2nd Opinion
Is the New Joint Commission Mandate that Healthcare Instititions Address Disruptive Behaviors an Appropriate Standard?

2nd Opinion is coordinated by Kathleen Leask Capitulo, DNS, RN, FAAN

Writing for the Pro Position: Monica B. Latayan, DNP, RN

I applaud the efforts of The Joint Commission for including disruptive and inappropriate behavior as a new leadership standard effective January 1, 2009. This new standard requires that institutions "have a code of conduct that defines acceptable and disruptive and inappropriate behaviors"; and that "leaders create and implement a process for managing disruptive and inappropriate behaviors." (The Joint Commission, 2008).

There is a growing focus on the role of prevailing hospital culture as a contributing factor in medical errors, and the healthcare industry has begun to realize that human interaction is an important source or error. While we know that most healthcare workers perform their duties with care, compassion and professionalism, there are times when professionalism breaks down and can devolve into unprofessional behaviors. This can threaten patient safety, and therefore it is imperative that healthcare organizations take a stand by clearly identifying such behaviors and refusing to tolerate them. It is well known that safety and quality of patient care is dependent on teamwork, communication and a collaborative work environment (The Joint Commission, 2008). Disruptive behaviors include yelling and screaming, intimidating gestures, profane language, condescending comments, outbursts of anger, threats, retribution, and other such behaviors. These disruptive behaviors create an unhealthy and potentially hostile work environment and are toxic to the nursing profession, the patients and healthcare team. In addition, they have a negative impact on retention of quality staff. Disruptive behaviors often increase the risk for errors by breaking down communication, which can result in delays in contacting healthcare providers who are known to behave badly, and in errors in critical medical decisions.

Inappropriate and disruptive behaviors are often manifested by healthcare professionals in positions of power. It has been shown that when disruptive behaviors among physicians, nurses and other member of the healthcare team are ignored, collaboration and information exchange are affected, as are team dynamics and patient outcomes (Rosenstein & O'Daniel, 2005). Research published in 2002 by the same authors documented the negative impact of physician disruptive behavior on nurse satisfaction and retention. We also know that patient care is affected; the Institute for Safe Medication Practices (2003) found that 40 percent of clinicians have kept quiet or remained passive even in the face of deleterious patient care events rather than question a known intimidator. Disruptive behavior does not cultivate a culture of safety, which is an atmosphere characterized by open and respectful communications among all members of the healthcare team aimed at inspiring and providing safe patient care.

Healthcare organizations have an obligation to protect patients from harm. One of the ways they can do this is to address disruptive and inappropriate behavior and hold all team members accountable for modeling desirable behaviors, thus enforcing a code of professionalism consistently and equitably. In addition, in my opinion, each institution must establish strong policies and systems to protect those who report or cooperate in the investigation of disruptive behavior. Critical decisions regarding patients' lives are entrusted to us everyday. Disruptive behavior in our healthcare culture is a toxic factor and must be vigorously eliminated.

Monica B. Latayan is Director of Nursing Education, Research, and Professional Practice, North Shore University Hospital, Manhasset, NY.

References
Institute for Safe Medication Practices. (2003). Survey on workplace intimidation. Retrieved December 12, 2008, from www.ismp.org.
Rosenstein, A.H. & O'Daniel, M. (2005). Disruptive behavior & clinical outcomes: Perceptions of nurses & physicians. American Journal of Nursing. 105(1). 54-64.
The Joint Commission. (2008). Sentinel event alert: Behaviors that undermine a culture of safety (40) July. Retrieved December 30, 2008, from www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.

Writing for the Con Position: Michael J. Schoppmann, Esq.

The impact of being branded by a "scarlet letter" in Nathaniel Hawthorne's time pales in comparison to what is wrought upon by unsuspecting practitioners labeled as "disruptive" in today's medicine. Virtually irremovable once affixed, the brand of "disruptive" can summarily ruin an otherwise brilliant medical career and should prompt every practitioner to immediately, and aggressively, risk manage their practive to avoid even the inference of any such status.

"Disruptive" - defined in countless fashions throughout medical staff bylaws, employee manuals/handbooks and other governing rules and/or regulations - is basically any style of interaction with practitioners, hospital personnel, patients, family members, or others that is deemed to interfere with patient care (American Medical Association, 2001; The Joint Commission, 2008). While no one questions the need for the orderly administration of patient care, the abuse of that worthwhile goal is revealed when one considers the stunning breadth of "any style of interaction" - interpreted by some to include even facial expressions, tone of voice and/or body language. "Disruptive" may include profanity, hostility, insensitivity, sexuality, and incompatibility. Equally disturbing is the question of who will hold the power to "deem" such interactions to be disruptive? Does that person hold inappropriate (i.e. economic, personal, etc.) or appropriate motivations? Further, and in essence, is there anything that cannot be "deemed" to "interfere with patient care"?

The overly broad and unduly vague nature of such a label as "disruptive" can only lead to further misuse and greater abuse against practitioners. I would advise practitioners to immediately obtain, review and challenge, if necessary, the following from their employer and/or medical staff: (1) Any and all code(s) of conduct; (2) Any employee handbooks/manuals; (3) Any medical staff bylaws; (4) Any departmental procedures and protocols. If any of these are poorly defined, unworkable in its vagueness or subject to self-serving interpretation, it should be challenged immediately through the offices of the medical staff, human resources, union representatives, etc. If one accepts that "behavioral standards" in an employment setting, lack of compliance carries the risk of being adversely and permanently labeled as "disruptive."

In the event of an investigation of practitioner conduct, there is potential for serious and irreparable professional damage. Therefore, no practitioner should (1) allow a complaint to go unaddressed and/or unresolved or (2) attend a meeting concerning their status (either as an employee and/or medical staff member) without first knowing who will be attending and what will be discussed. If attending such a meeting, one should take careful and copious notes of what is said and by whom, demand an opportunity to weigh what has been presented and respond at a later point - possibly in writing, and never be coerced into signing any document or documents at such a meeting. Moreover, if an investigation is concluded in the practitioner's favor, that disposition should be in writing, and secured in the practitioner's relevant file in order to accurately, and permanently, reflect the practitioner's standing.

Every practitioner's ability to avoid the label of "disruptive" rests with whether he or she is willing to proactively secure a firm grasp of the standards by which such an adverse judgment may be placed. Then they must either abide by those standards, intitiate the effort to change the standards or remove themselves from the institution. To remain silent, unaware or uninvolved will only serve to empower the structures, which seek to abuse the intentions, process and goals of those who honorably seek to address the truly "disruptive" practitioner.

Michael J. Schoppmann is Partner at Kern, Augustine, Conroy & Schoppmann, P.C., Attorneys to Health Professionals Offices in New York, New Jersey, Florida, Pennsylvania and Illinois.

References
American Medical Association (2001). Code of Ethics. Retrieved December 30, 2008, from http://www.ama-assn.org/ama/pub/category/2512.html
The Joint Commission (2008). Behaviors that undermine a culture of safety (40) July. Retrieved December 30, 2008, from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm