Many would contend that we currently live in a polarized society in the United States. Whether the issue is the environment, healthcare, taxes, religion, economic theory, immigration, globalization or politics, interaction between competing philosophies is often characterized by animosity, accusations, verbal abuse, and even physical harm. Make no mistake — this has been going on since the Garden of Eden (Ask Cain; better yet, ask Abel!). The impact on society is rarely, if ever, beneficial.
In any society, interactions between individuals and between groups of individuals is not only unavoidable but an essential characteristic of society itself. When those interactions are uncivil and when behavior is disruptive, the nature of those interactions can significantly impair the ability of individuals to perform and organizations to succeed. The magnitude of that impact is dependent upon a number of factors, including the degree of incivility, the severity of the disruptive behavior, the response of others and of the organization, and perhaps most importantly, the potential for harm.
Incivility in Business Organizations
“Incivility” can be defined as rude or unsociable speech or behavior; it encompasses a wide gamut of overt and covert actions. Although aggressive actions such as actual physical harm, throwing objects, threats, inappropriate language and verbal intimidation are easily recognized as disruptive, less aggressive behavior such as facial expressions, social remarks and demeaning comments may also be considered disruptive. More subtle forms of incivility may include deliberate avoidance, failure to respond to phone calls or emails, non-participation and lackadaisical performance.1
The topical interest in such rude behavior in the workplace was addressed by a recent essay in the Wall Street Journal2 that suggested that “rudeness can harm an employee’s well-being and job performance.” The importance of incivility in the corporate environment was addressed by Porath and Pearson,3 who reported that 98% of workers indicated they experienced uncivil behavior; furthermore, when polled in 2011, half of all workers reported being treated rudely at least once per week. The impact on employee performance was significant, with workers indicating that they lost time at work thinking of the incident (80%), their commitment to the organization declined (78%), their performance declined (66%), and they lost work time avoiding the offender (63%). Although the percentages may vary in different industries and in different settings, the concept is the same — incivility in the workplace has a negative effect on employees, efficiency, performance and organizational success.
Porath and Pearson3 offer several suggestions for management. In addition to considering incivility in hiring decisions, leaders should reward good behavior, not incivility. If bombastic employees who are rude and/or disruptive are tolerated or, worse yet, promoted, other employees will emulate their conduct. Rather than ignoring such behavior or “dealing with it” by transferring the offending employee, disruptive behavior should be addressed and corrected.
In a subsequent publication, Porath4 reported that usual responses of avoidance or confrontation often fail. Avoidance is not a viable option when continued employment requires working collaboratively with the offending individual; confrontation often escalates the situation rather than resolving it. The author found that the vast majority of people (85%) who elected to avoid or confront the offender were dissatisfied with the result.
Many of the concepts relevant to business organizations are applicable to healthcare organizations. Such organizations present an increased propensity for incivility, greater consequences to disruptive behavior, and heightened challenges for management at the employee, leadership and organizational levels.
Incivility in Healthcare
Although the concepts and challenges found in many other fields are frequently applicable to healthcare, they are often greatly modified by the inherent high-stress environment, the essential need for communication and collaboration among individuals, and the nature of the individuals themselves, including disparate levels of training and authority. The problem of unruly behavior among healthcare workers has almost certainly existed for decades if not centuries, but only (relatively) recently has it been identified as unacceptable and associated with adverse effects and outcomes.
An overview of the topic by Porto and Lauve5 noted that disruptive behavior was not limited to physicians; it also occurs among nursing, pharmacy, radiology and laboratory staff. Central to the issue of disruptive behavior by physicians is the position of relative power they hold in healthcare settings. Not only is such behavior often driven by that disparity in power, but it is often (inappropriately) tolerated. Physicians, particularly those who generate high income for the healthcare system, often receive a more lenient response when they are disruptive;5 this perpetuates the problem, and it establishes a culture wherein such behavior is expected and tolerated. The authors posited several possible causes of such behavior, such as temporary staffing, increased government and institutional oversight, a plethora of managed care regulations, and high liability risks. Whatever the cause, workplace intimidation can lead to situations that threaten patient safety.
An early study by the Institute for Safe Medication Practices6 surveyed 2,095 healthcare providers — predominantly nurses and pharmacists — and found that most experienced condescending language (88%), impatience with questions (87%), and a reluctance or refusal to answer questions or phone calls (79%) within the last year. Patient safety was jeopardized when the respondent had questions about a medication order but avoided questioning or clarifying the order with the intimidating prescriber.
The Joint Commission (TJC) issued a Sentinel Event Alert in 20087 noting that intimidating and disruptive behaviors can lead to medical errors, adverse outcomes, poor patient satisfaction and increased cost of care. They postulated that high-stake situations and heightened emotions as well as individual characteristics such as self-centeredness, immaturity and/or defensiveness can lead to unprofessional behavior. Systems factors such as high productivity demands, cost containment, established hierarchies and fear of litigation were also contributory. TJC created new Leadership Standards8 addressing the problem and made several actionable suggestions, including but not limited to the following:
- Define appropriate behavior in a code of conduct
- Enforce the code consistently and equitably regardless of position or seniority
- Establish a zero tolerance policy for disruptive behavior
- Encourage and protect those who report unprofessional behavior
- Develop a formal surveillance system for detecting such behavior.
In “Putting the Brakes on Health Care ‘Road Rage,’”9 TJC noted that intimidating or disruptive behavior is, admittedly, difficult to define. Most healthcare workers would likely include physical abuse, throwing objects, engaging in tantrums or angry outbursts, foul or abusive language, and other forms of belligerent behavior as disruptive. Yet intimidating behavior can also be less aggressive, even passive-aggressive in nature. TJC provides a wide variety of examples of disruptive behavior, including: “Engaging in patronizing nonverbal communication, such as eye rolling, raised eyebrows, smirking, and so on”; and “Displaying an attitude of superiority regarding another’s knowledge, experience and/or skills.” Such behavior is not uncommon in healthcare.
TJC refers to three reasons that healthcare is particularly susceptible to such behavior: 1) the high-stress environment may reduce one’s ability to control emotions; 2) the economic demands of the system; and 3) the hierarchal nature of healthcare. Standard LD.03.01.01 of the 2009 Comprehensive Accreditation Manual10 stipulated that “Leaders create and maintain a culture of safety and quality throughout the [organization].” The two elements of performance for LD.03.01.01 were EP4 and EP5; effective July 1, 2012, these were modified to EP4: “Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety”; and EP5: “Leaders create and implement a process for managing behaviors that undermine a culture of safety.”11 This makes it clear that ANY behavior that undermines safety must be defined and managed.
Although it is easy to censure others and demand adherence to best practices, physicians, nurses and all healthcare personnel are human beings besieged by human frailty and influenced by both external and internal factors.1 Internal factors such as alcohol and drug addiction are problematic as are mental disorders, but most physicians who exhibit “behaviors that undermine a culture of safety” are not so impaired. Few physicians receive formal training in communication and interpersonal skills, and these factors can be considered contributory. However, the preponderance of causes is external in nature. Disruptive behavior may be demonstrated by role models, found amusing by colleagues, ignored by other team members, and unpunished by leadership wary of offending a highly talented individual and/or one who produces much needed revenues. Such a culture reinforces, sustains, and even rewards incivility.
The role of leadership cannot be overemphasized. An organizational culture that demands devotion to patient safety and refuses to abide behaviors that undermine that safety is absolutely essential. Administration, Chief Medical Officers, Chief Nursing Officers, Departmental Chairpersons, Divisional Directors and Residency Directors, among others, must clearly and constantly lead by example. Behaviors that undermine a culture of safety are unacceptable. Deviations from this philosophy may occur, but they can never be ignored or tolerated. Intimidating and/or disruptive behaviors impair the effectiveness of the team and acutely jeopardize patient safety. Although this is applicable to all healthcare settings, perhaps nowhere is this problem more pervasive, more often tolerated, and more impactful upon patient outcomes than in the Operating Room. We will examine this unique venue, how it can exacerbate the problem, and possible management techniques in our next blog, Consequences & Patient Safety Implications of Disruptive Behavior in the Healthcare Setting.
1 Swiggart WH, Dewey CM, Higkson GB, Finlayson AJR, and Spigkard Jr WA. A Plan for Identification, Treatment and Remediation of Disruptive Behaviors in Physicians. Frontiers of health services management. 25. 3‐11.
2 JB Wallace. The High Costs of Workplace Rudeness. Wall Street Journal. August 19‐20, 2017.
3 C Porath and C Pearson. The Price Of Incivility Lack Of Respect Hurts Morale‐And The Bottom Line. Harvard Business Review. Jan‐Feb 2013.
4 C Porath. An Antidote to Incivility. Harvard Business Review. April 2016.
5 Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Saf Qual Healthc. July / August 2006. Available at: http://www.psqh.com/julaug06/disruptive.html; 2006. Accessed Aug 24, 2017.
6 Institute for Safe Medication Practices. “Intimidation: Practitioners Speak up About This Unresolved Problem (Part 1).” March 11, 2004. Available at: https://ismp.org/Newsletters/acutecare/articles/20040311_2.asp. Accessed August 25, 2017.
7 The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008.
8 The Joint Commission. “Leadership Committed to Safety.” Issue 473 August 27, 2009 (Revised Sep 8, 2009).
9 The Joint Commission. “Putting the Brakes on Health Care ‘Road Rage.’” Environment of Care News. January 2010.
10 The Joint Commission. “2009 Comprehensive Accreditation Manual for Hospitals.” Joint Commission Resources; 2008.
11 The Joint Commission. Joint Commission Perspectives®. January 2012, Volume 32, Issue 1. Available at: http://www.jointcommission.org/assets/1/6/Leadership_standard_behaviors.pdf. Accessed August 30, 2017.