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.

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. While most patient safety problems are attributable to underlying systems issues, disruptive behaviors are primarily 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.

Recent studies have identified promising ways to identify clinicians at risk for disruptive behavior, remediate such clinicians, and mitigate these behaviors to avoid institutional disruption. 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. Among practicing physicians, studies indicate that a small proportion of physicians account for a disproportionate share of both patient complaints and malpractice lawsuits. Earlier identification of such clinicians might allow for targeted interventions to address disruptive behavior and reduce patient risk. 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 a strong organizational emphasis; Vanderbilt University has achieved notable success in this area through identification of problem behaviors using a formal early detection and structured intervention approach (described in a 2009 PSNet interview). A systems-level approach would also 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.

Other interventions to prevent disruptive behavior include measures to improve safety culture. 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 safety culture, such as teamwork training and structured communication protocols, may have the potential to reduce disruptive behaviors, or at least promote early identification of them.

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 March 2017 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.