Disruptive, offensive behavior on the part of providers is still such a significant and frequent problem in health settings, it jeopardizes patient safety, and can affect quality of care, despite Joint Commission guidance that took effect Jan. 1 to prevent such breakdowns.
Of more than 1,500 providers responding to an e-mail questionnaire, three-fourths said they had been the target of unprofessional, intimidating or inappropriate behavior within the last 24 months. Two-thirds said they considered leaving their job because of it and 41% said they actually did.
The 64-question survey was designed and distributed in May and June by the Center for Patient and Professional Advocacy of Vanderbilt University Medical Center and the Studer Group, an outcomes-based health consulting firm devoted to teaching evidence-based tools and processes, which works with providers to prevent such incidents. Healthcare professionals were solicited through blogs and by e-mail and were promised confidentiality.
The survey defined such behavior in almost the exact terms used by The Joint Commission: Intimidating and disruptive behaviors include "overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.
"Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Unprofessional behavior impairs or disrupts a healthcare team member's ability to achieve intended outcomes."
The survey asked respondents not to consider acts of sexual harassment or age, gender or racial discrimination in their responses because they are governed by specific laws.
In a sentinel event alert issued July 9, 2008, the accreditation agency said, "There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care. Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it."
James Pichert, professor of medical education and co-director of the Vanderbilt Center that guided the survey, says the project was launched in part to learn what factors influence a patient to sue his or her caregiver. It is known that patients who do sue would often report to offices of patient relations that they had witnessed disruptive behavior during their care, he says.
"And when the patient had a bad outcome, the patients felt that it was because the team was not working together," says Pichert.
In one case, for example, someone was on the operating table not fully anesthetized, and would hear an argument breaking out between staff members who gathered around, Pichert explains. "They'd say 'I could feel the tension in the room, and it did not give me confidence. And when I had a bad outcome, I had to wonder whether it was because they were more focused on the argument than they were on me.'"
Pichert says the study cannot be called a scientific one because it was not conducted in a random fashion, and those who answered may have been more likely to respond because they have fresh memories of a hostile encounter.
Only 15% of the 1,521 people responding said they had not been a target of such behavior, according to Colleen Thornburgh, Studer Group coach and speaker.
But Thornburgh adds that the graphic experiences described by those responding raises concerns that such behavior may very well affect quality of care and patient safety.
For example, she says, one technician responded that after being yelled at by a medical superior for asking a question, he now delays asking that person again or doesn't ask at all. "And that delay may be just enough to make a difference in outcome," Thornburgh says. "That's where we see a real threat to quality and safety, maybe not at that moment, but maybe downstream from that moment."
Thornburgh and Pichert believe the questionnaire's responses are a strong indication that a significant problem remains in healthcare settings. For example, some of those who participated gave these examples of their anger and frustration with their interactions with superiors or peers:
- "A physician wanted to do something that put the patient in an unsafe situation, violated State and Federal laws and regulations and JCAHO standards. When I informed the physician he couldn't do this, and that he put patients at risk, he told me I couldn't do that and he would have me fired...The physician was yelling and using many expletives."
- "I have been targeted by a physician that exhibits unprofessional behavior on a regular basis. He yells, throws charts and degrades nurses always looking for something wrong and someone to blame. He has told patients not to listen to the nurses; they don't know what they are talking about. His behavior is not addressed—he is one of our biggest admitters."
Those initiating such behavior most often were nurses, physicians, managers or administrators, according to the survey results.
The issue of intimidating and disruptive behavior among workers in healthcare settings is bound to receive more attention as hospitals attempt to comply with new rules and recommendations from the Joint Commission.
Effective Jan. 1, 2009, all Joint Commission accredited programs must have adopted leadership standards that address "disruptive and inappropriate behaviors" in two ways:
- 1. The hospital or organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
- 2. Leaders create and implement a process for managing disruptive and inappropriate behaviors.
Additionally, the agency suggests 16 other actions, including adoption of "zero tolerance" for intimidating and/or disruptive behaviors, especially the most egregious instances...such as assault and other criminal acts," and "reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior."
The commission's Sentinel Event Alert references studies showing that disruptive and intimidating behavior "can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments."