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But what about the other potential interpretation of the
association, i.e. that the disruptive behavior might be the result rather than
the cause? Some new research actually raises that
possibility.
Heslin and colleagues (Heslin 2019) analyzed 314 reports of disruptive
behavior, involving 227 healthcare professionals, at a single institution over
a 2-year period. They compared both reporter accounts and involved party
responses to determine if disruptive behavior was inherent to the surgeon or
the hospital environment and its relationship to patient safety. 76% of
involved parties had only a single event. All involved parties were physicians,
2/3 being attending physicians and 1/3 residents.
In an interview with Anesthesiology News (Frangou
2020) the investigators said “To us, this is an indication that further
resources are needed to address the systemic stressors that can lead to frustration
that is perceived as disruptive behavior, resulting in event reports for
individuals who are most often focused on delivering high-quality patient
care.”. They note that efforts to improve the culture of communication in
hospitals might not be addressing the root causes of many cases of disruptive
behavior.
They also noted that reported cases involving a physician
who had been reported for more than one incident of disruptive behavior were
less likely to be related to a patient safety event.
Reported causes or contributing factors included:
Some incidents involved more than one factor.
We’ve had plenty of experience dealing with disruptive
physician behavior over the years. And, yes, there are always 2 sides to every
story. While you cannot dismiss the disruptive behavior, you do need to listen
to and look for events or circumstances that may have served as triggers for
such behavior. Our own experience would identify inadequate resources
(personnel or equipment/supplies), overwork, and fatigue as the most frequent
contributing factors.
Contrary to what Heslin et al. found, we often saw such triggers in
system issues even for those “repeat offenders”. So, a good rule is to always
look at the entire picture, even in cases where that physician has exhibited
more than one episode of such behavior. But beware: be very sure that
your investigation and actions do not serve to deter anyone from coming forward
with such complaints against healthcare professionals. We’ve certainly seen
examples where actions taken by Medical Executive Committees have appeared to
show retribution to those who came forward. That leads to a culture that is
detrimental to both patient safety and workforce morale in general. In fact, we
might argue that the biggest factor contributing to disruptive behavior is a
culture that tolerates such behavior.
So, is there a lesson here? Yes. When we see something that
violates a patient safety concept, we need to look for a root cause or
contributing factors. You have heard us before state that when you come across
a workaround, you always need to look for reasons that workaround was used (i.e.
a root cause). The same probably applies in cases of disruptive behavior, perhaps
more so when the “offending party” has no history of previous disruptive
behavior. If you identify an instance of disruptive behavior, you must deal not
only with the individual and the behavior, but also look to see what system
factors may have contributed to that behavior.
Some of our prior
columns on the impact of “bad behavior” of healthcare workers:
January 2011 “No Improvement in Patient Safety: Why Not?”
March 29, 2011 “The Silent Treatment: A Dose of Reality”
July 2012 “A
Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
April 2017 “Relation
of Complaints about Physicians to Outcomes”
October 2, 2018 “Speaking
Up About Disruptive Behavior”
August 2019 “More
on the Cost of Rudeness”
References:
Heslin MJ, Singletary B, Benos K, et al. Is Disruptive Behavior Inherent to the
Surgeon or the Environment? Analysis of 314 Events at a Single Academic Medical
Center. (Abstract #8) American Surgical Association Annual Meeting 2019
https://meeting.americansurgical.org/abstracts/2019/8.cgi
Frangou C. Disruptive Behavior Mostly Arises from Systemic
Causes, Study Finds
Most Cases Involve Physicians With
No History of Abusive Behavior. Anesthesiology News 2020; January 3, 2020
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