Martha E. Brown, MD PRN Associate Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division William Swiggart, MS, LPC/MHSP

Disruptive Behavior In The Workplace

Behaviors that undermine a culture of safety and quality

Martha E. Brown, MD

PRN Associate Medical Director

And

UF Associate Professor of Psychiatry

Addiction Medicine Division

William Swiggart, MS, LPC/MHSPAssociate in Medicine

Co-DirectorVanderbilt Center for Professional Health

www.mc.vanderbilt.edu/cph

http://www.mc.vanderbilt.edu/cph

We judge ourselves by our motives

others judge us by our behavior.

AA saying

Give learners an overview of

disruptive/distressed behaviorProvide resources and

examples of interventions.

Goals

Describe the Joint Commission requirements List examples of disruptive behavior Estimate the impact of disruptive behavior Explore the etiology of disruptive behavior Discuss the components of a comprehensive

evaluation Apply specific educational approaches Identify some appropriate resources

Disruptive/Distressed Physician Behavior Objectives

2004 AAMC Council of Deans

“Physicians are often poorly socialized and enter medical school with inadequate

social skills for practice.”

“There is a growing body of literature documenting that residency programs do

not prepare resident physicians adequately for the practice of medicine.”

Defined disruptive behavior as a Sentinel Event Recognition that disruptive behavior can:

Foster medical errors Contribute to poor patient satisfaction Contribute to preventable adverse outcomes Increase the cost of care (including malpractice) Lead to turnover/loss of qualified medical staff

Joint Commission, Issue 40July 9, 2008

Defined by The Joint Commission as:

“Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.”

Sentinel Events

Goal of including Disruptive Behavior as a Sentinel Event:

Reform health care settings to address the problem

There is a history of tolerance and indifference Promote a culture of safety Improve the quality of patient care by improving

the communication and collaboration of health care teams

Joint Commission

Hospitals establish a formal Code of Conduct Leadership creates a process for reporting,

evaluating and managing disruptive behavior

Joint Commission Requirements

Educate all team members about

professionalism Hold all team members accountable for

modeling desirable behaviors Enforce the code consistently and equitably Non-confrontational intervention strategies Progressive discipline

Joint Commission Recommendations

Disruptive behavior includes, but is not limited to, words or actions that:

Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution)

Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating)

Threaten personal or group safety, such as aggressive or violent physical actions

Behavior or behaviors that undermine a culture of safety Violate Vanderbilt University and/or VUMC policies, including those

related to conflicts of interest and compliance

Definition of Disruptive Behavior

Vanderbilt University and Medical Center Policy #HR-027,

2010

An occasional “out of character” reaction of an

individual Lack of perfectionism. No one is perfect Constructive criticism in good faith with the aim of

improving patient care or education Expressions of concern about a patient’s care and

safety Expressions of dissatisfaction with policies through

appropriate grievance channels or other non-personal means

Disruptive Behavior Is Not

Vanderbilt University and Medical Center Policy #HR-027,

2010

Aggressive

Anger Outbursts

Profane/Disrespectful

Language

Throwing Objects

Demeaning Behavior Jokes

Physical Aggression

Sexual Comments or Harassment

Racial/Ethnic

PassiveAggressive

Derogatory comments about institution, hospital, group, etc.

Refusing to do tasks

Passive

Chronically late Alcohol and other drugs

Not responding to call

Inappropriate or inadequate chart notes

Spectrum of Disruptive Behaviors

Policies will not work if

disruptive behavior goes unreported and unaddressed.

14

DVD

Examples of disruptive behavior and a do over

Why bother dealing with disruptive behavior?

Perceptions of inequality when members of the

team compare their contributions to those of the disruptive member (Kulik & Ambrose, 1992)

Some team members will decrease their contributions, withdraw (Schroeder et al, 2003; Pearson & Porath, 2005)

Failure to Address Disruptive Conduct Leads

to:

Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.

Team members may adopt disruptive person’s

negative mood/anger (Dimberg & Ohman, 1996) Lessened trust among team members can lead

to lessened task performance (always monitoring disruptive person)... effects quality and patient safety (Lewicki & Bunker, 1995; Wageman, 2000)

Financial costs and litigation


To:


High turnover

Pearson et al, 2000 found that 50% of people who were targets of disruptive behavior thought about leaving their jobs

Found that 12% of people actually quitThese results indicate a negative effect

on return on investment


To:



To: disharmony and poor morale1, staff turnover2, incomplete and dysfunctional

communication1, heightened financial risk and litigation3, reduced self-esteem among staff1, reduced public image of hospital1, financial cost1, unhealthy and dysfunctional work

environment1, and potentially poor quality of care1,2,3

1. Piper, 20002. Rosenstein, 20023. Hickson, 2002

Communication breakdown factored in OR errors

50% of the time2

Communication mishaps were associated with 30% of adverse events in OBGYN3

Communication failures contributed to 91% of adverse events involving residents4

Gerald B. Hickson, MD

James W. Pichert, PhD

Center for Patient & Professional Advocacy

Vanderbilt University School of Medicine

Disruptive Behavior Leads to Communication Problems…Communication

Problems Lead To Adverse Events1

1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44. 3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.

2. Gewande et al, Surgery 2003; 133: 614-621. 4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334

Disruptive Behavior Creates

fear confusion or uncertainty vengeance vs. those

who oppose/oppress them

hurt ego/pride grief (denial, anger,

bargaining) apathy burnout unhealthy peer pressure

ignorance (expectations, behavioral standards, rules, protocols, chain of command, standards of care)

distrust of leaders dropout: early

retirement or relocation errors disruptive behavior

begets disruptive behaviorVanderbilt University and Medical Center Policy #HR-027

Etiologies

Why Might a Medical Professional Behave in

Ways that are Disruptive?

Lack of Emotional

IntelligenceLack of awarenessLack of clear boundariesMultiple triggersSlippery slope behaviorsOverworked and isolatedBurnoutMultiple etiologies

Evolution of distressed physicians risk factors

©CPPA, 2008

Why Might a Medical Professional Behave in Ways that are Disruptive?

1. Substance abuse and psychiatric issues Alcohol and Drugs Psychiatric Disorders including Major

Depressive, Bipolar, & Anxiety Disorders

2. Narcissism, perfectionism or other personality traits/disorders

3. Spillover of family/home problems

Gerald B. Hickson, MDJames W. Pichert, PhDCenter for Patient & Professional AdvocacyVanderbilt University School of Medicine

©CPPA, 2008

Why Might a Medical Professional Behave in Ways that are Disruptive?

(cont’d)

4. Poorly controlled anger/Snaps under heightened stress, perhaps due to:a. Poor clinical/administrative/systems supportb. Poor mgmt skills, dept out of controlc. Back biters create poor practice environments

5. Well, it seems to work pretty well and the system reinforces the behavior6. No one addressed it earlier (why? See #5)7. Family of origin issues—guilt and shame8. Training or poor social skills entering into medicine9.10.

“The Perfect Storm”

PhysicianHospital/Clinic

The external system

The internal system

Two Systems Interact

Good skills

Poor skills

Functional & nurturing

Dysfunctional

Systems

"Every system is perfectly designed to get the results it

gets.”

BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

Individual Factors

Predisposing Psychological Factors (1) Alcohol and Drug Family History Trauma History Religious Fundamentalism Familial High Achievement, lack of skills regarding conflict

and negotiation and other family of origin patterns Personality Traits (2)

Narcissism Obsessive/Compulsive

Physician Burnout (3) Clinical Skills Satisfactory or Above Average (4)

Etiologies

1. Valliant, 1972 2. Gabbard, 19853. Spickard and Gabbe, 2002 4. Papadakis, 2004, 2005

Institutional Factors (1)

Scapegoats System Reinforces Behavior Individual Pathology may over-shadow

institutional pathology

Etiologies

Williams and Williams, 2004

The role of a comprehensive evaluation The importance of consequences Educational programs Feedback from colleagues, patients, staff, etc. Monitoring and accountability External resources

Methods to Address Behavioral Problems

Clinical Approaches To The Disruptive

Professional

Confirm facts Immediately talk with the professional and discuss

that what happened was not appropriate Obtain assurances the behavior will not reoccur Complete a record of the incident and conversation

for the personnel file Closely follow up and monitor their behavior Do not be intimidated by threats of legal action

What to do? (Protocol for all cases)

First time incident of disruptive behavior that is

relatively “mild” and not egregious (i.e., routinely failing to complete records in a timely manner affecting patient care, being chronically late, or not answering pages) might be handled by executive committee

CME course should be mandated in most cases (MD should allow committee to talk with CME staff)

Mentoring of professional Behavior closely watched by executive committee

Step-wise Protocol for Handling Disruption

Originally developed at the Vanderbilt Center for

Professional Health (now offered at Vanderbilt, University of Florida, and Professional Renewal Center)

Designed to address the specific needs of professionals whose workplace conduct has become problematic, but

not risen to the point of a formal referral 3 days with 1 day follow-ups at 1, 3, and 6 months

CME Program for Distressed Physicians

Repeated behavior that disrupts healthcare system or

if 1st incident particularly egregious (throwing objects, continual/demeaning language such as profanity/sexual comments) must be addressed more formally

Call your PHP to discuss whether formal assessment is warranted or if referral to CME might be sufficient in lieu of a more formal report to the PHP at this time

Brief contract outlining expectations/requirements should be signed by professional (include written permission to talk with CME staff or PHP)


If behavior reaches a level that there is an

immediate risk of harm to patients or staff, then a more formal procedure needs to happen

The professional should be directed to contact their PHP immediately

Strong consideration should be given to suspension of privileges until the PHP deems the professional safe to practice again

This type of behavior usually results in a comprehensive residential evaluation and treatment


Professional will be sent to a program that specializes in

evaluating disruptive professionals Multidisciplinary evaluation lasting 1-5 days

Medical workup Psychiatric/substance abuse evaluation Psychosocial information including genogram Neuropsychological testing Collateral information

Comprehensive report results with recommendations by evaluation team which may include Outpatient treatment Residential treatment Long-term psychotherapy 360 evaluations

Comprehensive Evaluation

CME Program for Distressed Physicians

Components:Phone interviewThree-day CME course (47.5 AMA PRA

Category 1 Credits ™)Teach Specific tools/skills - e.g., grounding

skills, Alter, communication strategiesThree follow-up sessions with the core group

over the next six months; importance of group process

Teach specific skills related to preventing disruptive

behavior Promote peer accountability and support Identify risk factors and prevention strategies Understand their own behavior and how it affects

others Discuss healthy boundaries and appropriate

expression of emotions Understand socialization of professionals learned in

training that contributes to maladaptive patterns This is NOT treatment, but rather education

CME Course Goals

Let’s practice

Flooding*“ This means you feel so stressed that you become emotionally and physically overwhelmed…”

“Pounding heart, sweaty hands, and shallow breathing.”

“When you’re in this state of mind…you are not capable of hearing new information or accepting influence.”

*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.

SELF-TEST: FLOODING 1. At times, when I get angry I feel confused. Yes No 2. My discussions get far too heated. Yes No 3. I have a hard time calming down when I discuss disagreements. Yes No 4. I’m worried that I will say something I will regret. Yes No 5. I get far more upset than is necessary. Yes No 6. After a conflict I want to keep away or isolate for a while. Yes No 7. There’s no need to raise my voice the way I do in a discussion. Yes No

8. It really is overwhelming when a conflict gets going. Yes No 9. I can’t think straight when I get so negative. Yes No 10. I think, “Why can’t we talk things out logically?” Yes No

John M. Gottman, All Rights Reserved (revised 11/17/03)

11. My negative moods come out of nowhere. Yes No 12. When my temper gets going there is no stopping it. Yes No 13. I feel cold and empty after a conflict. Yes No 14. When there is so much negativity I have difficulty focusing my thoughts. Yes No 15. Small issues suddenly become big ones for no apparent reason. Yes No 16. I can never seem to soothe myself after a conflict. Yes No 17. Sometimes I think that my moods are just crazy. Yes No 18. Things get out of hand quickly in discussions. Yes No 19. My feelings are very easily hurt Yes No

20. When I get negative, stopping it is like trying to stop an oncoming truck. Yes No 21. My negativity drags me down. Yes No 22. I feel disorganized by all this negative emotion. Yes No 23. I can never tell when a blowup is going to happen. Yes No 24. When I have a conflict it takes a very long time before I feel at ease again. Yes No

Scoring: If you answered “yes” to more than eight statements, this is a strong sign that you are prone to feeling flooded during conflict. Because this state can be harmful to you, it’s important to let others know how you are feeling. The antidote to flooding is to practice soothing yourself. There are four secrets of soothing yourself: breathing, relaxation, heaviness, and warmth. The first secret is to get control of your breathing. When you are getting flooded, you will find yourself either holding your breath a lot or breathing shallowly. Change your breathing so it is even and you take deep regular breaths. Take your time inhaling and exhaling. The second secret is to find areas of tension in your body and first tense and then relax these muscle groups. First, examine your face, particularly your forehead and jaw, then your neck, shoulders, arms, and back. Let the tension flow out and start feeling heavy. The secret is to meditate, focusing your attention on one calming vision or idea. It can be a very specific place you go to that was once a very comforting place, like a forest or a beach. Imagine this place as vividly as you can as you calm yourself down. The fourth part is to imagine the body part becoming warm.

Flooding - Scoring

John M. Gottman, All Rights Reserved (revised 11/17/03)

GROUNDING

Categories exercise Judge versus describe Mindfulness with all senses Breathe

SKILLS TO USE WHEN FLOODING

Describe an incident you are concerned about.

Who was there?Pick someone to play you.A powerful cathartic exercise viewing their

behavior from multiple points of view.Example.

Role Play Exercise

When asking for something, use the

acronym DRAN

DescribeReinforce

AssertNegotiate

ASSERTIVE COMMUNICATION GUIDELINES

Describe the other person’s behavior objectively Use concrete terms Describe a specified time, place & frequency of

action Describe the action, not the “motive”

Describe

Recognize the other person’s past efforts

Reinforce

Express your feelings Express them calmly State feelings in a positive manner Direct yourself to the offending behavior, not

the entire person’s character Ask explicitly for change in the other person’s

behavior

Assert Directly & Specifically

Request a small change at first Take into account whether the person can meet

you needs or goals Specify behaviors you are willing to change Make consequences explicit Reward positive changes

Negotiate: Work Towards A Compromise That is

Reasonable

The 8:1 Ratio

Communication

*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.

It is not enough to have good motives;

others respond to our behavior.

Physicians are often not given essential feedback about their behavior.

The Team Behavior Survey (B-29) is designed to provide feedback from those we work with.

© Swiggart, Williams, and Williams

B-29 Survey©

Disruptive behavior Social Systems

If the physician is returned to the institution to practice, it is necessary to ensure that the behavior does not recur. There is a significant level of recidivism As high as 20% among “severe offenders”

(Grant and Alfred 2007) Prior behavioral issues are a significant risk

factor for later disruption (Papadakis, Arnold, et. al. 2008)


Disruptive behavior Social Systems

A monitoring system that measures these issues using a 360◦ survey.

Early data show the survey to be valid.

The survey was developed to facilitate integration with institutional systems.


Communication Concern for patients and families Accessibility and timeliness Work environment Ethical behavior Interpersonal behavior & respect for others System-based practice Ability to work with other members of the

medical team

The Survey is Based on the Core Competencies of the

ACGME

Potential Resources for Healthy Coping

Courses Coaches,

counselors Comprehensive

Evaluation 360° Evaluations Risk Managers Physician

Wellness Treatment

Centers

Office of General Counsel

State BME Professional Societies QI Officers EAP Others State Physician Health

Program

There is a need to develop standard, model policies for

hospitals and medical practices Medical student and resident training cultivates many of

the disruptive behaviors, as trainees learn from their mentor’s behavior

Many physicians and other professionals come to training “predisposed” to having problems

Information needs to be widely distributed to hospitals and medical practices that this is treatable, saves money, prevents malpractice suits, and that early intervention is best

Disruptive behavior is a patient safety issue and needs to be quickly addressed

Not all can be helped or saved

What we have learned?

Please visit our websites

http://drmarthabrown.comhttp://www.mc.vanderbilt.edu

University of Florida and Vanderbilt Center for Professional Health

Additional resources can be found on the website

Documents

Martha E. Brown, MD PRN Associate Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division William Swiggart, MS, LPC/MHSP