Published in the October 2008 issue of Today’s Hospitalist
A PATIENT COMES TO THE HOSPITAL with GI bleeding, only to see a physician yelling at staff. When the patient asks if that’s his physician and is told “yes,” he refuses treatment and has to be transferred to another hospital.
A nurse balks at calling an abusive physician for new orders after an IV antibiotic runs out. The patient goes without antibiotic therapy for four days and later dies.
These are real-world examples of something that everyone who works in a hospital knows: Some physicians (and nurses and pharmacists) are chronically aggressive, verbally abusive, condescending or just plain uncooperative. But far from being just intimidating, it’s increasingly clear that disruptive behavior can be dangerous and even deadly.
Disruptive behavior has become a hot topic because a growing body of research shows that it contributes to poor patient care and medical errors. Survey results published in the August 2008 issue of The Joint Commission Journal on Quality and Patient Safety, for instance, found that more than three-fourths of responding inpatient physicians, nurses and administrators had witnessed bad behavior in a physician.
Those numbers are leading the Joint Commission to require hospitals to soon have policies in place to prevent disruptive behavior and deal with offenders. The organization’s new standard, which takes effect in January of 2009, has sparked some complaints from physicians. They fear that hospitals might use codes of behavior to silence doctors who speak out about legitimate concerns. Quality experts say, however, that because disruptive behavior is very real, hospitals are obligated to confront it in a way that is consistent and fair.
“It’s not physician-bashing,” says Alan H. Rosenstein, MD, MBA, the lead author of the August 2008 study. “And it’s not just physicians who are doing this.”
Disruptive behavior is nothing new, adds Dr. Rosenstein, who has authored several studies and articles on bad behavior. Cultural, gender and generational differences all contribute to different ways of collaborating and communicating, he points out, which makes managing disruptive behavior even more difficult.
And while bad behavior certainly isn’t limited to physicians, Dr. Rosenstein explains, it’s no surprise that hospitals have been more willing to look the other way when perpetrators produce much-needed revenue and bring in patients.
Disruptive behavior appears to be most prevalent in the operating room, ICU and emergency department, says Dr. Rosenstein, who is vice president and medical director of the West Coast region of VHA, a not-for-profit hospital alliance. Surgical specialties like cardiovascular surgery, neurosurgery and orthopedics, as well as cardiology and neurology, seem to have more than their fair share of bad apples. That’s due in part to the stressful nature of the work, he adds, as well as the types of personalities that are drawn to those specialties.
Where do hospitalists fit into this picture? According to Dr. Rosenstein, who began his career as a hospital-based physician before the term “hospitalist” existed, hospitalists tend to be more on the receiving end of bad behavior than on its delivery. As a specialty, he explains, hospitalists are inclined to be more team-oriented and have less stressful work schedules than physicians in some other specialties.
“They know how valuable the rest of the hospital team is,” he says. “Hopefully, enjoying their job and depending on the input of others is going to make them less apt to be disruptive “and less tolerant of individuals who are.”
A threat to patient safety
Several years ago, Dr. Rosenstein set out to determine whether disruptive physician behavior affected nurse retention rates. He found that the answer to that question was a resounding “yes.” But he also found that nurses were just as guilty, and that such behavior jeopardized communication and increased the risk for medical errors.
Consider some responses to the survey of VHA member hospitals that Dr. Rosenstein published this summer. While 77% of respondents reported witnessing disruptive behavior in physicians, 65% reported seeing equally bad behavior in nurses.
One respondent said that poor postoperative communication due to disruptive behavior resulted in delayed treatment, aspiration and a patient death. Another commented that disruptive behavior caused increased stress and lack of concentration, leading to more nursing mistakes.
“People became stressed, frustrated and lost their ability to focus,” Dr. Rosenstein says of the survey results. “Important information would not be exchanged, and eventually this led to bad things for patient quality and safety.”
New liability risk
The reality is that hospitals can no longer afford to ignore such behavior. In addition to the new Joint Commission standard, hospitals must contend with increasing litigation, the impact on staff morale, negative publicity and poor showings on publicly-reported patient satisfaction scores.
In a sentinel event alert published in July, the Joint Commission suggested a number of actions that hospitals should take to combat disruptive behavior. Among them are educating physician and nonphysician staff on appropriate professional behavior; having “zero tolerance” for intimidating behavior; and developing an organizational process for dealing with disruptive behavior that includes input from doctors, nurses, administrators and other employees. That process needs to include ways to acknowledge and apologize for bad behavior witnessed by patients or their families.
Dr. Rosenstein recommends that hospitals create a multidisciplinary task force that draws on not only clinical and nursing leadership but human resources as well.
“You need to address a complaint, not an individual,” he explains. Applying a policy fairly, instead of unevenly to nurses and physicians, is also key. “Just having a code of behavior policy does nothing to make it effective,” says Dr. Rosenstein. “It really has to be backed up.” That includes, he adds, having a strong commitment from administration on enforcement and follow-through.
As long as the process involves a broad spectrum of stakeholders and is objective, he says, any confrontation regarding bad behavior is less likely to be construed as personal retaliation.
Hospitals also need to put in place a system “preferably confidential “to report incidents. Employees should be asked to acknowledge the hospital’s behavioral policy when they sign on for a job, and physicians should agree to it when applying for privileges.
Hospitals also need to offer educational courses on sensitivity training, assertiveness and conflict management, Dr. Rosenstein suggests. Hospitalists, because they are always on the scene, are in an ideal position to assess the need for such resources and implement them.
All those efforts together should send a clear message to would-be bullies that patient safety is at stake “and that they will be held accountable for their actions.
“I don’t think anyone starts the day out wanting to be disruptive or a poor communicator,” he says, “but they may not have the tools to communicate effectively.”
Barbara Kirchheimer is a freelance health care writer based in Highland Park, Ill.