Running head: DISRUPTIVE BEHAVIORS

Consequences and Solutions for Disruptive Behaviors in Healthcare

Stephanie Rebeiro
California State University, Stanislaus
Date Submitted: March 31, 2015

DISRUPTIVE BEHAVIORS

Consequences and Solutions for Disruptive Behaviors in Healthcare

Disruptive behaviors are an increasing concern in the work place. Many people may be
guilty of participating in disruptive behaviors, which may make this topic difficult to attend to,
but the negative effects of the behaviors are worth addressing. At times the results of these
behaviors may be subtle, but is not uncommon for the consequences to expand beyond the
current situation. Disruptive behaviors are especially harmful in healthcare; the negative
outcomes effect not only the employees involved, but also the patients. Strategies need to be
executed in order to help decrease the amount of incivility that occurs. Disruptive behaviors in
healthcare may be decreased through the implementation of awareness and education training,
policies and procedures, and a zero tolerance standard.
The Problem: Disruptive Behaviors in Nursing
According to a survey by Rosenstein and ODaniel, disruptive behaviors in health care
have a direct correlation to preventable adverse events, compromises in safety and quality, and
patient mortality (2008). This is unacceptable. It was also indicated through this survey that
incivility leads to stress, frustration, and impaired nurse-physician relationships (Rosenstein &
ODaniel, 2008). This type of behavior occurs not only between physicians and nurses, but
between colleagues as well. It is nearly impossible to give safe and quality patient care under
such circumstances. Disruptive behavior may cause a disruption in communication, teamwork,
and trust. These are pertinent qualities in the healthcare setting and without it both employees
and patients reap the consequences.
Context: Conflict

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Conflict occurs in all of lifes experiences including the workplace. It is important to

recognize all types of conflict which may be interpersonal, intrapersonal, intergroup, or
intragroup (Hill, n.d.). These encounters may arise from differences in values, methods,
personalities, or leadership styles. Disruptive behaviors result from these conflicts.
Incivility can be verbal, nonverbal, or physical. Verbal disruptive behavior or incivilities
include derogatory or demeaning statements, name calling, scapegoating, and broken
confidences. Non-verbal disruptive behavior consists of ignoring, negative facial gestures,
withholding information, isolating, and failure to respect privacy. Physical incivility includes
intimidating postures, throwing items, pushing, grabbing, or inappropriate sexual contact
(Disruptive Behavior, n.d.). Longo stated: Personal conduct, whether verbal or physical, that
affects or that potentially may affect patient care negatively constitutes disruptive behaviors
(2010). Along with being able to recognize conflict and disruptive behaviors, it is also important
to implement strategies to manage or resolve them.
There are several different conflict resolution styles. Thomas and Kilmann describe five
different resolution styles that tend to be used most often. They are competitive, collaborative,
compromising, accommodating, and avoiding. According to a study by Losa and Bacerro,
nurses are most likely to use compromising, a method described as finding a solution that will at
least partially satisfy everyone involved (2012). The other Thomas and Kilmann methods
resulted in order of competing, avoiding, accommodating, and lastly collaborating (Losa &
Bacerro, 2012).
A second conflict resolution style is the interest-based relational approach. This style
emphasizes a good relationship and mutual respect between those in conflict. It then promotes
listening to the interests at hand and using facts to come to a solution together (Hill, n.d.).

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A third resolution style is the conflict resolution process. This style uses a series of steps
including agreeing on the problem and negotiating a solution. The three guiding principles of
this techniques are be calm, be patient, and have respect (Hill, n.d.).
The conflict resolution style that I use most frequently is collaborating, in the ThomasKilmann Conflict Mode Instrument. It uses cooperation by all participants to come up with a
solution that benefits everyone. I feel that this is a rational way for conflicts to be discussed and
resolved.
The Evidence: Impact of Disruptive Behaviors on Patients
A survey performed by Rosenstein and Naylor studied emergency department employees
perceptions on the effects of disruptive behaviors on patient outcomes. It was reported that
nearly 33% of the respondents felt that disruptive behavior was directly linked to an adverse
event, with 18% reporting they were aware of specific events. Approximately 35% felt that these
behaviors led to medication errors and over 12% to patient mortality (2011).
In Veltmans study of labor and delivery units, over 60% reported the presence of
disruptive behavior (2007). There was also a positive correlation between the number of
deliveries and the amount of disruptive behaviors. Physicians accounted for nearly 70% of these
disruptive behaviors while nurses accounted for the remaining 30%. Over 50% of the labor and
delivery units surveyed reported near misses of adverse outcome related to disruptive behaviors.
The issue of communication failures as a cause of poor perinatal outcomes as well as team work
failures coming from intimidation and hierarchy has recently been emphasized by JCAHO in an
analysis of 47 sentinel events resulting in perinatal death or permanent neonatal injury
(Veltman, 2007 par. 8).

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According to Rosenstein and ODaniels study, 67% of nurses reported adverse events are
at least sometimes related to disruptive behaviors (2008). Over 70% felt that there was a link
between disruptive behaviors and both medication errors and quality of patient care. Over 25%
of those surveyed reported that disruptive behaviors are at least sometimes related to patient
mortality (Rosenstein & ODaniel, 2008).
Johnson tells of an incident in her article that addresses disruptive behavior and its effect
on patients. The nurse contacted the doctor and the doctor yelled at the nurse and refused to
come and see the patient. The nurse contacted the doctor again when the patients symptoms
did not improve. The doctor became even more verbally upset. The nurse refused to call the
doctor again, and when she finally did, the patient was hemorrhaging internally, rushed back to
the operating room and expired. The nurse did not follow the escalation process and the doctor
never came to see the patient (2009). This is an extreme, but honest example of how disruptive
behaviors can effect patient care.
The Evidence: Impact of Disruptive Behaviors on Nurses
Rosenstein and ODaniel found in their study that over 90% of respondents believed that
disruptive behavior leads to increased stress, increased frustration, reduced communication, and
impaired nurse and physician relationships. Over 80% felt that it led to loss of concentration,
reduced team collaboration, and reduced information transfer (2011). This greatly hinders nurses
care of patients.
A survey completed by the Institute of Safe Medical Practices in 2009, found that nearly
40% of the nurses reported sometimes feeling reluctance or refusal to answer questions or return
a phone call to a physician. The same percent also reported condescending language from
physicians, and over 40% reported impatience from physicians when asking questions.

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A survey of nurses and physicians regarding disruptive behavior found that over 90% of
the nurses reported seeing disruptive behaviors demonstrated by physicians. They rated this
behavior at a 7 with 10 being most serious in regards to the effects of disruptive behavior. Over
30% of respondents reported knowing nurses leaving their job due to disruptive behavior.
(Rosenstein, 2002).
All of these surveys have an overall similar message. Disruptive behavior does occur
between both nurses and nurses and also nurses and physicians. It is occurring more often than
most people realize and having bigger effects on nurses than most would expect. Disruptive
behavior is causing the breakdown of communication, teamwork, and trust in the health care
setting. It is even causing nurses to leave their job.
Context: Story
Patient care settings often work best using team work. Nurses are typically assigned
certain patients to care for throughout the shift. Often the help of another nurse is required,
especially with co-signing medications and turning patients. It is unfortunate when there are
situations where nurses are not willing to help each other. There was a time, while I was
following a nurse, when I heard her say to her friend, Oh do not help out Nurse A, she needs to
learn how to do her own work. The second nurse agreed and neither one of them offered any
help to her throughout the shift. Although it was only a few spoken words, this type of behavior
can be very disruptive. It breaks the communication between nurses. It completely neglects the
teamwork needed for excellent patient care. It also puts the patients at risk. Fortunately, I do not
know of any adverse event that occurred because of this agreement, but it definitely increased the
possibility. There is no reason to not help out a fellow nurse on the unit. This comment was

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completely inappropriate and it brought two nurses against one. These situations need to be dealt
with in a professional, yet stringent manner.
Possible Solutions
Disruptive behavior is such a wide spread dilemma, that it needs to be dealt with on a
hospital-wide basis. The first way to bring disruptive behavior the attention it deserves is to
educate the staff. Many nurses and physicians may be participating in disruptive behavior and be
completely unaware. A seminar that discusses what disruptive behaviors are and the negative
consequences that it is having on both staff and patients will bring light to the seriousness of the
issue at hand. The nurse managers, along with physicians should together to develop an
educational workshop to present to the entire staff of the hospital. It needs to be a mandatory
event that takes place multiple times a year in order to address all current and newly hired staff.
This presentation will discuss items such as, a description of disruptive behaviors, policies and
procedures in place regarding these behaviors, and how to handle these behaviors when
witnessed. This workshop should involve the audience with role play of potential situations, and
discussions on how it should be handled. The attendees should leave the seminar with confidence
in being able to recognize disruptive behaviors and how to report it, knowing that the
management team stands completely behind them. According to Johnson, surveyors believed
that education was the number one way to improve the physician-nurse relationship. One of the
respondents wrote, Reduction of behavioral problems can only be corrected through early
education for both physicians and nurses, (Johnson, 2009). Rosenstein performed a similar
survey, and education was the second most recommended solution for disruptive behavior and
the nurse-physician relationship. It was suggested that, increase availability of training and
educational programs for nurses and physicians that focus on improving teamwork and working

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relationships (for example, sensitivity training, assertiveness training, conflict management,

collaboration skills, stress management, time management, and phone etiquette, with emphasis
on courtesy, respect, promptness, and preparation) would bring about improvement.
(Rosenstein, 2002). Longo reported that nurses need to be aware of their own actions, and need
to develop the skills needed to confront and report disruptive behaviors (2010). Had education
been provided to the nurses in the previous story, this behavior may have been prevented.
Education would have made the nurse who made the comment aware of her behavior and the
consequences it potentially carried. It also would have provided the nurse who heard the
comment how to react or report such behavior.
The hospital needs to have published policies and procedures that are strictly enforced.
Administrators need to demonstrate a concern for the frequency of disruptive behaviors and
implement a clearly outlined plan to address them (Longo, 2010). These policies should be
developed by a team of both nurses and physicians. These policies will address specific code of
conduct, how to implement it on the floors, and how employees can safely and efficiently report
breaches of this code of conduct. These policies will also address how to manage offenders.
Examples of how to deal with those who demonstrate disruptive behaviors include coaching and
mentoring, addressing underlying issues, and lastly discipline. If there is a true infraction of the
code, an intervention, in which the emphasis for corrective action needs to be placed on the
behavior and not the person, may be warranted (Longo, 2010). It is important to develop a
compact to protect reporting employees against retaliation and establish penalties for those that
do retaliate (Longo, 2010). To disseminate code-of-conduct policies and reporting guidelines
to both nurses and physicians, and apply policies consistently and quickly, providing feedback to
all involved is the fifth most recommended improvement strategy for disruptive behavior.

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(Rosenstein, 2002). These policies and procedures may have prevented the example mentioned
previously, by having a set code of conduct in place for each nurse to hold themselves to, and by
providing strict reporting and disciplinary guidelines.
Lastly, developing a zero tolerance standard towards disruptive behavior can be executed
to reduce disruptive behavior. Johnson reports survey findings for nurses suggestions of
possible solutions including, a zero-tolerance policy, a clearly-enforced code of conduct, and a
process for promptly dealing with complaints (Johnson, 2009). A zero tolerance policy will
enforce the severity of the problem and provide a stable ground for both management and staff to
act on. In order to ensure that this zero-tolerance policy is enforced, nursing management will
need to attend the disruptive behaviors workshop annually, to maintain updated information on
policies and procedures. Rosenstein suggests that a zero-tolerance standard will hold both nurses
and physicians more accountable for their actions (2002). Education can serve to introduce all
workers to a zero-tolerance policy, the organizational code of conduct, and related policies so as
to change the organization culture to one that does not tolerate these behaviors (Longo, 2010).
This zero-tolerance standard may have been enough to convince the disruptive nurse from
making that comment, knowing that it would not have been accepted by anyone.
The budget is provided in appendix A and accounts for all expenditures needed to
accomplish these solutions.
Disruptive behavior is a universal dilemma that is effecting hospital staff and patients.
By addressing this behavior and providing education, employees will be more aware of the
disruptive actions occurring every day. This education will also prepare the staff with the skills
necessary to report and appropriately react to such behavior. The implementation of strict
policies and procedures will set an accepted code of conduct, reporting method, and disciplinary

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protocols. A zero tolerance standard will provide a strong ground for both management and staff
to stand on. All of these solutions will work together to help eradicate disruptive behavior from
the health care system. It will help increase trust and communication between nurse and nurse
and also nurse and physician. It will not only improve work environment, but also patient safety,
allowing for the most effective and efficient care to be provided at all times.

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Proposed Budget

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Year:

2015

Development of Policies and

Procedures

Implemenation of Workshop

Solutions for Diruptive Behavior Budget

$47,000

$47,000
Total Budget:
Budget Planning
Total
Qty. Unit Cost/Rate
Description/Justification
$2,000
$2,000
1
An education and awareness workshop will be put
together by nursing management and physicians. Cost will
include pay for the development of the workshop.
$40,000
$5,000
8
This workshop should be help for all hospital staff at least 8
times a year. This cost will include pay for the instructor(s)
and pay for the attendees.
$3,000
$3,000
1
This will include a team of nursing management and
physicians to develop policies and procedures on
disruptive behaviors. This cost will include the pay for this
team. An annual review and update of these policies and
procedures should be implemented.
$2,000
$250
8
This wil include any printed material or other supplies used
during the workshop.

Organization: St. Joseph's Medical Center

Submitted by:

Supplies for Worshop

Item
Line
1 Education and Awareness Workshop
Development

Grand Total

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References

Hill, R. (n.d.). Conflict resolution. Mind Tools. Retrieved March 15, 2015, from
http://www.mindtools.com/pages/article/newLDR_81.htm.
Iglesias, L., & Vallejo, B. (2012, December 1). Conflict resolution styles in the nursing
profession. National Center for Biotechnology Information doi:
10.5172/conu.2012.43.1.73.
Johnson, C. (2009, November 1). Bad blood: Doctor-nurse behavior problems impact patient
care. ACPE. Retrieved March 15, 2015, from
https://www.ache.org/policy/doctornursebehavior.pdf?ref=driverlayer.com/web
Longo, J. (2010, January 30). Combating disruptive behaviors: Strategies to promote a healthy
work environment. OJIN: The Online Journal of Issues in Nursing, Vol. 15, No. 1,
Manuscript 5.
Rosenstein, A. (2002, June 1). Nurse-physician relationships: Impact on nurse satisfaction and
retention. Lippincott Nursing Center. Retrieved March 15, 2015, from
http://www.nursingcenter.com/lnc/pdfjournal?AID=278949&an=00000446-20020600000040&Journal_ID=&Issue_ID=.
Rosenstein, A., & Naylor, B. (2011, March 1). Incidence and impact of physician and nurse
disruptive behaviors in the emergency department. National Center for Biotechnology
Information. doi: 10.1016/j.jemermed.2011.01.019.
Rosenstein, A., & O'Daniel, M. (2008, August 1). A survey of the impact of disruptive
behaviors and communication defects on patient safety. Retrieved March 15, 2015,
from http://www.mc.vanderbilt.edu/root/pdfs/nursing/ppb_article_on_disruptive.pdf.

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Veltman, L. (2007). Disruptive behavior in obstetrics: a hidden threat to patient safety. Am J
Obstet Gynecol. doi:196:587.e1-587.e5.
What is disruptive behavior. (n.d.) California Nurses Healthy Work Environment. Retrieved
March 15, 2015, from https://sites.google.com/site/rncanhwe/what-are-disruptivebehaviors.
Workplace Intimidation. (2009). Institute for Safe Medication Practices. Retrieved March 15,
2015, from https://ismp.org/Survey/surveyresults/Survey0311.asp.

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