96%! In a poll of nurses, physicians, and healthcare executives, 96% of nurse respondents said they have witnessed or experienced disruptive behavior by a physician. 96%!

Several other surveys show that nurses are the primary victims of disruptive behavior. And increasingly, those in health care are recognizing that disruptive behavior can undermine patient care and cause staff dissatisfaction and turnover.

In response to the problem, the Joint Commission released draft standards on behavioral expectations for hospital staffs, including the medical staff. These standards require hospital leaders to develop a code of conduct that defines desirable and disruptive behavior and to establish processes for managing disruptive behavior. Plus, the medical staff must manage disruptive behavior by physicians and others who are granted clinical privileges.

Defining disruptive behavior

The American Medical Association defines disruptive behavior as personal conduct, whether verbal or physical, that affects or potentially may affect patient care negatively. That’s a good starting point, but a policy or code of conduct needs to specify which behaviors are disruptive. These behaviors can be classified as four types:

• intimidation and violence
• inappropriate language or comments
• sexual harassment
• inappropriate responses to patient needs or staff requests.

Intimidation and violence includes throwing objects, threatening violence, pushing or hitting others, finger pointing, and invading another’s space. The most common display of intimidation is yelling. Most surveys of nurses show that 40% to 80% have had a physician yell at them.

Inappropriate language consists of racial, ethnic, or socioeconomic slurs; profanities or obscenities; sarcastic, cynical, or demeaning remarks; and comments that show a distain for another staff member. Jokes about sex and comments with sexual innuendo are considered sexual harassment.

The fourth category; inappropriate responses to patient needs or staff requests;includes late replies to pages, inflexible responses when asked for assistance, and retaliatory notes in the medical record. Inappropriate responses also include disregarding policies, blaming others for adverse outcomes, and routinely making rounds at odd hours.

Establishing a code

Despite this broad spectrum of disruptive behaviors, most nurses summarize their experience with problem physician behavior with the word disrespect. All hospital employees have the right to be treated with respect. But merely feeling disrespected is not enough to trigger a meaningful intervention. The disrespectful behavior must be described in terms of institutional definitions of bad behavior.

That’s why every hospital medical staff should have a behavioral policy or code of conduct that contains a clear statement of the type of behavior expected from members and a detailed list of prohibited behaviors. Also, the policy must contain a clear description of the process for documenting and reporting disruptive behavior and for protecting those who make such reports from repercussions. Nurses need to be familiar with the policy. If the hospital medical staff doesn’t have such a policy, nursing leaders should intervene. (To see examples of medical staff codes of conduct and behavioral policies, visit http://lazoritz.com/
samplebehaviorpolicies.html”target=”_blank”>www.lazoritz.com.)

Establishing a code of conduct or reviewing and updating an established one provides an excellent opportunity to educate the nursing and medical staffs about expectations for professional interactions and the negative effect disruptive behavior has on patient care. Grand rounds, educational sessions, debriefings after an episode, and newsletter articles can reinforce these expectations.

Reporting bad behavior

If you have been directly affected by or have observed behavior that violates the medical staff’s policy or code of conduct, you may want to try talking calmly and privately to the physician and explaining the effect of the behavior. (See Discussing disruptive behavior with the disrupter by clicking on the PDF icon above.) Whether you try this approach or not, you must document the incident and report it. You may be reluctant because you believe the behavior is an isolated act by a well-liked physician who usually acts professionally or because you’ve already talked to the physician privately and he has apologized. In fact, many incidents result from the stress of the moment, not from a chronic pattern of bad behavior. But your role is not to decide whether the behavior is acute or chronic. If it was disruptive, report it no matter what. The hospital and medical staff leaders will decide if it’s an isolated incident or part of a pattern.

You may also be reluctant to report disruptive physician behavior because you fear reprisals. This fear is understandable, but remember that intimidation allows disruptive physician behavior to persist. Hospital and medical staff policies must protect you.

The method of documenting and reporting varies, depending on medical staff policy, but typically, you’ll write a factual description of the incident, including the time, the place, and a list of witnesses, including patient witnesses. Make sure your report is objective, and include any effect on patient care. Follow your nursing policy for incident reporting. Document any verbal exchanges verbatim, if possible. And make the report as soon as possible after the incident. (See What happens after you file a report by clicking on the PDF icon above.)

After you document and report the incident, continue to act professionally. Remember, patient care always comes first. Even if the physician is rude and demanding, continue carrying out your duties in a professional manner. Likewise, your intervention should be conducted in a calm, professional way. Yelling back at a physician who is yelling creates an excuse for disruptive physician behavior.

Benefits for all

The intervention by the medical staff should benefit both nurses and physicians. If the physician has a history of abusive, disruptive behavior, obviously the medical staff needs to intervene promptly and effectively for the good of all. Luckily, this type of physician is in the minority. The majority of disruptive incidents involve competent, effective physicians who resort to this type of behavior during times of stress. (See More than a collegial discussion by clicking on the PDF icon above.) By filing a report, you create an opportunity to make such physicians aware of their disruptive behavior and help them change.

Selected references

American Medical Association. Physicians and disruptive behavior. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/”>www.ama-assn.org/ama1/pub/upload/mm/
21/disruptive_physician.doc. Accessed September 4, 2007.

Johnson CL, Martin SLD, Markle-Elder S. Stopping verbal abuse in the workplace: nurses should not tolerate this behavior and it should be reported when it occurs. Am J Nurs. 2007;107(4):32-34.

The Joint Commission. Proposed standard for disruptive behavior. Available at: <ahref=”http://www.jointcommission.org/NR/rdonlyres/”>www.jointcommission.org/NR/rdonlyres/
E7FF18DD-4667-42C0-A1F53E121A76BD78/
0/Disruptive_Behavior_hap_stds.pdf. Accessed May 1, 2007.

Rosenstein AH. Nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs. 2006;102:26-34.

Weber DO. Poll results: doctors disruptive behavior disturbs physician leaders. Physician Exec. 2004;30(5):6-14.

Stephen Lazoritz is Principal of the Lazoritz Group, Hospital Interaction Specialists; Clinical Professor in the Departments of Pediatrics and Psychiatry at Creighton University School of Medicine; and Adjunct Professor in the Department of Pediatrics at the University of Nebraska Medical Center in Omaha. Pamela J. Carlson is Vice President, Patient Care Services and Chief Nursing Officer at Children’s Hospital in Omaha.