Over the years, generally, some particularly egregious unprofessional behaviors have significantly decreased, for example, surgeons throwing instruments at team members during surgery. However, other behaviors that have a significant negative impact on patient safety continue. As a consultant to hospitals and healthcare systems, I have encountered numerous victims of disruptive clinician behavior and reviewed many reports of events that should not be happening in the context of heightened awareness and rigorous evidence of the relationship between a culture of safety and patient outcomes. Many of these events of disruptive clinician behavior are linked to preventable patient harm.
If you are fortunate enough to be working in a hospital that promotes patient safety and takes steps to immediately address disruptive clinician behavior, it may be surprising that there are still hospitals where this type of behavior is routinely overlooked. In some hospitals, unprofessional behaviors from "big volume providers" are more likely to be overlooked or dismissed. There may be concern that this provider would leave for a competing hospital if the behavior is properly addressed. Sometimes the threat is implied, while in other cases, the administrative team is told "I can always take my patients somewhere else" when the issue of behavior is raised. In some hospitals, there is a palpable fear of speaking up. When the disruptive behavior is exhibited by a member of the leadership team, the hierarchy of power plays a significant role. Clinicians are concerned about losing their jobs or retaliation from the perpetrator/s. When considering hospital hierarchy, nurses, especially staff nurses, are often in a vulnerable position. Labor nurses have discussed in detail their avoidance strategies because often encounters with those who are acting unprofessionally are most unpleasant. No one wants to be berated or demeaned. Intimidation can be a great deterrent to effective, timely communication and thus to appropriate intervention in time to prevent harm. Notifications may not occur as clinical deterioration progresses because one party wants to prevent "being yelled at" or "made to feel stupid"; two of the most common comments I hear when asking "why didn't you call the provider?" as an adverse event is being reviewed. If every time the nurse calls to report late decelerations, they are told "they are not lates" and "they don't know how to interpret the fetal monitoring tracing," they are going to avoid making the call to that provider. Likewise, comments such as "get me someone who knows what they are doing" do not encourage a follow-up call.
In 2008, the Joint Commission (TJC) issued a sentinel event alert in response to many reports of disruptive behavior and the effects on patient outcomes. Hospitals that are TJC accredited are expected to have a code of conduct that outlines acceptable, disruptive, and inappropriate behaviors and to initiate practices and policies for handling disruptive and inappropriate behaviors including actionable consequences (TJC, 2008). Numerous steps are listed that can be successful in promoting a culture of safety and having zero tolerance (TJC). The American College of Obstetricians and Gynecologists (ACOG, 2017) recently updated their committee opinion on disruptive behavior and included various suggestions for institutions and practitioners to consider when promoting professional collaborative behaviors. The committee opinion and the sentinel event alert (TJC) are worth reading to make sure your hospital is doing all that it can to promote a culture of safety that is conducive to optimal patient outcomes.
Most clinicians do not exhibit disruptive or inappropriate behavior. Most communicate in a respectful manner and most share the common goals of the perinatal team, a healthy mother and baby. However, even one or two clinicians routinely behaving inappropriately can have a significant negative impact on unit culture. As others see no consequences, there tends to be gradual erosion of behavior standards and the unit culture of safety is undermined, thus mothers and babies are at risk for preventable harm. Disruptive clinician behavior as a contributor to preventable patient harm should not be a factor in today's healthcare environment.
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