OPERATIONS __

Behaviour mattersWhat to do when a staff membergets abusiveBY DR AK KHANDELWAL

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Surgeons hurling instruments atassistants or walking out in themiddle of a surgery, physicianhumiliating nurses, healthcarestaff getting physically assaulted by

senior hospital members. Shocking, as they mayseem, such occurrences are more common thatone would think in healthcare organisations.They are examples of disruptive or abusivebehaviour, which has been observed in almost allmembers of the healthcare team, be it doctors,nurses, pharmacists or technicians. However,when a doctor exhibits such behaviour, it mayhave the greatest impact because of the positionof authority sjhe wields as a member of thehealthcare team.

The rate of such incidents is alarming. As pera study by the American College of PhysicianExecutives, more than 95 per cent of physiciansreported encountering "disturbing, disrup-tive, and potentially dangerous behaviourson a regular basis!' In another study coveringmore than 140 hospitals, over one-third of theparticipants reported nurses leaving institutionsbecause of disruptive behaviour by physicians.Twenty-three percent of nurses reported at leastone instance of physical threat from a physician.According to yet another study, around 18 percent of nurse turnover is directly attributed toverbal abuse.

According to AMA, 'disruptive conduct' is:"personal conduct, whether verbal or physical,that affects or that potentially may affect patient-care negatively constitutes disruptive behaviour!'These may include disrespectful, profane, de-meaning, or rude language, sexually inappropri-ate speech, sexual boundaryviolationsjinappro-priate touching, intimidation, harassment, racial/ethnic innuendo or insults, tirades and outburstsof anger and throwing objects. Criticising othercaregivers in front of patients or other staff, com-ments that undermine a patient's trust in othercaregivers or the hospital, repeated, intentional

Healthcare Radius July 2013 35

• OPERATIONS

DOS AND DON'TS OFADDRESSING DISRUPTIVEHEALTHCARE PROVIDER

••,/ Act promptly on every incident of disruptive

conduct.,/ Speak about errors ln private.,/ Involve a third person in the conversation.,/ State that you are representing on behalf of

hospital management.,/ Plan your strategy beforehand.,/ Refer any past violations if they have

occurred and identify any patterns ofmisconduct that are in evidence.

,/ Referthe staff code of conduct and any prioragreement by the practitioner to complywith it.

,/ Clearlystate the consequences of this orfuture violations.

DON'TS)( Do not get provoked. Keepcool.)( Do not get judgmental, focus on the incident

only.)( Don't allow the disruptive practitioner

to change the subject-agree to talk atanother time about his or her concernsregarding other staff members or aboutquality issues.

x Do not make excuses for the disruptivebehaviour.

)( Avoid 'circling the wagons' to put up a showof collegiality.

)( Do not get intimidated by threats of legalaction.

)( Don't fail to investigate 'quality concerns'when alleged by disruptive practitioners.

)( Do not allow a disruptive doctor/staffmember's allegations of wrong-doing byothers to distract yotJfrom addressing thatdoctor's own unprofessional conduct.

x Avoid manufacturing evidence of clinicaldeficiencyto support allegations ofunprofessional behaviour.

)( Not clearly communicating behavioralexpectations (e.g. through a code of conductor compact).

)( D.onot avoid to strictly enforce a code ofconduct.

)( Avoid responding to a physician's disruptiveconduct differently from other healthcareprovider.

36 Healthcare Radius July 2013

non-compliance with organisation rules andpolicies, deliberate interference with the smoothfunctioning of hospital or medical staff opera-tions, inappropriate comments in the medicalrecord-especially those impugning the qualityof the work done by others, unethical/dishon-est behaviour, repeated lack of response to callsfrom other health personnel and unwillingnessto work collaboratively." It also includes inap-propriate arguments with patients, their families,hospital staff and other physicians.

The effect of disruptive behaviour on a health-care organisation is manifold. 'Sentinel EventAlert' by The Joint Commission on July 9,2008observed that it can lead to medical error, de-creased patient satisfaction, high staff turnover,preventable adverse outcomes and increased costof care. It also leads to poor patient satisfaction.Leaders of health care organisation should takeinitiatives to minimise this problem to improveorganisation's performance.

JCI prescribes following guidelines to preventsuch behaviour.1. Educate all team members, physicians and

non-physician staff, on appropriate profes-sional behaviour defined by the organisation'scode of conduct. It should include training inbasic business etiquette and people skills.

2. Hold all team members accountable for mod-elling desirable behaviours, and enforce thecode equitably among staff, regardless of sen-iority or clinical discipline in a positive fashionthrough reinforcement and punishment.

3. Develop and implement policies and processesthat show 'zero tolerance' towards intimidat-ing and/or disruptive behaviours. Incorporatethe zero tolerance policy into medical staffbylaws and employment agreements as well asadministrative policies.

4. Ensure that staff policies regarding intimidat-ing and/or disruptive behaviours of physiciansare complementary and supportive of thepolicies that are present in the organisation fornon-physician staff.

5. Reduce fear of intimidation or retribution andprotect those who report or co-operate in theinvestigation of intimidating, disruptive andother unprofessional behaviour. Non-retali-ation clauses should be included in all policystatements that address disruptive behaviour.

6. Respond to patients and/or their familiesinvolved in or witness to intimidation and/or disruptive behaviour. The response shouldinclude hearing and empathising with theirconcerns, thanking them for sharing thoseconcerns, and apologising.

7. Create a plan on how and when to begindisciplinary actions (such as suspension, ter-mination, loss of clinical privileges, reports toprofessional licensure bodies).

8. Provide skills-based training and coachingfor all leaders and managers in relationship-building and collaborative practice, includingskills for giving feedback on unprofessionalbehaviour, and conflict resolution. Culturalassessment tools can also be used to measurewhether or not attitudes change over time.

9. Develop and implement a reporting/sur-veillance system (possibly anonymous) fordetecting unprofessional behaviour. Includeservices of ombudsmen and patient advocatesto provide feedback from patients and families,who experience intimidating or disruptivebehaviour from health professionals.

10.Monitor system effectiveness through regularsurveys, focus groups, peer and team memberevaluations. Have strategies to learn whetherintimidating or disruptive behaviours exist orrecur, such as through direct inquiries at rou-tine intervals with staff, supervisors, and peers.

11.Support surveillance with tiered, non-con-frontational interventional strategies, startingwith informal conversations, directly address-ing the problem and moving toward detailedaction plans and progressive discipline, ifpatterns persist. These interventions shouldinitially be non adversarial in nature, with thefocus on building trust, placing accountabilityon and rehabilitating the offending individual,and protecting patient safety. Make use of me-diators and conflict coaches when professionaldispute resolution skills are needed.

12.Conduct all interventions within the contextof an organisational commitment to the healthand wellbeing of all staff, with adequateresources to support individuals whose be-haviour is caused or influenced by physical ormental health pathologies.

13.Encourage inter-professional dialoguesacross a variety of forums as a proactive wayof addressing ongoing conflicts, overcomingthem, and moving forward through improvedcollaboration and communication.

14.Document all attempts to address intimidat-ing and disruptive behaviours. IlIlJ

Dr AK Khandelwalis medical director atAnandaLoke Hospital Et

Neurosciences Centre,Siliguri, West Bengal