"I don't care how many patients you have. I want my patient induced now and I'm sending her over." "Get me a real nurse." "Where did you go to nursing school? You obviously didn't learn much there." "If you ever question my judgment again, I'll make sure it's your last day here."
Sound familiar?
Disruptive behavior can be overt, such as yelling, using profanity, throwing instruments, slamming charts, using physically threatening or abusive actions, making berating comments, or having a rude, demeaning attitude (Porto & Lauve, 2006). More subtle examples are disrespect, nonverbal devaluation, eye-rolling when a colleague makes a suggestion, gender discrimination, or sexual innuendo (Weber, 2004). Although disruptive behaviors are not limited to one discipline, physicians' disruptive behaviors often have a much greater impact on other clinicians and the system as a whole because of their relative power in the healthcare system (Porto & Lauve). Hierarchy plays a key role in disruptive behavior, with intimidation, disrespect, and self-indulgent outbursts more likely to be directed at those with less perceived professional clout (Weber, 2004). Therefore, most reported cases of disruptive behavior involve physicians who interact inappropriately with nurses (Rosenstein & O'Daniel, 2005; Weber).
After an experience with a disruptive clinician, many victims intentionally avoid additional interactions to minimize further opportunities for abuse (Rosenstein & O'Daniel, 2005). During labor, this can involve the nurse not calling the physician about a nonreassuring fetal heart rate (FHR) pattern because the last time they interacted, the nurse felt berated and demeaned. Nurses may feel pressured to increase oxytocin rates during hyperstimulation but avoid speaking up to prevent another unpleasant encounter with the physician who believes more oxytocin will speed labor. A nurse may be reluctant to seek advice from a nurse colleague concerning FHR interpretation due to past inferences of inadequacy during similar consultation. Because most (but not all) nonreassuring FHR patterns are not the result of fetal acidemia and most (but not all) hyperstimulation will not cause maternal or fetal harm, these avoidance strategies will work for some time until the inevitable adverse outcome occurs.
Various processes have been proposed that organizations can adopt for disruptive clinician behavior and are presented in the box (Porto & Lauve, 2006; Weber, 2004). Success depends on leadership support from the top to the down and a willingness to act immediately when disruptive behavior is reported. A zero-tolerance policy for disruptive behavior and/or retaliation against those who report it is essential.
Disruptive clinician behavior is more than inappropriate, unprofessional, and hurtful. It can have significant negative implications for patient safety by increasing risk of medical errors and patient harm, negatively affecting nurse retention, creating a hostile work environment, disrupting unit operations, and increasing risk of professional liability (Porto & Lauve; Rosenstein & O'Daniel, 2005).
Organizational Processes for Disruptive Clinician Behavior
* A universal code of conduct should provide guidance to both clinicians and administrators.
* Expectations for professional behavior should be outlined explicitly in institutional policies for good citizenship and reaffirmed both by leaders and each clinician on an annual basis during contract renewal and performance reviews.
* Behavior should not be qualified by discipline (throwing instruments, "temper tantrums," or demeaning comments should not be tolerated by any clinician). Exceptions should not be made because he or she is "a good doctor or nurse otherwise," "we need their patient volume," or they are "one of the few who are always willing to work overtime," and so on.
* Processes for reporting disruptive behavior and behavior code enforcement should be widely disseminated and their use actively encouraged.
* There should be accountability and meaningful follow-up with clear actionable implications.
* Each instance should be addressed in a timely manner rather than delaying interventions until "trends" are apparent.
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