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Disruptive and Unprofessional Behavior
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Background

Although the television physician of old was sometimes depicted as grandfatherly (Marcus Welby), today's iconic TV physician is Dr. Gregory House: brilliant, irascible, and virtually impossible to work with. This stereotype, though undoubtedly dramatic and even amusing, obscures the fact that disruptive and unprofessional behavior by clinicians poses a definite threat to patient safety. Such behavior is common: in a 2008 survey of nurses and physicians at more than 100 hospitals, 77% of respondents reported witnessing physicians engage in disruptive behavior (most commonly verbal abuse of another staff member), and 65% reported witnessing disruptive behavior by nurses. Most respondents also believed that unprofessional actions increased the potential for medical errors and preventable deaths. Disruptive and disrespectful behavior by physicians has also been tied to nursing dissatisfaction and likelihood of leaving the nursing profession, and has been linked to adverse events in the operating room. Physicians in high-stress specialties such as surgery, obstetrics, and cardiology are considered to be most prone to disruptive behavior. These concerns should not obscure the fact that no more than 2%-4% of health care professionals at any level regularly engage in disruptive behavior.

Disruptive behaviors linked to adverse events in survey* of hospital staff. 71% felt that disruptive behaviors were linked to medical errors; 27% felt that disruptive behaviors were linked to patient mortality; 18% report that they were aware of a specific adverse event that occurred because of the disruptive behavior. (*Of 4530 participants: 2846 nurses, 944 physicians, 40 administrative executives, 700 other.)

Source: Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008:34;464-471. [go to PubMed]

Although there is no standard definition of disruptive behavior, most authorities include any behavior that shows disrespect for others, or any interpersonal interaction that impedes the delivery of patient care. Fundamentally, disruptive behavior by individuals subverts the organization's ability to develop a culture of safety. Two of the central tenets of a safe culture—teamwork across disciplines and a blame-free environment for discussing safety issues—are directly threatened by disruptive behavior. An environment in which frontline caregivers are frequently demeaned or harassed reinforces a steep authority gradient and contributes to poor communication, in turn reducing the likelihood of errors being reported or addressed. Indeed, a workplace culture that tolerates demeaning or insulting behavior is likely to be one in which workers are "named, blamed and shamed" for making an error. The seriousness of this issue was underscored by a 2008 Joint Commission sentinel event alert, which called attention to this problem.

Preventing and Addressing Disruptive Behavior

As the sentinel event alert noted, "There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care." This attitude is so widespread that, in some settings, disruptive behavior is considered the norm. Several studies have demonstrated that unprofessional behavior during medical school is linked to subsequent disciplinary action by licensing boards, suggesting that an early emphasis on teaching professionalism and addressing disruptive behavior during training may prevent subsequent incidents.

Unfortunately, there are few data to guide efforts to prevent and address disruptive behaviors. It is clear that eliminating such behaviors, and developing a strong culture of safety, requires a strong organizational emphasis. Role modeling desired behaviors, maintaining a confidential incident reporting system, and training managers in conflict resolution and collaborative practice are likely to be beneficial. Although not formally studied, other interventions designed to improve a culture of safety, such as teamwork training and structured communication protocols, may have the potential to reduce disruptive behaviors, or at least promote early identification of them. An editorial by Dr. Lucian Leape, one of the founders of the patient safety movement, proposed a systems-level approach to identifying, monitoring, and remediating poorly performing physicians, including those who regularly engage in unprofessional behavior. This approach would require collaboration between hospital accreditation organizations, federal and state medical licensing boards, and individual hospitals to establish formal standards for professional conduct, monitor adherence to those standards through confidential evaluations, and provide punishment and/or remediation in response to violations.

Although most patient safety problems are attributable to underlying systems issues, disruptive behaviors are fundamentally due to individual actions. The concept of just culture provides an appropriate foundation for dealing with disruptive behavior, as it calls for disciplinary action for individuals who willfully engage in unsafe behaviors. The Joint Commission requires that organizations have an explicit code of conduct policy for all staff and recommends including a "zero tolerance" approach to intimidating and disruptive behaviors. One example of a successful approach is the "disruptive behaviors pyramid" approach developed at Vanderbilt University Medical Center. A stepwise process for identifying and managing problem behaviors is outlined in this AHRQ WebM&M perspective.

Current Context

The Joint Commission's Leadership Standard went into effect in 2009, including mandates for organizations to maintain a code of conduct that defines disruptive behaviors and a process for managing such behaviors. A subsequent sentinel event alert issued in August 2009 reinforced the importance of leadership in ensuring a culture of safety, with prevention of disruptive behavior among the key leadership attributes delineated. Adherence to the leadership standard is evaluated as part of Joint Commission accreditation surveys.

 
What's New in Disruptive and Unprofessional Behavior on AHRQ PSNet
STUDY
Nurses' perspectives regarding the disclosure of errors to patients: a qualitative study.
McLennan SR, Diebold M, Rich LE, Elger BS. Int J Nurs Stud. 2014 Oct 9; [Epub ahead of print].
NEWSPAPER/MAGAZINE ARTICLE
Alarm management: first things first: using reliable data to eliminate unnecessary alarms.
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
BOOK/REPORT
GMC National Training Survey 2014: Bullying and Undermining.
Manchester, UK: General Medical Council; November 2014.
REVIEW
Conflict of interest, Dr Charles Denham and the Journal of Patient Safety.
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
STUDY
Systematic biases in group decision-making: implications for patient safety.
Mannion R, Thompson C. Int J Qual Health Care. 2014;26:606-612.
STUDY
Silence that can be dangerous: a vignette study to assess healthcare professionals' likelihood of speaking up about safety concerns.
Schwappach DLB, Gehring K. PLoS One. 2014;9:e104720.
STUDY
Error in intensive care: psychological repercussions and defense mechanisms among health professionals.
Laurent A, Aubert L, Chahraoui K, et al. Crit Care Med. 2014;42:2370-2378.
 
Editor's Picks for Disruptive and Unprofessional Behavior
From AHRQ WebM&M
How to Identify and Manage Problem Behaviors.
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA. AHRQ WebM&M [serial online]. December 2009
In Conversation with…Gerald B. Hickson, MD.
AHRQ WebM&M [serial online]. December 2009
Danger in Disruption.
Dorrie K. Fontaine, RN, PhD. AHRQ WebM&M [serial online]. October 2009
Difficult Encounters: A CMO and CNO Respond.
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS. AHRQ WebM&M [serial online]. October 2009
Do Not Disturb!.
F. Daniel Duffy, MD; Christine K. Cassel, MD. AHRQ WebM&M [serial online]. October 2007
Is the "Surgical Personality" a Threat to Patient Safety?
Charles L. Bosk, PhD. AHRQ WebM&M [serial online]. April 2006
 
From AHRQ PSNet
BOOK/REPORT
Defusing Disruptive Behavior. A Workbook for Health Care Leaders.
Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
Silence Kills: The Seven Crucial Conversations for Healthcare.
Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. VitalSmarts; 2005.E45
JOURNAL ARTICLE
Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.
Speck RM, Foster JJ, Mulhern VA, Burke SV, Sullivan PG, Fleisher LA. Jt Comm J Qual Patient Saf. 2014;40:161-167.
Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.
Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. BMJ Qual Saf. 2013;22:532-540.
Perspective: a culture of respect—part 1 and part 2.
Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012;87:845-858.
Professionalism: a necessary ingredient in a culture of safety.
DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.
 Classic iconA survey of the impact of disruptive behaviors and communication defects on patient safety.
Rosenstein AH, O'Daniel M. Jt Comm J Qual Patient Saf. 2008;34:464-471.
 Classic iconA complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.
Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. 2007;82:1040-1048.
 Classic iconProblem doctors: is there a system-level solution?
Leape LL, Fromson JA. Ann Intern Med. 2006;144:107-115.
 Classic iconDisciplinary action by medical boards and prior behavior in medical schools.
Papadakis MA, Teherani A, Banach MA, et al. N Engl J Med. 2005;353:2673-2682.
 Classic iconDisruptive behavior and clinical outcomes: perceptions of nurses and physicians.
Rosenstein AH, O'Daniel M. Am J Nurs. 2005;105:54-64.
 Classic iconPatient complaints and malpractice risk.
Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. JAMA. 2002;287:2951-2957.
LEGISLATION/REGULATION
Leadership committed to safety.
Sentinel Event Alert. August 27, 2009;(43):1-3.
Behaviors that undermine a culture of safety.
Sentinel Event Alert. July 9, 2008;(40):1-3.
ACOG Committee Opinion #366: disruptive behavior.
ACOG Committee on Patient Safety and Quality Improvement of American College of Obstetricians and Gynecologists. Obstet Gynecol. 2007;109:1261-1262.
NEWSPAPER/MAGAZINE ARTICLE
Arrogant, abusive and disruptive — and a doctor.
Tarkan L. New York Times. December 1, 2008;Science Desk:1.
Hospitals try to calm doctors' outbursts: medical road rage affecting patient safety, group says.
Kowalczyk L. The Boston Globe. August 10, 2008;Metro section:1A.
 
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Last Updated: August 2014