CHAPTER
9

The OR is often a tense, rapidly evolving, and anxiety-provoking environment where seconds count and hierarchical gradients are the rule rather than the exception, and failure of communication can lead to interpersonal conflict and disruptive behavior.1 Many “tense” communications occur between team members during each OR procedure, with some of these resulting in outright conflict.^2,3 As illustrated in Table 9.1, causes of these unacceptable and potentially dangerous behaviors include factors endogenous to the disruptive individual and exogenous factors related to a stressful health care environment.^4,5 Disruptive behavior is not always as it appears. Sometimes disruptive behavior can be a sign of medical disease (cognitive decline, depres sion, uncontrolled diabetes), and other times it might signal alcohol or substance abuse.⁶

Table 9.1 Causes of disruptive behavior

Disruptive Behaviors

There is no single universally accepted definition of disruptive behavior, but the American Medical Association (AMA) defines it as follows: “Personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care constitutes disruptive behavior. (This includes but is not limited to conduct that interferes with one’s ability to work with other members of the health care team.) However, criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior.”7 We prefer the more simple definition of “any behavior that impairs the medical team’s ability to achieve intended outcomes.”⁸ Examples of disruptive behavior are highlighted in Box 9.1.⁹ Highly inappropriate actions and any action with the potential for imminent danger, including throwing or breaking things, and use of a threat of unwarranted physical force must be dealt with immediately.⁴

Abuse does not need to be physical to have a major impact on outcome. Verbal abuse is an endemic phenomenon in the OR and has numerous deleterious sequelae. For example, uncivil behaviors have been shown to decrease work effort, time on the job, productivity, and performance.¹⁰

Another important problem that may directly or indirectly relate to disruptive behavior is that of institutional intimidation. This can manifest as passive-aggressive behaviors and gossip, which ultimately result in a negative and potentially incendiary environment. This phenomenon is often less overt than disruptive behavior on the part of individual health care providers but is nonetheless common and damaging. Because it is difficult to quantify, the victims often feel helpless and are less likely to report this problem. Those guilty of such behaviors come from every level of the health care organization. This “insidious intimidation” disrupts communication, reduces workplace morale, and may ultimately result in patient harm.¹¹

Disrespect may be passive, consisting of a range of uncooperative behaviors. Leape et al4 beautifully summarized this, stating “whether because of apathy, burnout, situational frustration, or other reasons, passively disrespectful individuals are chronically late to meetings, respond sluggishly to calls, fail to dictate charts or operating notes in a timely fashion, and do not work collaboratively or cooperatively with others.”

Prevalence of the Problem

The prevalence of disruptive behavior has been described across a spectrum of health care settings. One report showed that 91% of perioperative nurses had experienced at least one incidence of verbal abuse in the previous year¹²; another stated that 67% of nurses reported between one and five instances of disruptive behavior in the previous month.¹³ Disruptive behaviors have been directly observed by attending physicians and medical students in plastic surgery programs, with more than half of health care providers reporting direct observation of bullying or intimidation, dishonesty, and confidentiality violations and more than 70% reporting witnessing poor anger management.¹⁴ Anesthesiologists are often on the receiving end of such behaviors, and 64% of anesthesiologists have reported observing disruptive behavior in the perioperative setting.¹⁵ Similarly, 73% of respondents in one study observed a coworker who was the target of inappropriate behavior.¹⁶ Interestingly, observing a disruptive behavior event can be as damaging to the observer as it is to the target of the behavior.¹⁶ Misbehavior in the OR is well known to hospital administrators and hospital leadership, who may be complicit in allowing these problems to continue. More than 95% of physician executives reported knowledge of disruptive physician behavior within their organization.¹⁷ Potential reasons for organizational reluctance to deal with disruptive behavior include cultural inertia, fear of antagonistic physician reactions, organizational hierarchy, lack of organizational commitment, and ineffective structure or policies.¹⁸

Trainees

Tomorrow’s physicians (including both medical students and residents) are commonly directly or indirectly involved in disruptive behaviors. Because of the hierarchy seen in medicine, they are often mistreated by both attending physicians and nurses. Medical student mistreatment has been documented by the Association of American Medical Colleges (AAMC) for more than 25 years through questions on the annual Medical School Graduation Questionnaire. Public humiliation is the most commonly reported form, with approximately one third of all students reporting either public belittling or humiliation. In a meta-analysis of 51 studies including 38,353 trainees, the pooled prevalence of harassment and discrimination was approximately 60%. Verbal abuse, gender discrimination, academic harassment, sexual harassment, and racial discrimination were common.19

At one academic medical center, 93% of interns reported experiencing disruptive behavior, with 54% reporting the frequency to be once a month or more.²⁰ The interns cited nurses as a common source of disruptive behaviors, including condescending behavior (74.6%), exclusion from decision-making (43.7%), yelling or raising the voice (24.1%), inappropriate jokes (23.6%), and berating (20.3%) as commonly experienced behaviors.²⁰ Residents and medical students seldom report disrespectful acts because they fear reprisal or vindictive retaliation, such as a lower grade, critical evaluation, or a poor recommendation for residency applications.⁴ In the AAMC Medical Student Questionnaire, only one third of respondents who were mistreated reported incidents of mistreatment to their faculty or administrators, with nearly half citing fear of reprisal (48%) as the reason they did not report. Furthermore, 21% of trainees reported a lack of clarity about what to do, and 37% reported a sense of futility, feeling that reporting the incident would not be effective.²¹

Residents can also be the perpetrators of disruptive behavior. Sanfey and colleagues²² recommend the following steps for dealing with disrespectful behavior in residents: reflection, increase in self-awareness, punitive consequences, simulation activities, and structured mentoring.

Consequence of Disruptive Behaviors

Disruptive behaviors wreak havoc on workplace morale and team function and are related to adverse patient events and disruption of patient safety efforts.^4,23,24

Immediately after an incident, the recipient of such behavior may lose the ability to think clearly and decrease focus and concentration. These are associated with errors in decision-making or unsafe acts. Long-term effects include decreased morale, high turnover, reduced team collaboration, failure to comply with system processes, and reduced information transfer.^4,25,26

Disruptive behavior also has financial effects, threatening hospital image and decreasing nursing satisfaction and retention of health care personnel.²⁷ This is a major issue in the current era of difficulty in being able to recruit and retain nurses.^18,28 Furthermore, disruptive behaviors have been shown to have a negative effect on “process flow,” which can also significantly impact a hospital’s finances.^18,29

Solutions

Clearly conflicts and responses to aggressive behavior are common occurrences in the OR, and conflict management tools and educational programs should be incorporated into OR management.^2,30 Effective leadership and the implementation of proper preventive measures are necessary to prevent severe dysfunction and disruptive behavior.^31,32 Tolerating disruptive behaviors ultimately supports and reinforces them. Allowing such behaviors to continue (regardless of financial concerns) has been shown to un dermine morale.⁴ The Joint Commission^33,34 requires that a code of conduct be established in each hospital defining “disruptive and inappropriate” behaviors and also requires that a process for managing disruptive and inappropriate behaviors be created and implemented.

Identification, Investigation, and Fair Peer Review

Whenever disruptive or disrespectful behavior is reported, appropriate action should be taken and leadership should be involved in ongoing plans. Leape and colleagues⁹ have suggested that the organization’s leader is ultimately responsible for creating a culture of respect, because only he or she can set the tone and initiate the process that will lead to change across the organization. Effective policies for managing disruptive behavior should include fairness, consistency, graded response, restorative process, and the presence of surveillance mechanisms. In addition, others within the institution must be able to share in any lessons learned from such actions. To change culture, it is necessary to create awareness of the problem so that others are motivated to take action.³⁵

When a disruptive physician has been identified, the first step should be a rapid, fair, and thorough review of the allegation that obtains all perspectives of the situation, including that of the alleged disruptive individual, without taking sides. Input should be sought from relevant supervisors and multidisciplinary team members, including nursing, administration, and staff, and impartiality should be maintained. This will allow everyone involved to feel that their right to respectful treatment is honored.

After the unbiased data collection, a synthesis of findings usually allows the reviewer to assess whether the findings support or refute the allegations that were made, or whether there were insufficient findings to allow for evidence-based conclusions. Also, any immediate threats to patient or staff safety should be identified and addressed. Supervisor (typically the department Chair) input should be sought to identify prior behaviors to determine whether a sustained pattern has emerged that may modify interpretation of the current incident. The results of the review should be dealt with in accordance with institutional rules, policies, and any potential legal standards that may apply. General Counsel or institutional officials in the Human Resources department or the Office of Faculty Affairs may be of assistance. Once a decision has been reached, potential interventions, consequences, and next steps should be discussed to address the incident being reviewed. A document outlining the steps of review, findings, relevant policies, and chosen actions should be created for the faculty file. Depending on the hospital or university bylaws, this document should be shared with the faculty member, when appropriate. A final step should always be to focus on institutional learning; specifically, institutional opportunities to remove barriers, improve systems, or educate team members should be identified and acted upon in a continuous improvement framework.

Physicians who are accused of abusive or disruptive behavior may actually be innocent of such behavior. In fact, the label of “disruptive physician” has been used by hospitals to control physician behavior and perform “economic credentialing.” Zbar and colleagues36 reported that “because of the hemorrhaging of revenue, some hospital administrators have taken the easy route of labeling surgeons who remove better paying cases to private ambulatory surgery centers as disruptive.” The need to protect providers who respectfully and appropriately identify concerns or call for institutional improvement is directly referenced in the second part of the AMA definition of disruptive behavior: “However, criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior.”⁷

Reviews involving disruptive physicians may have legal implications and dire career consequences and should be undertaken with meticulous attention to fairness, clear documentation, and appropriate due process. Organizational leadership, commonly including a chief medical officer or leader of the practice group, may engage input from General Counsel’s office if revocation or nonrenewal of clinical privileges is being considered. Legal guidance will also be critical—for example, if there is a question as to whether a physician’s behavior and institutional management has to be reported to a State Medical Board. Central to any potential legal review, the organization’s policies and procedures should be followed and documented consistent with the organization’s bylaws. When direct patient care is involved, the peer-review process should be engaged as a basic component of institutional safety and quality assurance programs intended to assess and maintain standards of care. Guiding principles for a hospital’s peer-review process are outlined in Box 9.2.³⁷

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