Denial, The Problem, and Professional Codes of Conduct

Reasons for Inaction

  • Someone else was handling the problem (19%)
  • No effective action would occur if reported (15%)
  • Fear of retribution (12%)  

(DesRoches 2010)  

Why address disruptive behavior?

  • Professional and ethical considerations
  • Negative effect on the health care team
  • Negative effect on patient care
  • Disruptive behavior may signal psychological stress
  • Joint Commission Sentinel Event Alert  

The PHR committee developed this material to help physicians learn practical tools and tips for preventing, recognizing, and addressing disruptive behaviors.  The goals of this section are to differentiate between appropriate, inappropriate, and disruptive behaviors, and to discuss an action plan that addresses behaviors which undermine the culture of safety.

The PHR Committee promotes the treatment and recovery of colleagues in distress in order to prevent deterioration of relationships and health and to provide a lifeline to save lives and careers.

Disruptive behavior alone may not be reportable, but a sentinel event resulting in patient harm due to disruptive behavior would be reportable.

Disruptive behavior increases the likelihood of errors. Nurses and colleagues avoid the physician who is exhibiting disruptive behavior, hesitate to ask for clarification of orders, and show reluctance to make suggestions for improving patient care. This not only has a negative effect on patient safety, but also is corrosive to morale.

AMA Definition: Disruptive Behavior

“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.”  

(Opinion 9.045. Physicians with Disruptive Behavior, American Medical Association)

Professional Ethics.  There appears to be an increase in reporting of disruptive behavior in physicians due to public attention of professional ethics.  

Sound data are lacking for the incidence of disruptive behavior. Surveys of nurses suggest that most have witnessed episodes caused by 4-5% of the physicians at their institutions, but these data are flawed by low response rates. Surveys of physician executives indicate that the percentage of disruptive physicians range from 1% to 5%. Hickson and colleagues found that 6% of physicians received 25% or more complaints from patients over a six-year period. Leape and Fromson estimate that 3% to 5% of physicians present a problem of disruptive behavior.

Although there are varying opinions, there are no good data on whether there is more disruptive behavior in physicians today than in the past. A combination of competition, health care payment plans, patient’s expectations of health care services, and more active participation of patients in their own health care are cited as contributing factors for the increased reporting of disruptive behavior in physicians. Ignoring disruptive behavior is not an option in today’s health care environment.  

Joint Commission Alert (7/08 & 1/09)

  • Leadership standard
  • Disruptive behavior regarded as a sentinel event
  • Sentinel event designation requires an immediate "root cause analysis"
  • Patient safety and patient care
  • Hostile work environment  

Disruptive behavior increases medical errors and adverse outcomes. The Joint Commission (JC) Sentinel Event Alert holds all team members accountable for modeling desirable behaviors. It also enforces the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.  There is zero tolerance for intimidation, disruptive behavior, or retaliation.

Under JC Standard LD.03.01.01, leaders must create and maintain a culture of safety and quality throughout the organization. There are ten Elements of Performance, which include (a) the hospital having a code of conduct that defines acceptable, disruptive, and inappropriate behaviors and (b) leaders creating and implementing a process to manage disruptive and inappropriate behaviors.

JC Medical Staff Standard 11.01.01 requires the Medical Staff to implement a process to identify and manage matters of individual health for licensed independent practitioners that is separate from actions taken for disciplinary purposes. There are nine Elements of Performance, which include (a) education of Medical Staff and organization about illness and impairment recognition issues specific to licensed independent practitioners and (b) a process design that addresses self-referral.

AMA Code of Conduct

  • Purpose is to encourage a culture of safety and quality
  • Contains standards for review of inappropriate or disruptive behavior
  • Applies to all members of the medical staff
  • Defines appropriate, inappropriate, and disruptive behavior, and includes examples  

Ask yourself these questions:

  1. Do you know if your hospital has a policy? Where is it?
  2. Have you read it?
  3. Have you ever been personally involved with such an instance or are you aware of any physician who has, and its outcome?
  4. Would you know what to do if you were accused?
  5. Do you know how to appeal?  

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Last Updated On

January 26, 2012

Originally Published On

March 23, 2010