Behavior of Physician adversely affect other health care provider and reduce their performance,This significantly hit the quality care. This problem should be addressed all health care provider.

1. OPERATIONS __
Behaviour matters
What to do when a staff member
gets abusive
BY DR AK KHANDELWAL
S
urgeons hurling instruments at
assistants or walking out in the
middle of a surgery, physician
humiliating nurses, healthcare
staff getting physically assaulted by
senior hospital members. Shocking, as they may
seem, such occurrences are more common that
one would think in healthcare organisations.
They are examples of disruptive or abusive
behaviour, which has been observed in almost all
members of the healthcare team, be it doctors,
nurses, pharmacists or technicians. However,
when a doctor exhibits such behaviour, it may
have the greatest impact because of the position
of authority sjhe wields as a member of the
healthcare team.
The rate of such incidents is alarming. As per
a study by the American College of Physician
Executives, more than 95 per cent of physicians
reported encountering "disturbing, disrup-
tive, and potentially dangerous behaviours
on a regular basis!' In another study covering
more than 140 hospitals, over one-third of the
participants reported nurses leaving institutions
because of disruptive behaviour by physicians.
Twenty-three percent of nurses reported at least
one instance of physical threat from a physician.
According to yet another study, around 18per
cent of nurse turnover is directly attributed to
verbal abuse.
According to AMA, 'disruptive conduct' is:
"personal conduct, whether verbal or physical,
that affects or that potentially may affect patient-
care negatively constitutes disruptive behaviour!'
These may include disrespectful, profane, de-
meaning, or rude language, sexually inappropri-
ate speech, sexual boundaryviolationsjinappro-
priate touching, intimidation, harassment, racial/
ethnic innuendo or insults, tirades and outbursts
of anger and throwing objects. Criticising other
caregivers in front of patients or other staff, com-
ments that undermine a patient's trust in other
caregivers or the hospital, repeated, intentional
Healthcare Radius July 2013 35

2. • OPERATIONS
DOS AND DON'TS OF
ADDRESSING DISRUPTIVE
HEALTHCARE PROVIDER
••,/ Act promptly on every incident of disruptive
conduct.
,/ Speak about errors ln private.
,/ Involve a third person in the conversation.
,/ State that you are representing on behalf of
hospital management.
,/ Plan your strategy beforehand.
,/ Refer any past violations ifthey have
occurred and identifyany patterns of
misconduct that are in evidence.
,/ Referthe staff code of conduct and any prior
agreement by the practitioner to comply
with it.
,/ Clearlystate the consequences of this or
future violations.
DON'TS
)( Do not get provoked. Keepcool.
)( Do not get judgmental, focus on the incident
only.
)( Don't allow the disruptive practitioner
to change the subject-agree to talk at
another time about his or her concerns
regarding other staff members or about
quality issues.
x Do not make excuses for the disruptive
behaviour.
)( Avoid 'circling the wagons' to put up a show
of collegiality.
)( Do not get intimidated bythreats of legal
action.
)( Don't fail to investigate 'quality concerns'
when alleged by disruptive practitioners.
)(Do not allow a disruptive doctor/staff
member's allegations of wrong-doing by
others to distract yotJfrom addressing that
doctor's own unprofessional conduct.
x Avoid manufacturing evidence of clinical
deficiencyto support allegations of
unprofessional behaviour.
)( Not clearlycommunicating behavioral
expectations (e.g. through a code of conduct
or compact).
)( D.onot avoid to strictlyenforce a code of
conduct.
)( Avoid responding to a physician's disruptive
conduct differentlyfrom other healthcare
provider.
36 Healthcare Radius July 2013
non-compliance with organisation rules and
policies, deliberate interference with the smooth
functioning of hospital or medical staff opera-
tions, inappropriate comments in the medical
record-especially those impugning the quality
of the work done by others, unethical/dishon-
est behaviour, repeated lack of response to calls
from other health personnel and unwillingness
to work collaboratively." It also includes inap-
propriate arguments with patients, their families,
hospital staff and other physicians.
The effect of disruptive behaviour on a health-
care organisation is manifold. 'Sentinel Event
Alert' by The Joint Commission on July 9,2008
observed that it can lead to medical error, de-
creased patient satisfaction, high staff turnover,
preventable adverse outcomes and increased cost
of care. It also leads to poor patient satisfaction.
Leaders of health care organisation should take
initiatives to minimise this problem to improve
organisation's performance.
JCI prescribes following guidelines to prevent
such behaviour.
1. Educate all team members, physicians and
non-physician staff, on appropriate profes-
sional behaviour defined by the organisation's
code of conduct. It should include training in
basic business etiquette and people skills.
2. Hold all team members accountable for mod-
elling desirable behaviours, and enforce the
code equitably among staff, regardless of sen-
iority or clinical discipline in a positive fashion
through reinforcement and punishment.
3. Develop and implement policies and processes
that show 'zero tolerance' towards intimidat-
ing and/or disruptive behaviours. Incorporate
the zero tolerance policy into medical staff
bylaws and employment agreements as well as
administrative policies.
4. Ensure that staff policies regarding intimidat-
ing and/or disruptive behaviours of physicians
are complementary and supportive of the
policies that are present in the organisation for
non-physician staff.
5. Reduce fear of intimidation or retribution and
protect those who report or co-operate in the
investigation of intimidating, disruptive and
other unprofessional behaviour. Non-retali-
ation clauses should be included in all policy
statements that address disruptive behaviour.
6. Respond to patients and/or their families
involved in or witness to intimidation and/
or disruptive behaviour. The response should
include hearing and empathising with their
concerns, thanking them for sharing those
concerns, and apologising.
7. Create a plan on how and when to begin
disciplinary actions (such as suspension, ter-
mination, loss of clinical privileges, reports to
professional licensure bodies).
8. Provide skills-based training and coaching
for all leaders and managers in relationship-
building and collaborative practice, including
skills for giving feedback on unprofessional
behaviour, and conflict resolution. Cultural
assessment tools can also be used to measure
whether or not attitudes change over time.
9. Develop and implement a reporting/sur-
veillance system (possibly anonymous) for
detecting unprofessional behaviour. Include
services of ombudsmen and patient advocates
to provide feedback from patients and families,
who experience intimidating or disruptive
behaviour from health professionals.
10.Monitor system effectiveness through regular
surveys, focus groups, peer and team member
evaluations. Have strategies to learn whether
intimidating or disruptive behaviours exist or
recur, such as through direct inquiries at rou-
tine intervals with staff, supervisors, and peers.
11.Support surveillance with tiered, non-con-
frontational interventional strategies, starting
with informal conversations, directly address-
ing the problem and moving toward detailed
action plans and progressive discipline, if
patterns persist. These interventions should
initially be non adversarial in nature, with the
focus on building trust, placing accountability
on and rehabilitating the offending individual,
and protecting patient safety. Make use of me-
diators and conflict coaches when professional
dispute resolution skills are needed.
12.Conduct all interventions within the context
of an organisational commitment to the health
and wellbeing of all staff, with adequate
resources to support individuals whose be-
haviour is caused or influenced by physical or
mental health pathologies.
13.Encourage inter-professional dialogues
across a variety of forums as a proactive way
of addressing ongoing conflicts, overcoming
them, and moving forward through improved
collaboration and communication.
14.Document all attempts to address intimidat-
ing and disruptive behaviours. IlIlJ
Dr AK Khandelwal
is medical director at
AnandaLoke Hospital Et
Neurosciences Centre,
Siliguri, West Bengal