Policy for

Disruptive behavior in a health care setting can lead to an unsafe environment for patients. The Joint Commission is requiring that health care facilities adopt zero tolerance policies for disruptive behavior. These policies include codes of conduct, ways to encourage staff to report bad behavior, and a process for helping and, if necessary, disciplining offenders. 

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety

and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested . . .see Behavior p.3

Sairey Gamp Summer/Fall 2009

Joint Commission Sets Standards I N S I D E T H I S I S S U E :

Disruptive Behavior

The Joint Commission Standard

Zero Tolerance Policy 2

Nurse-Physician Relationships 2

Platinum Rule 2

Are Employers Victimized Too+ 3

Horizontal Violence in Nursing 3

Cost of Compliance to Standard 4

Joint Commission Suggestions 4

References and Further Info 4

Policy: The Joint Commission has a new Leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two of its elements of performance:

EP 4:  The hospital/organization has a code of conduct that defines acceptable, disruptive and inappropriate behaviors.

EP 5:  Leaders create and implement a process for managing disruptive and inappropriate behaviors.

49% felt pressured todispense or administera drug despite seriousand unresolved safety concerns,

40%have kept quietrather than question a known intimidator.

-ISMP Survey

One method that organizations use to eliminate disruptive behavior consists of establishing a zero-tolerance policy. Basic tenets of the policy include the following:

• No discussion concerning another person can take place if that person is not present.

• All issues must pertain to a behavior that threatens the mission of the organization, patient safety, and professional values.

• If a person has an issue with another person, he or she must discuss the issue with the other party in private and directly.

• All disruptive or inappropriate interactions will be documented. Corrective actions must be behavioral, time-limited and constructive.

• All personnel must enforce the policy. Gossip and destructive social behavior must be addressed by others in the environment.Source: Ramos M.C.: Eliminate destructive behaviors through example and evidence. Nurs Manag 9:34–41, 2006

Zero-Tolerance Policy

Nurse/Physician Hospital Relationships: Impact on Nurse Retention and SatisfactionWhat type of disruptive behaviors have you witnessed or experienced?

Top Bar = Nurses Middle Bar = Physicians Bottom Bar = Executives

To some platinum is considered more valuable than other precious metals such as gold. It would logically follow that a Platinum Rule would be better advice than a Golden Rule.

Platinum Rule Improves On the Golden Rule While the age-tested

Golden Rule,states: “Do unto others as you would have them do unto you.” The Platinum Rule states: “Do unto others as they would have you do unto (or for) them.” Thus, this principle speaks to treating others as they want to be

treated, not necessarily how you would want to be treated. This sets a universal behavior code rather than just a .personal standard.

About 44 percent of the participants indicated that barriers to reporting disruptive behavior existed. The most common barriers included:

• Fear of retaliation

• The fact that nothing ever changes

• Lack of confidentiality

• Lack of administrative support

Source: Rosenstein, A.

Policy for Disruptive BehaviorPage 2

Source: Rosenstein, A.

Most formal research centers on intimidating and disruptive behaviors among physicians and nurses,

But evidence shows these behaviors occur among other health care professionals: pharmacists, therapists, and support staff, as well as among administrators.

Source: Sentinel Event Alert Issue 40

Policy for Disruptive Behavior Page 3

Disruptive behaviors affect more than just the primary victim. In addition to its primary victim, disruptive behaviors like horizontal violence (HV) also affects the victim’s patients and employer In addition to potential physical harm to patients Farrell reported that “intrastaff aggression is more upsetting to deal with than a patient assault.” Longo also

Are Employers Victimized Too?

indicates that a “culture that condones horizontal violence or bullying is a significant reason why many nurses leave their work settings and in some cases the profession of nursing.” She adds, “Horizontal violence may limit your ability to recruit new nurses . . . an experience with horizontal violence as a student sends a strong message that the culture isn't supportive of novice nurses”

. . . by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with

Disruptive Behavior continued from page 1

questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated.

The Effects of Nurse-Nurse Horizontal Violence

Effect of Nurse to NurseHorizontal Violence

SOMEONE COULD GET HURT!

Source: Longo and Sherman

Source: The Joint Commission Sentinel Event Alert Issue 40

Cost of Replacing an

RN is 1.5 – 2 x that

RN’s annual salary!

Larry Fisher Sairey Gamp3410 Tradewinds CoveCanton, OH 44708

Establishing a conflict resolution process.

Encourageconfidential reporting. Enforce zero tolerance, but confront offenders with “data, authority and compassion” rather than punishment.

Provide ongoing education and training.

Reward outstanding examples of teamwork.

Establish steering committee drawn from all levels of MMC — top to bottom.

Creat a code of conduct to be signed by all staff when hired and again each year.

Survey staff attitudes about intimidation and how they handle it.

Open a dialogue using objective moderators.

Establish a standard, assertive communications process.

Joint Commission Suggestions

E-mail larsfish@gmail.com

Cost of compliance to this standard is high. This cost would include a mandatory one hour in-service for all employees. Content for the in-service would include the Joint Commission standard, our Code of Conduct, reporting procedures and interventions. In addition, professional staff would receive educational programming in horizontal violence, assertive communication techniques and conflict resolution. Since most of the medical staff are not hospital employees legal and expert consultation would be required to amend the medical staff’ bylaws.

Although this cost is high compliance is necessary to maintain Joint Commission Accreditation. And, relative to the cost of recruitment and retention of professional or the costs associated with avoidable, adverse patient events this cost seems justifiable.

Web Resources

www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.html

Policy for Disruptive BehaviorPage 4

THAT WAS THE MOMENT I DECIDEDI COULD FIGHT BACK!

Cost of Compliance to the Standard

References

.Behaviors that undermine a culture of safety. (2008). Sentinel Event Alert(40). Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.html

Farrell, G. A. (2001). From tall poppies to squashed weeds*: Why don’t nurses pull together more?. Journal of Advanced Nursing, 35, 26-33

Institute for Safe Medication Practices:  Survey on workplace intimidation. (2003)Retrieved from https://ismp.org/Survey/surveyresults/Survey0311.asp (

Longo, J., & Sherman, R. O. (2005). Leveling horizontal violence. Nursing Management, 38(3), 34-37, 50-51.

Porto, G., & Lauve, R. (2006). Disruptive clinician behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare. Retrieved from http://www.psqh.com/julaug06/disruptive.html

Ramos M.C. (2006) Eliminate destructive behaviors through example and evidence. Nursing Management (38)9, 34–41,

Rosenstein, A. .(2002).” Nurse-Physician relationships: impact on nurse satisfaction and retention. American Journal of Nursing. (102)6., 26-34.