Disruptive behavior is defined as any type of unprofessional behavior that negatively impacts care relationships and, consequently, has the potential to affect patient safety and quality of care adversely. It is not a new concept in the medical environment, but until relatively recently, it was either ignored or tolerated as a cost of doing business, because organizations did not know the consequences or have the right incentives, policies, or procedures in place to address the issue in an effective manner.
We began to look at disruptive physician behaviors in early 2000. One of my responsibilities as Vice President and Medical Director for Voluntary Hospital Association (VHA) West Coast (a nationwide group purchasing collaborative of acute care hospitals), was to ask the medical directors, chief managing officers, and vice presidents of medical affairs of member hospitals what their key priorities were so we could develop educational programs and networking opportunities to help them deal with these issues. The usual topics included costs of care, quality of care, and organizational issues. Lower down on the list was disruptive physicians. When I approached the subject, no one wanted to talk about it.
In an effort to learn more, I went to the literature to see what I could find. Other than a few anecdotal examples of physicians harassing or yelling at staff, I couldn’t find any objective data as to the type or frequency of disruptive events, so we decided to develop our own survey. Surveys were made available to all VHA hospital members (physicians, nurses, administrators, and other relevant support staff). In the end we had over 10,000 responses from more than 300 different hospitals. The original survey results were published in the Physician Executive Journal and The American Journal of Nursing, to reach both physician and nursing audiences.(1,2) I expected a backlash or pushback from publishing these findings, but instead received a tremendous amount of support and encouragement with thanks for bringing this issue to the forefront. We published multiple follow-up survey reports to address high-intensity services such as the perioperative arena, emergency department, obstetrics, and neurology/neurosurgery.(3-6) The key publication was in The Joint Commission Journal of Quality and Patient Safety in 2008 which led The Joint Commission on Accreditation of Hospital Organizations (JCAHO) to issue Sentinel Event Alert #40, emphasizing the seriousness of this issue.(7,8) Soon after, the American Medical Association (AMA) also became involved in this area.(9) JCAHO subsequently required organizations to address disruptive physician behavior by setting up definitions, guidelines, and standards of behavioral conduct, mandating that organizations have a disruptive behavior policy in place with an appropriate follow-up plan as part of the hospital accreditation process. Things began to change.
Types of Disruptive Behaviors
The most common types of disruptive behaviors reported were yelling, anger, verbal abuse, bullying, harassment, condescension, or other types of demeaning, berating, belittling, or disrespectful remarks. Physical abuse was rare. Survey results highlighted that only 3% to 5% of the medical staff exhibited these types of behaviors, but they were witnessed by more than 95% of the staff who completed the surveys. The specialties with the highest reported incidence of disruptive behaviors were cardiovascular, neurovascular, obstetric, orthopedic, general surgery, and emergency department categories, which are, of course, the high-intensity service specialties working in high-pressure situations. Disruptive physician behavior was not limited to these groups, however; it was reported in all specialties. Other forms of disruptive behavior included poor compliance in following policies and protocols, absent or delayed chart documentation, non-availability, and not returning calls. Most of the events involved physician–nurse interactions, but there was also a high incidence of reported disruptive nurse–nurse interactions. Whereas most of the physician–nurse interactions took on more of an overt aggressive posture, most of the nurse–nurse interactions were more a passive-aggressive, undermining, sabotage type of activity, which is often more difficult to assess and manage. The term horizontal hostility has been used to describe these types of interactions.(10,11)
Causes
Table 1 presents an outline of factors that may contribute to disruptive behaviors. I have divided these factors into Internal and External categories. The internal factors include values and perceptions related to age (generation gap preferences), gender (including sexual identity), culture, ethnicity, and spiritual beliefs. These factors contribute to conscious and unconscious (implicit) biases that become part of the individual’s personality.(12) The internal factors are deep seated and may be more difficult to change.(13) They contribute to the individual’s current mood and emotional state.
The external factors come from chosen (life choice) or accidental life experiences. In the medical environment, medical school and specialty training are key contributing factors. Students learn in a high-pressure, high-stress hazing type of training environment that leads to low self-esteem and self-dependence. The focus of medical training is on gaining knowledge and technical competency rather than developing team relationships and coping skills, which leads to a strong egocentric autocratic style of behavior. When training is completed, these graduates transition into a complex high-pressure hierarchal medical environment where long work hours, fatigue, sleep deprivation, and a host of other frustrating non-clinical administrative responsibilities lead to unwanted physical and emotional symptoms. There is a significant degree of stress and burnout, which can lead to a fragile emotional state.
Consequences
In our surveys we found that 95% of the individuals impacted by a disruptive event reported feeling stressed and frustrated; 90% felt that it impeded communication, information flow, and team collaboration; and 85% felt that it caused them to lose focus and hampered their ability to concentrate. More than two thirds felt that it could lead to the occurrence of medical errors and adverse events that could compromise quality of care. More than 50% felt it could jeopardize patient safety. Specific examples were given in which disruptive behavior led to a preventable unwanted adverse event. Ongoing studies link the occurrence of disruptive behavior to poor patient outcomes.(14-16)
The consequences of disruptive behavior can be divided into three major categories: economic; patient safety and quality of care; and staff satisfaction and morale.
Economic consequences are related to adverse events, delays in service or discharge planning resulting in prolonged lengths of stay, higher hospital readmission rates, and below par reported outcomes related to substandard coding and documentation, resulting in low scores for selected pay for performance metrics. In 2011, I reviewed the medical literature at that time and outlined the costs of certain adverse events.(17) As an example, a medication error can cost the organization $2,000 to $5,800 in non-reimbursable expense. A hospital-acquired infection can cost from $20,000 to $38,000 per event. Extended lengths of stay can cost the hospital $2,000 to $3,500 per day. Under Medicare’s value based care programs, hospitals with high readmission rates stand to lose as much as 3% of their total Medicare inpatient revenue.(18) Malpractice cases can lead to multimillion dollar settlements. From a satisfaction and morale perspective, hospitals stand to lose up to 2.5% of their Medicare revenues for poor patient HCAHPS satisfaction scores.(19 ) Poor staff satisfaction leads to increased turnover and a poor reputation, which hinders staff retention and recruitment. This is particularly important given the current post-pandemic Great Resignation, with nurses and physicians leaving their positions prematurely.(20) The average cost of replacing a nurse can range from $50,000 to $100,000, counting recruitment, training, and opportunity costs.(21)
Addressing Disruptive Behavior
Table 2 outlines a 10-step plan for addressing disruptive behavior. The first step is to raise levels of awareness and establish accountability. Most of the individuals involved do not recognize that they are acting in an unprofessional disruptive manner. They do not think about any downstream effect. The individual believes that they need to take command and do what they think is necessary to get things done. Unfortunately, they don’t realize the negative impact these behaviors have on their team members who are part of the patient care process. There is no justification for this type of behavior.
The process should start with a general overview educational program. Individuals need to be made aware of what “disruptive” is, who is doing it, how and when it occurs, and how it impacts team relationships and patient care. Individuals need to recognize their role in the process and better understand how their behaviors are construed by the healthcare team. The content needs to focus on concerns around maintaining patient safety and high quality of care by stressing the importance of effective communication, team collaboration, information transfer, task completion, and the overall impact of unprofessional behaviors on staff satisfaction and morale.
How do you find out what’s going on in the work environment? Informally, you can pay attention to staff lounge gossip or hallway chats, but that’s not the most effective way of truly understanding the issue. You can review incident reports, but unfortunately many of the events never get reported. The most effective way to assess the situation is to do an internal survey. The assessment can address overall working conditions, issues concerning the impact of stress and burnout, organizational culture and morale, and the frequency and impact of unprofessional behaviors. Two commonly used surveys are the Maslach Burnout Inventory and Professional Quality of Life (ProQOL) assessment tools. All results must be kept confidential, and the findings must be addressed. Aggregate results should be shared with all relevant healthcare staff involved in care management. When presented with the findings, the subject’s usual response is “I didn’t know I was doing that,” or “I didn’t know you thought that, I only meant to …” This opens opportunities for discussion. Most physicians will respond positively to the comments and adjust their behaviors accordingly.
Once you have identified the problems and shared the information with members of the healthcare team, the next step is to provide further training. Training courses can include such topics as diversity training, cultural competency, sexual harassment, anger management, conflict management, stress management, customer satisfaction, and the like. Given the influence of implicit bias, advanced training in emotional intelligence and diversity, equity, and inclusion (DEI) techniques can be particularly beneficial, because as it teaches individuals how to better understand themselves in regard to their pressure points, triggers, and hidden biases; enable them to gain a better understanding of how this can affect their attitudes and behaviors; and learn how to better manage their emotions to achieve desired goals and objectives. It also teaches the individual how to gain better insight into the needs, concerns, values, and perceptions of others so they can gain a better perspective of how to achieve mutually beneficial goals and objectives.(22,23)
More advanced training in relationship management is key. Providing more extensive training to improve communication, team collaboration, and customer satisfaction skills will improve understanding of individual roles and responsibilities that enhance overall efficiency, productivity, and quality outcomes of patient care.(24,25) Physicians are trained to give orders. They need to spend more time listening, avoiding distractions, and focusing on the needs of others.(26)
It is essential to have structure and policy in place that defines appropriate behavior standards and sets up a process for reviewing and acting on complaints. Standard Code of Behavior or Disruptive Behavior policies are available through several resources, including the AMA and JCAHO.(27,28) A recent article has gone into great detail about the importance of developing policies that support ethics and professionalism.(29) Policies should include a code of conduct, definition and description of unprofessional disruptive behaviors, the process for incident review and follow-up, and the ramifications of noncompliance.
One of the key components of the structure is incident reporting. This requires a standardized process in which individual complaints are reviewed and acted on by a designated committee composed of staff well trained in risk management techniques who can make the appropriate recommendations for follow-up evaluation. Follow-up actions must be conducted by responsible individuals in a nonbiased, professional manner, with findings reported back to the committee; the committee can then make recommendations for next steps. It is crucial that the entire process be held confidential. Healthcare is a hierarchal system, and many individuals are reluctant to make negative reports about superiors. There is often an underlying code of silence that inhibits reporting. One of the biggest barriers to reporting is the fear of retaliation, and submitters need to be reassured that any retaliation efforts will be dealt with accordingly. Another reason for not reporting is the sense that people report and report and nothing ever changes, because the organization is reluctant to address behavioral issues, particularly in high-volume, high-profit providers.
Organizational culture plays a strong role in staff engagement, satisfaction, and morale.(30) Employees want to work in an organization where they feel respected and supported, and can trust leadership to support staff in maintaining a positive work environment. With the growing concerns about staff shortages, recruitment and retention are pivotal issues for organizational success, and staff satisfaction and morale are key motivators for employment.
Intervention is the key to resolution. Table 3 outlines a tiered process for behavioral intervention. The process starts with early intervention and prevention.(31) General education can help raise levels of awareness to enable individuals to recognize and adjust their emotions to prevent a disruptive event. Role-play scenarios can help provide real-time observations and adjustments suggested to reduce potential conflict.
The next step is an informal intervention. These meetings are sometimes referred to as “coffee time chats.” The meeting should be held in a neutral site away from the daily hubbub of activities. The meeting should be conducted by someone familiar with conflict management techniques. It is designed to raise awareness, not be confrontational or punitive, and to allow the individual to respond to observations such as “it’s been noticed that you’ve been behaving a little differently, how are things going?” conversation. It is important to let the individual explain from their point of view what’s been going on, but, more importantly, make them aware of how this affects others and their ability to perform their jobs. In most cases, the individuals didn’t recognize that they were behaving unprofessionally, they didn’t mean it, and will adjust their behaviors accordingly. Fortunately, this approach works most of the time.
For repeat or resistant offenders, the process must migrate to a more formal type of intervention. Interviews with the involved individuals should include a discission of events, provide an opportunity for the physician to discuss their take on the situation, and identify possible underlying triggers or causes. Despite any attempts at excusing, justifying, or rationalizing, the physician needs to take accountability for their actions and must be made aware that these types of behaviors will not be tolerated. Depending on the suspected underlying issues, individualized training in anger management, conflict management, or stress management may be in order. Issues related to unconscious bias may require more advanced diversity management, cultural competency, or sexual harassment training.(32) Additional training in enhancing communication skills, collaborative team building, or sessions designed to improve emotional intelligence may be required.
Some physicians will require individualized coaching or counseling.(33) In some cases, they will require focused behavioral modification therapy from psychologists or psychiatrists. One must always consider the possibility of underlying substance abuse — in such a case, individuals should be referred to an appropriate substance abuse program. In more extreme cases, physicians can be required to attend a specialized behavioral counseling program such as those offered by Pace University or Vanderbilt University.(34-36)
When all attempts to correct the situation have failed, the organization must consider sanctions in the form of not recredentialing, reduction or suspension of privileges, or termination. When imposing sanctions for disruptive behavior, the organization needs to recognize the legal implications and be sure they follow due process.(37) From my experiences as an expert witness working on both sides of the table (i.e., representing the organization or representing the physician), I have learned a lot about how things unfold. I look at the specifics of the Code of Conduct policy. Physicians are required to sign the Code of Conduct policy during the application or recredentialing process. I review all the incident reports and committee minutes and summarize the findings into a chronology of events that help to establish a trend and measure of severity. I look at the process, including recommendations made and documentation of follow-up compliance. I review letters offering legal opinions. I then look for the potential downstream effect these behaviors can have in terms of compromising patient safety and quality of care. Even if an adverse event was avoided, it’s the potential for causing harm that’s the issue. These findings are shared with principals involved with the case.
Due process starts with the Code of Conduct. The policy must contain a definition of inappropriate (counterproductive/disruptive) behavior, the process for reviewing and evaluating complaints, and the recommendations for follow-up action. All discussions in these meetings must be documented, with a recommended course of action. Final status determinations are executed through the Medical Executive Committee and Governing Board. If the physician disagrees with the decision, they are entitled to request a fair hearing. The last resort is for them to take legal action to restore privileges or collect lost potential wages. Common reasons for appeal include failure to follow due process, a biased unjustified targeting of the physician, retaliation for speaking up, breech of contact, tortuous interference, or staff incompetence.
Current Status
Despite all these safeguards, disruptive behavior continues to plague the medical environment.(38-40) Although many of the behavioral disorders are related to the more entrenched internal factors discussed previously, the external factors may be easier to deal with.
One of the key areas to address is the growing prevalence of stress and burnout and its effect on provider attitudes, behaviors, and overall well-being. Physicians are used to stress. It was stressful going through the competition to get into medical school, stressful getting through the high pressure and extreme demands of medical school and specialty training, and then stressful to transition into medical practice. Now comes the added stress of dealing with the post-pandemic medical environment and the changes that have occurred in modes and models of practice delivery. Stress and burnout can lead to anger, frustration, dissatisfaction, and fatigue, any of which can trigger the potential for disruptive behaviors.(41) The growing stress and burnout epidemic in healthcare providers needs to be considered as a national priority.(42) So where do we begin?
Many of the issues start in medical school. In recent years, many articles have addressed the high rates of stress and burnout during the medical training process and its long-lasting effect on physician attitudes and behaviors.(43) Medical schools are becoming more aware of the seriousness of this issue and have begun to take steps to provide needed resources to help students and residents better cope with the high pressures of training.(44) The same can be said for the high levels of bullying and incivility in clinical nursing.(45)
The stress continues as medical trainees graduate and transition into medical practice.(46) As mentioned previously, stress traditionally had been tolerated as a cost of doing business. It wasn’t until 2016 that the significant degree of stress and burnout among healthcare providers was first statistically documented.(47) The report showed that more than 50% of physicians reported high levels of stress and burnout, which was prevalent across all medical specialties. A follow-up report four years later showed that conditions had not changed.(48) Stress and burnout continue to be an ongoing problem that has been aggravated by the COVID pandemic. Every year Medscape publishes its annual “Physician Stress and Burnout” report. The latest report revealed specialty burnout rates as high as 60%, with reported rates of clinical depression of 24%.(49)
To reduce the potential for disruptive behaviors, we must make every effort to reduce the stress and burnout in our healthcare providers.(50) This is a complex process involving both organizational (system) and individual efforts.(51) Table 4 presents a recommended plan of action for responding to stress and burnout. There are many similarities to the recommendations for addressing disruptive behaviors.
The first step is to do an assessment. Many different types of stress and burnout surveys are available. Typical examples include the Maslach Burnout Inventory, the Mini Z survey, and the ProQOL survey, among others. These provide an opportunity to assess the specific situation at the individual institution and help set priorities for moving forward.
The next area is support. Three types of support can be provided: structural, clinical, and behavioral.
Structural support has to do with administrative issues. It addresses concerns about capacity and productivity expectations, performance of non-clinical tasks, schedule commitments, coding and documentation requirements, and compliance with the EMR. Systemwide issues account for more than 80% of staff frustrations.(52) Administrative support can help by reducing administrative tasks and responsibilities, reducing productivity, committee, or on-call requirements, more training in the EMR, or by providing scribes to help with electronic medical record input and documentation.
Clinical support can be provided by utilizing physician assistants or nurse practitioners to handle routine matters and free up time for the physician to focus on more complex cases. Care coordinators, case managers, or navigators can take on scheduling and logistical responsibilities for guiding the patient through the full spectrum of care.
Behavioral support requires a more individualized approach.
As discussed previously more advanced training in stress management, time management, anger management, or conflict management, can help the physician (and other staff) better adjust to the intensity of stressful practice situations. Mindfulness and resiliency training have become a popular way of teaching physicians coping skills to better manage a stressful event.(53,54) Diversity training, training in emotional intelligence, communication skills, and team collaboration training will help improve relationships and reduce the stress of the team managing care. Coaching and mentoring can be of particular value. In some cases, more intense behavioral modification may be needed. We must remember that the individual physician can only do so much; we need to look for system redesign for the ultimate solution.(55)
It is essential to focus on the importance of physician and staff well-being.(56-58) We must encourage and support the need for rest, relaxation, adequate sleep, good nutrition, and exercise. We need to recognize capacity overload and allow the physician to say no. Some organizations have revamped their wellness committees to provide resources for physician assistance. More progressive organizations have initiated the role of a Physician Wellness Officer, whose primary job is to foster physician well- being.(59) Other organizations have offered a physician-specific employee assistance program, where physicians can call in and speak confidentially with trained personnel. One of the key problems is getting the physician to open up and seek advice.
There is a real stigma that leads to physician reluctance to seek outside help.(60,61) Doctors have very strong, independent, narcissistic, egocentric personalities and don’t want any outside help. They often don’t admit that they are under stress, and even if they do, they have worked under stress all their lives and think they can handle it by themselves. They are too busy to take time away from their practice. Then there’s the fear of reprisals: If they are willing to seek advice, people may think of them as weak and question their competency. Then there is the concern that it may impact their privileges or license requirements. When offering advice, it is crucial to maintain confidentiality, give them a safe place for discussion, and focus on the goal of working together to enable the physician to be successful in their practice.
We need to reinvigorate the physician’s passion for medicine and remind them of all the good that they do.(62,63) The Institute of Healthcare Improvement offers a program that focuses on returning joy to the practice of medicine.(64) Providing tangible support services such as childcare, resting lounges, food services, and opportunities for social connection and interaction will do a lot to enhance staff happiness.(65) Happier, more satisfied physicians are more engaged in their work, become more effective members of a collaborative healthcare team, and are less apt to exhibit disruptive behaviors. We need to more visibly recognize their efforts, show them respect, and make sure we thank them for all the work that only they can do.(66)
Approaching the Disruptive Physician
Physicians are just trying to do their jobs. They have worked exhaustive hours though years of stressful education and training and are dedicated to their craft. Physicians, nurses, and all medical support staff are an overworked precious resource, in short supply, and we need to help them keep going.(67-69) With growing concerns about physician and nurse shortages, we need to do whatever we can to help them better adjust to the pressures of medical practice.(70,71) Disruptive behavior cannot be tolerated, but instead of taking a punitive approach to behavioral management, it would be preferable to focus on helping to improve physician and staff overall well-being.
The first step is prevention. Making physicians aware of how their behaviors are perceived. Their possible effect on compromising care relationships, with the potential negative impact on patient care, will raise their concerns, and most physicians will adjust their behaviors accordingly. Some may require additional training. Some may require more individualized behavioral counseling. Every effort should be made by the organization to provide needed support to encourage and enable the physician to practice in a professional manner and to help minimize the contributing factors. For chronic offenders resistant to change, appropriate sanctions or termination may be the only recourse. The organization needs to adopt a zero-tolerance policy and be willing to address this issue in an effective manner, even if it involves a prominent high-volume specialty provider who otherwise has an acceptable quality of care profile. The organization must consider the economic, quality and safety, satisfaction, reputation, and morale consequences of inaction. Significant organizational efforts need to be made to enhance clinician well-being. Provide logistical support, provide clinical support, and provide behavioral support. Ensure confidentiality, and make it a safe place for the physician to engage and share their concerns. Work with them on advice, strategies, and therapies that will help them achieve their career goals. If all efforts fail, it may be necessary to terminate their privileges to protect staff and patient care. The ultimate goal is to help them succeed and thrive in medical practice.
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