Disruptive Practitioner Behavior

A healthcare organization striving to maintain an environment that minimizes patient harm may do so through initiatives like a culture of safety program. The impact of practitioner behavior on patient safety and institutional culture has been studied for many years. Inappropriate or disruptive practitioner behaviors can undermine open communication, trust, and collaboration, which are hallmarks of a culture of safety within an institution.

The American Medical Association (AMA) has identified unacceptable medical staff behavior as an area appropriate for discipline. The AMA divides these behaviors into two categories: 

Inappropriate behavior is unwarranted conduct that can be interpreted by a reasonably prudent person to be demeaning or offensive. Persistent, repeated inappropriate behavior can rise to the level of disruptive behavior.

Examples of this behavior include: 

• Belittling or berating statements.
• Profane or disrespectful language.
• Inappropriate comments in the medical record.
• Deliberate failure to cooperate.
• Refusal to return phone calls, answer pages, or respond to messages.

Disruptive behavior is any abusive verbal or non-verbal behavior or harassment that harms or intimidates others to the extent that quality of care is compromised. Examples of this behavior include: 

• Physically threatening or intimidating language or behaviors directed at anyone in the hospital.
• Throwing or wielding objects as weapons.
• Threatening or intimidating physical contact with another person.
• Exhibiting sexual harassment and lewd gestures or comments.
• Exhibiting other forms of harassment.
• Making repeated threats of litigation.
• Repeated, persistent inappropriate behavior.  

These behaviors interfere with concentration and communication, impair professional relationships, undermine patient care, and erode trust and resiliency within the healthcare team. The effect of disruptive behavior on organizational culture is cyclical—an environment of hostility leads to behaviors that undermine trust and safety, which leads to a culture of isolation and mistrust that contributes to an atmosphere of hostility. Additionally, because these behaviors create hostility, they may increase the risk of workplace violence. 

Misconceptions

Common misconceptions about disruptive behavior include: 

• The rules don’t apply to some people. High-revenue producing practitioners are sometimes viewed as exempt from the rules. This belief undermines a culture of safety almost immediately by eroding trust and system integrity. Consistent application of norms and expectations to all employees, regardless of role, is critical. 
• Disruptive behavior is normal. Some believe that because the healthcare environment is stressful, disruptive behavior is to be expected. Healthcare providers should never be subjected to disruptive and inappropriate behavior, regardless of the stress level of the work environment. Burnout and stress management is key to developing resilient behavior. 
• Physicians are to blame. While physicians are often the focus of discussions about disruptive behavior in the healthcare setting, other healthcare providers, such as dentists, nurses, medical assistants, and technicians, can also engage in inappropriate or disruptive behaviors.
• Mental health and substance misuse account for disruptive behavior. In fact, only 10% of these behaviors are attributable to mental health issues and substance misuse.

Why is disruptive behavior tolerated?

There are many reasons why these behaviors exist and are tolerated. Healthcare is traditionally hierarchical, which leads to exploitable power differentials. Sometimes the personalities involved are combative or hostile. Organizational processes may be inadequate to address the concern, or the approaches may be inconsistently applied. There may not be a consistent or comprehensive plan in place to handle disruptive behaviors.

Managers may not want to address the behavior out of fear or appeasement. Sometimes, managers simply give in to the individual to stop the disruptive behavior. 

Disruptive behavior tends to be triggered by less-than-ideal circumstances in the healthcare environment, such as lack of equipment or supplies, understaffing, fatigue, illness, depression, and/or stress. These disruptive behaviors often go unreported because the victim or witness is afraid of reprisal. Whatever the reason, lack of a consistently applied accountability program reinforces and normalizes disruptive behavior. 

Risk management recommendations 

Every organization should create a culture in which all employees feel supported and empowered to speak up and report disruptive behavior. The organizational culture should foster an environment that is less likely to trigger disruptive behavior, and implement robust, definitive policies and procedures that address disruptive behaviors. Consider the following when addressing disruptive behavior at your organization:  

• Define expectations. Engage leadership and staff in developing clear, written descriptions of unacceptable behavior. Communicate behavioral expectations and describe the system of accountability to staff and practitioners. Ensure that policies address issues such as reporting, documentation, response, follow-up, monitoring, and support for victims. Designate a point person(s) to oversee these processes. Ensure that policies and procedures regarding disruptive behavior are adopted by the medical staff and appropriately incorporated into the medical staff bylaws as required by applicable state law and regulatory and accreditation agencies. Consult legal counsel when developing or changing human resources policies or medical staff bylaws.
• Be timely and consistent. A lack of timely and consistent response to disruptive behaviors creates a culture that permits and reinforces disruptive behavior. Once a report is made, it is crucial to investigate and intervene as quickly as possible. The longer it takes to address a concern, the less likely it is that meaningful change will occur. Set deadlines to keep the process moving and be alert to potential retaliatory acts. Ensure the reporter understands that retaliation is unacceptable and should be reported. Most importantly, executive leadership must be committed to applying the expectations and system of accountability to everyone. Selective enforcement can undermine your policy and potentially increase the opportunity for litigation.
• Maintain confidentiality. Privacy and confidentiality are crucial when investigating and acting on a report of disruptive behavior. Sitting for an investigative interview requires the reporter to place a great deal of trust in the interviewer. If that trust is eroded and an individual does not feel psychologically safe to report, they will not. The reporter should understand that actions taken against the person being reported are also confidential. 
• Communicate effectively. Develop policies and procedures that focus on how and when to respond to disruptive or inappropriate behaviors. A high-reliability organization builds in the expectation that some behaviors can be managed professionally without the need for escalation. In some cases, the individual may not know how their words or actions are being interpreted, and self-awareness may change the behavior. Egregious or continuous behaviors may need escalation. Response training should include active listening and empathetic response. 
• Provide support. Reporting behaviors that undermine a culture of safety is a brave action. The reporter, reported person, and witnesses may need support services. Determine which services are available (e.g., employee assistance program, peer support, impaired practitioner programs, anger management, etc.) and when to deploy them. Maintain contact with the reporter to offer ongoing support and encouragement. 
• Monitor behavior. Leaving disruptive behaviors unchecked and without accountability exposes an organization to patient harm risks, workplace culture issues, and litigation. Lack of follow-up and accountability can exacerbate disruptive behavior and foster the perception of an ineffectual system. Accordingly, it is important to develop a formalized process for ongoing behavior monitoring to reinforce accountability (e.g., credentialing, performance reviews, etc.) and collect data on behavioral trends. Continue to track behavioral adherence to corrective measures that have been implemented over time. 

Disruptive behavior undermines workplace expectations of civility and collegiality. These behaviors, when extreme, can lead to patient safety issues and workplace violence. Implementing a consistently applied, systemic approach founded on fairness and just principles can help manage the risk associated with these behaviors.

Additional resources: 

• The Joint Commission. Sentinel Event Alert 40: Behaviors that undermine a culture of safety.
• Coverys. Risk Management Brief: Disruptive Behavior: Practitioners
• Medical Group Management Association. Dealing with Disruptive Physicians.

 
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.