Disruptive behavior by doctors, nurses persists a year after crackdown
■ A survey of physician and nurse executives raises questions on how to implement zero-tolerance policies required by the Joint Commission.
One group of nurses banded together to try to get a physician unfairly disciplined, while another encouraged fellow nurses to disobey doctors' orders outright. A surgeon told his staff that monkeys could be trained to do what scrub nurses do, while another doctor told a patient that the nurse in the room didn't know what she was doing.
A nurse witnessed the onset of complications in an intensive care patient but refused to contact the on-call physician for fear of his temper -- a delay at least one observer thought contributed to the patient's death.
These are some of the disruptive behaviors that persist among physicians and nurses at hospitals, group practices and other health care facilities, according to anonymous responses to a national survey of 13,000 physician and nurse executives conducted by the American College of Physician Executives.
The survey comes almost one year after the Joint Commission began requiring health care facilities to implement zero-tolerance policies that define intimidating and disruptive behaviors. The commission also required that facilities establish disciplinary procedures for medical staff and other health care professionals who violate the standards.
With increasing concern over the impact of bad behavior on patient care, the findings renew questions about how to curb the problem effectively.
Ninety-seven percent of respondents experienced unprofessional outbursts and overreactions, with most saying these happened several times a year and sometimes even weekly. Most survey respondents, 48%, said doctors and nurses were equally culpable for the conflicts, but 45% said doctors were mostly to blame.
"This continues to be a problem in the workplace, and our health care industry has not done enough to get rid of it. And it's a universal problem. It's not just restricted to doctors," said ACPE Chief Executive Officer Barry Silbaugh, MD. The survey results were published with a series of articles on the topic in the organization's November/December Physician Executive Journal.
"The worst behavior problem is inappropriate behavior in front of a patient, regardless of whether it is from a doctor to a nurse or from a nurse to a doctor," one respondent said. "In our organization, the behavior goes both ways."
Making degrading comments, yelling and refusing to work together topped the list of complaints. Far fewer respondents reported incidents of sexual harassment and physical assault.
"We can't just look at the really egregious and obvious behaviors. We have to look at the passive-aggressive behaviors as well," said Dr. Silbaugh, who also serves on the board of the National Patient Safety Foundation. This includes actions such as ignoring another staff member or silently trying to undermine someone's authority.
Patient care, teamwork at stake
While a small number of individuals are typically responsible for negative behavior, the bottom line is that this behavior can interfere with patient care, said Alan H. Rosenstein, MD, a lead researcher on disruptive behavior.
"I don't think anybody starts out the day being disruptive. It's a bunch of deep-seated factors affecting the way they work ... and it has a profound effect on the rest of the organization," said Dr. Rosenstein, medical director at Physician Wellness Services, an organization that assists physicians and health care facilities in managing behavioral and other performance-related issues. Issues including medical training, stress levels and underlying conflicts of interest play a role, he said, and all can impede team communication and collaboration.
While the Joint Commission standard has helped call attention to the issue, simply having a policy in place is not enough, Dr. Rosenstein said.
"The issue is still there, and 75% of organizations are still having a lot of difficulty dealing with it," often because bad behaviors are not addressed until after the fact, he said. "The question is: What can we do to prevent this?"
While more than half of respondents said their organization offered training programs to try to reduce behavior problems, many felt that management was more lenient in its treatment of doctors, particularly those bringing in high patient volumes. Most respondents said nurses were terminated more frequently for bad conduct.
Disciplinary actions also subject to abuse
Tougher policies can go both ways, said Jay A. Gregory, MD, chair of the AMA Organized Medical Staff Section Governing Council. He said the Joint Commission standard gives health care facilities such broad discretion on disciplining certain behaviors that physicians can be unfairly targeted for speaking up about legitimate quality concerns.
"We see time and time again, physicians complain about things the hospital never addresses, and the physician decides to go public and all of a sudden gets labeled as disruptive," said Dr. Gregory, a general surgeon in Muskogee, Okla. The Joint Commission standard applies across the board, but "you have to do a root-cause analysis of what led to the behavior, no matter who it is."
One survey participant said that "in my experience I've never witnessed a physician with inappropriate behavior that wasn't triggered by a patient event. Remembering that their goal is good patient care -- and so is ours -- keeps the focus on the right place."
The AMA developed a policy model that calls for distinguishing between good-faith criticisms and actions that truly rise to the level of disruptive behavior, and for implementing fair medical staff review processes.
Paul M. Schyve, MD, senior vice president of the Joint Commission, agreed there are appropriate moments for speaking up. But he said the ACPE survey findings highlight types of behaviors that exceed constructive criticism, and if left unchecked, can inhibit others and ultimately can undermine patient care. "We can't let the little things slip."
Dr. Rosenstein said education and early, graded intervention are key. Punitive measures should be a last resort.
Commitment from the top down also is crucial, said the ACPE's Dr. Silbaugh. "Part of what we have to do is agree as a health care team [that there] are behaviors that are not acceptable."
That's where medical staff can play an important role, Dr. Gregory added. "The medical staff must address when one of their own is demonstrating inappropriate behavior."
Physician and nurse executives echoed many of those suggestions in their responses and had some of their own, including setting clear expectations, implementing consistent enforcement and focusing on teamwork.