Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment

Joy Longo, DNS, RNC-NIC

Disclosures

Online J Issues Nurs. 2010;15(1) 

In This Article

Addressing Disruptive Behaviors

Given the current awareness of the detrimental effects of disruptive behaviors, these behaviors can no longer be ignored. Accreditation of healthcare facilities now depends on an organization's ability to effectively address disruptive behaviors. A strong commitment on the part of healthcare agencies to eliminate disruptive behaviors, along with cooperation from everyone in the organization, will be imperative. This commitment and cooperation can be achieved by developing sound policies and by providing education that will help to combat disruptive behaviors. Both approaches will be discussed below. Table 1 describes steps to combat disruptive behavior.

Developing Sound Policies and Procedures to Eliminate Disruptive Behavior

Administrators need to demonstrate a concern for the frequency of disruptive behaviors and implement a clearly outlined plan to address them (Grenny, 2009). Individual staff members also need to play a role in this process. The initial step in this process is to take a zero-tolerance stance towards disruptive behaviors (Center for American Nurses, 2008; Christmas, 2007; Rosenstein, 2002; TJC, 2008). In order to effectively implement a plan of change, specific policies must be in place and followed in all circumstances. The Joint Commission leadership standard relating to disruptive behaviors (LD.03.01.01) addresses two elements of performance which can be used to formulate a plan to combat these behaviors, namely the existence of a code of conduct that defines acceptable and unacceptable behaviors and a process to manage such behaviors (TJC, 2008).

First, it is important to develop a code of conduct describing the types of behavior that are considered disruptive (AMA, 2002). The code needs to address all workers in an organization, including employees, such as nurses, and nonemployees, such as physicians (Barnsteiner, Madigan, & Spray, 2001). In order for a code of conduct to be effective, it must be applied in all circumstances where there is a possible breach. Without this enforcement, the code is meaningless. All team members, including hospital administrators, chief nursing officers, and other nursing leaders, need to be accountable for modeling and enforcing the code (Christmas, 2007; TJC, 2008). Table 2 provides guidance for drafting a code of conduct and Table 3 offers online resources for developing this code.

Next, successful implementation of the code depends upon a clearly delineated channel through which breaches in the code are reported (AMA, 2002; Weber, 2004). Once a breach has been reported, a review process needs to occur where the facts of the story are verified. Designated members of management or an independent review team can meet separately with the person reporting the breach and the perpetrator of the breach to listen carefully to both sides and evaluate if a breech has occurred (Capitulo, 2009). Based on this determination, further action may be needed.

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. During this process it is imperative that privacy and confidentiality are maintained (AMA, 2002). Sometimes people are not aware of how their behaviors are affecting others or how they appear to others, so a designated person in management needs to discuss their behaviors with them. In this conversation an important link must be made between the disruptive behavior(s) and the potential breach in patient safety (Capitulo, 2009). Providing actual data and relating this data to patient outcomes may serve as a wake-up call for necessary behavior change (Keough & Martin, 2004). If change does not occur, additional steps may need to be explored. Outside referrals to employee assistance programs, anger management classes, or individual executive coaching/mentoring may be appropriate (Capitulo, 2009). In some instances there may be an underlying pathological or psychological entity, such as stress or substance abuse, causing the behaviors. In these circumstances, appropriate referrals to mental health professionals may be needed (Keough & Martin, 2004).

Coaching and mentoring are ways by which an intervention can be implemented (Porto & Lauve, 2006). In coaching, behaviors are addressed by communicating the need to change and by having the person commit to the change. During coaching the fact that future behavior will be monitored for appropriateness should be conveyed, and the consequences of another breach outlined (Keough & Martin, 2004). A mentor can provide encouragement during this time and give feedback on the progress in attaining new skills (Thornby, 2006).

In instances where the disruptive behavior is clearly the result of a conflict, steps need to be taken to address the underlying issue. One way to address conflict management is through mediation which is used when both parties involved in the conflict seek to have a neutral third party guide them to reaching a neutrally satisfying agreement in resolving a particular issue (Keough & Martin, 2004). In these situations, an experienced mediator can be employed to establish a safe space for the individuals to discuss the situation and assist in guiding them towards a workable solution (Gerardi, 2004).

If despite the exploration of all possible avenues of intervention, a problem with behavior still exists, disciplinary action may be warranted. Although generally in this corrective process the focus should be on education and rehabilitation rather than punishment (Freeman, 2008), there are instances when disciplinary actions cannot be avoided. Proper steps must be followed before this occurs (TJC, 2008). One way to ensure that proper steps are taken is through documentation that includes the dates and times of the incident(s), a description of the incident, witnesses, consequences that resulted in relation to patient care and hospital operation, and any action that was taken to interrupt or remedy the behavior (Lapenta, 2004). When discipline results in termination, there may be a concern about legal action being brought against the hospital. In the past case reports have indicated that the courts have conceded to the authority of the hospital to take action against a disruptive physician (North Carolina Physicians Health Program, 2009).

If an action is taken against a physician that results in loss of privileges, the physician may use the whistleblower defense. In such situations the defendant states that the alleged disruptive behavior and dismissal was retaliation for voicing concern about a quality care or patient safety issue (Lapenta, 2004). Protection for the person making the complaint needs to be clearly outlined in advance in the procedure addressing the management of disruptive behavior. In instances where a potential patient issue does exist, hospitals must assume responsibility for follow-up to determine the legitimacy of the complaint (Lapenta).

Fear of retaliation is a concern for anyone reporting a breech in the code. It is important to develop a compact to protect reporting employees against retaliation and establish penalties for those that do retaliate (Porto & Lauve, 2006). Another way to protect against retaliation is by addressing retaliation in the code of conduct. Those reporting an incident of disruptive behavior(s) need to be backed by the organization in order to convey the message that an organization truly supports a zero-tolerance policy against disruptive behaviors.

Educational Initiatives to Combat Disruptive Behavior

To date, few evidence-based interventions for addressing disruptive behaviors have been reported. Most research relating to these behaviors and associated activities, such as bullying, focus on the incidence and consequences of the behavior (Johnson & Rea, 2009; Rosenstein & O'Daniel, 2005, 2008; Strauss, 2008; Veltman, 2007). The one area in which evidence-based interventions are being developed is that of education. In a study by Rosenstein (2002) 24% of the nurses, 21.3% of the physicians, and 20.8% of the executives stated that a needed strategy to decrease disruptive behaviors was that of teaching nurses and physicians to improve their working relationships. Griffin (2004) reported that newly licensed nurses who had been taught about the use of cognitive rehearsal techniques to address disruptive behaviors were better able to confront nurses who displayed lateral violence. MacIntosh (2006) reported 21 workers in a qualitative study of bullying suggested that increasing knowledge about terms and available services related to bullying would be a way to combat bullying. These early studies have suggested that education and practice can serve as power tools in addressing these disruptive behaviors. The following sections will discuss educational initiatives related to: (a) improving general communication skills, (b) increasing the desire to communicate effectively, (c) introducing policies regarding disruptive behaviors, and (d) interacting appropriately with those who are demonstrating disruptive behaviors. For those nurses wishing to learn more about disruptive behaviors, the Center for American Nurses (CAN) has a free webinar titled 10 Tips for Addressing Disruptive Behavior at Work that can be accessed at www.centerforamericannurses.org/displaycommon.cfm?an=1&subarticlenbr=195. The Center <http://centerforamericannurses.org//> also periodically offers other webinars related to workplace issues.

General communication skills. Skilled communication, a recognized standard in creating a healthy workplace, facilitates collaboration and assists in creating positive outcomes (AACN, 2005). Grover (2005) has listed eight skills that are essential for effective communication. These skills include: (a) listening to the other person; (b) asking open ended questions to gain more in-depth information; (c) asking closed questions to gain facts; (d) clarifying in-order-to get more details; (e) paraphrasing so that meaning can be interpreted; (f) using facilitators to encourage continuing dialogue; (g) assessing non-verbals; and (h) using silence to promote thinking. Though many of these skills are learned from an early age, when facing a challenging or confrontational situation the most fundamental approaches may be forgotten.

So as to keep these skills at an 'always ready' level, it is important to periodically conduct a self-evaluation as to how successful one has been as a communicator (Thornby, 2006). During this assessment an evaluation of past and current communication patterns can be made to look for behaviors that might be impeding the proper exchange of information. Such behaviors might include, among others, being timid and shy, emotional, overly aggressive, or too sensitive to how behaviors affect others (Thornby). Becoming aware of ineffective styles of communication may assist in recognizing areas for improvement.

The Desire to Communicate. A desire and a willingness to communicate are essential for maintaining safety in healthcare settings. In a study titled Silence Kills, conducted by VitalSmarts and the AACN (2005), two important workplace behaviors, namely teamwork and respect, were identified as factors that impede safety but are difficult to address with others (Maxfield, Grenny, McMillian, Patterson, Switzler, 2005). In this study 75% of the participants noted concern with a peer's poor teamwork and 77% were concerned about experiencing disrespect (Maxfield, et al.) Most of the participants stated that it was between difficult and impossible to confront providers demonstrating these behaviors. In contrast, the ability to talk with providers who were respectful team players did lead to positive outcomes. Those who were confident in confronting others concerning lack of teamwork experienced higher moral and intended to stay in their unit and hospital longer compared to those who were not confident in this behavior; those confident in confronting others concerning disrespect or abuse also had higher intentions regarding keeping their job (Maxfield, et al.). Managers may need to take steps to help staff learn to confront employees who show a lack of respect for and/or a lack of teamwork with other providers.

Introducing Zero-tolerance Policies. 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 (Keough & Martin 2004). This education should be included in orientation classes, continuing education classes, and institutional updates so that all members become aware of organizational expectations. The dangers of disruptive behaviors, the identification of these behaviors, and preparation for confronting these behaviors (Center for American Nurses, 2007) can be presented in these educational sessions.

Confronting Disruptive Behaviors. Education can also serve to teach employees how to confront a person displaying disruptive behaviors. This confrontation should occur as soon as possible after the incident (Briles, 2009; Namie & Namie, 2009). To avoid coming across as defensive, practice may be needed (Namie & Namie, 2009). This can be accomplished by rehearsing with a supportive peer. Patterson, Grenny, Mc Millian, and Switzler (2003) have provided the following helpful strategies for confronting fellow workers who use disruptive behaviors. They have noted that when the dialogue does take place, respect and privacy must be maintained. In order to initiate the conversation, the motives of the communication need to be clear and the conversation needs to stay focused on the topic at hand, with both parties being able to tell their stories. It is also imperative that a feeling of safety be maintained throughout the conversation so that relevant information is brought out into the open. A lack of safety can lead to silence where there is withholding of information, or to violence where undesired meanings are added to the conversation. Briles (2009) has explained that when addressing disruptive behaviors, a mutual understanding of what occurred needs to be reached, and confronters need to describe their feelings that resulted from the behavior as well as the impact the behavior had on them. The final step is coming to a mutual agreement as to how the situation will be resolved (Patterson et al.) This agreement should include a description of the desired behavior and the consequences if the behavior continues (Briles). Though at first the prospect of having this dialogue may be daunting, the results can be very positive and empowering. The more often these conversations occur, the more skilled and confident one becomes in holding these crucial conversations.

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