Published in:
Issue/Volume: August 25, 2008
Written by: Catherine Spader, RN

8/25/2008 – The trigger for the focus on disruptive behaviors comes from data compiled by The Joint Commission in its July 9 Sentinel Event Alert, “Bad Behaviors that Undermine a Culture of Safety.” The alert concludes intimidating and disruptive behaviors pose a serious threat to patient safety and the overall quality of care.

“There is no way to make real progress in patient safety until we address intimidating and disruptive behaviors,” says Grena Porto, RN, MS, ARM, CPHRM, a member of the Sentinel Alert advisory group.

Data cited by the alert says 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator, according to the Institute for Safe Medication Practices. “A negative environment that includes intimidating behaviors from a variety of staff creates a lack of cooperation, teamwork, and caring and an increased potential for errors,” says Peter B. Angood, MD, vice president and chief patient safety officer of The Joint Commission. “Disruptive behaviors also negatively impact healthcare recruitment and retention.”

Nurses, physicians neck and neck

The lay press, including the Los Angeles Times and the Chicago Tribune, focused its coverage of The Joint Commission’s new requirements on the intimidation and disruptive behavior of physicians. But current research says nurses are guilty of disruptive behavior almost as often as physicians.

In a survey of 4,530 nurses, physicians, administrators, and other healthcare employees and professionals, 77% of survey respondents reported witnessing disruptive behavior by physicians and 65% reported witnessing disruptive behavior by nurses. The survey was published in the August 2008 The Joint Commission Journal on Quality and Patient Safety. Also, 67% of respondents agreed disruptive behaviors were linked with adverse events. Intimidating and disruptive behaviors also are not limited to one gender, one profession, or a small number of perpetrators, according to the Sentinel Event Alert.

“The mistake is to think we are only talking about physicians,” says Porto. “A lot of people in health care behave badly and don’t think it’s a big issue.”

Disruptive behavior in the healthcare setting can be potentially dangerous to patient safety, says Alan H. Rosenstein, MD, MBA, co-investigator of the survey and vice president and medical director of VHA West Coast in Pleasanton, Calif. “We are all part of the healthcare team, and every person’s ability to communicate and interact with other members of the team and understand everybody’s roles can have a profound effect on patient care,” he says.

Not in my hospital

Timing couldn’t be better for the new requirements.

Joe Heyman, MD, chairman of the board of the American Medical Association (AMA) and a commissioner of The Joint Commission says he has seen a gradual decrease in disruptive behavior during his 40-year practice as a physician. “Society has changed, and it’s less acceptable now for people to behave disruptively at work,” he says, adding the AMA is very supportive of the new requirements.

Despite this, Porto believes disruptive behavior is a “leadership issue at its core and leaders have a long way to go.”

Porto cites common examples in which leadership enables disruptive behaviors. These include cases in which staff complaints of bad behavior are dismissed with comments from leadership such as “It’s not such a big deal” or when nurses are told it’s their duty to accept and deal with rude or intimidating behaviors from physicians.

It’s also common for physicians and hospital CEOs to deny there is a problem within their organizations.

To better address disruptive behaviors, leaders, professionals, and staff need to understand these behaviors include more than outbursts, temper tantrums, physical threats, and the throwing of objects, according to Porto. “People often think of these extreme behaviors, but there are more subtle behaviors, such as intimidation and rudeness, that are just as bad,” she says.

People who exhibit more subtle disruptive behaviors may believe they are acting professionally and are unaware of how others perceive them. For example, some nurses may find it intimidating when physicians give orders in non-emergent situations without an introduction or a hello.

“One person may think he or she is being efficient and brisk in his or her communication while others may find that intimidating and brusque,” says Nancy Foster, vice president for quality and patient safety policy for the American Hospital Association.

The Joint Commission recommends healthcare organizations provide education about courtesy during telephone interactions, business etiquette, and general people skills.

Patients also may unwittingly contribute to the situation, says Porto. They may accept bad behaviors they witness because they believe professionals who display disruptive behaviors are very skilled, really care, and are aggressively advocating in their best interest. To raise awareness among patients about inappropriate behaviors, The Joint Commission recommends organizations apologize to patients and families who are involved in or witness intimidating or disruptive behaviors.

The Joint Commission also recommends healthcare organizations have a code of conduct that defines acceptable, disruptive, and inappropriate behaviors. Leaders must implement a process for managing disruptive behaviors, and all team members should be held accountable for modeling desirable behaviors. The Joint Commission also recommends establishing a zero-tolerance policy and developing a system to detect and receive reports of unprofessional behavior.

The complete text of the new standards can be found at