is clear that when people treat others with disrespect based on their status, it has a corrosive effect on the workplace. People stop offering suggestions and do not perform as well,” said Lucian Leape, MD, an adjunct professor of health policy at Harvard School of Public Health.

They also find ways to “work around” the problem colleague. For example, a nurse may stop giving a complete report to a difficult physician, said Michael Buckley, MD, chief medical officer at Pennsylvania Hospital in Philadelphia. This can compromise patient safety. “Health care is complicated and there is no room for poor communication,” Dr. Buckley said.

It starts early

Disruptive behavior is a manifestation of deeper issues in the culture of many hospitals, Dr. Leape said.

“The U.S. has a dysfunctional health care industry. The culture is built on hierarchy and deference,” he said. “Doctors come out of medical school with a sense of entitlement and little respect for the value of teamwork in creating quality and safety. We need to be providing better role models at this level.”

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, and passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities, The Joint Commission said in a July 2008 report, “Behaviors that Undermine a Culture of Safety.”

“Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions,” the report said. “Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.”

Problematic workplace behavior is anything that adversely affects the ability of the team to achieve its desired outcomes, noted Gerald Hickson, MD, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

“Most often it is passive or passive-aggressive, such as ignoring pages or refusing to engage in dialogue with the staff,” he said. “The Joint Commission has made it clear that all forms of non-teamwork-enhancing behavior are a problem as they undermine the trust that is essential to teamwork.”

Hospitalists' unique position

Since hospitalists are in the hospital all the time, they are in a position to know what is really going on and serve as a conduit to the administration, Dr. Rosenstein said.

“They also can play a pivotal role in setting a good example for all team members,” he said. “When they don't behave well, it upsets the system even more than when other specialists misbehave because attending physicians aren't always around when they are. The complexity of their patients is often high, as is their level of direct patient contact,” he added.

When someone is disruptive, hospitalists have the proximity and authority to say something about it immediately. “No one starts out the day planning to be disruptive but things can get out of hand, and it is a good idea to bring it to their attention before an intervention has to take on a punitive nature,” Dr. Rosenstein said.

Hospitalists should be alert to early signs of burnout in colleagues, like undue irritability and personality changes. “Some people might not think their current stress level is new after all of their years of hard work to get where they are, and peer-to-peer feedback may be very helpful,” Dr. Rosenstein said.

Hospitalists also need to know their institution's policies on poor workplace behavior and the chain of command for reporting it. If such a chain does not exist, they need to request it from the administration, said Dr. Buckley.

Taking action

Around 5% of doctors are known to generate 35% or more of unsolicited patient complaints, and those same proportions seem to apply to coworker complaints, said Dr. Hickson. The worst thing a hospital—or the physician's colleagues—can do is assume the offender knows that his or her behavior is a problem; a group of peers should thus approach him or her in a professional, nonjudgmental way with this information, he said.

“Most really don't know and will self-correct if told. It is not up to the group to change them. Urge them to figure it out themselves and let them know that if they do not, there will be consequences,” Dr. Hickson said.

These conversations can be hard, but they are essential. “The mark of a profession is that it is a self-regulating entity. We need group accountability,” Dr. Hickson said.

Hospitalist teams can collectively agree on and enforce the core values that are expected of all members—expectations that should be defined in writing and given to all new hires. “This forms the basis for follow-up conversations if problems do arise,” Dr. Hickson said. “Groups that do this well will thrive.”

The Joint Commission requires hospitals to have a policy on disruptive behaviors. However, having a policy doesn't hold much value beyond getting Joint Commission approval, unless it is applied consistently, Dr. Rosenstein said. “All people need to be held accountable,” he said. “MDs cannot be immune.”

Administrators need to be serious in their commitment to taking action. “Once the leadership is on board, the mechanisms are straightforward. You only have to fire one person for people to get the message,” Dr. Leape said.

It is imperative that staff members know they can complain about disruptive behavior privately and the matter will be investigated. “Everyone needs to know their voice is important and that they can trust the system,” Dr. Hickson said.

Often the outcome of complaints is not conveyed to the staff member who complained. “Or sometimes the nurse is told the situation has ‘been handled,’ but she doesn't know what that means,” Dr. Buckley said. “We need to make sure that information doesn't fall through the cracks by giving her a complete follow-up report.”

The ultimate goal should be to salvage employment situations, not ruin them. “Doctors and nurses are precious, scarce resources and organizations need to have a zero tolerance policy at the highest levels to protect them,” Dr. Rosenstein said.