By Debra Wood, RN, contributor

While screaming, throwing things, backstabbing and gossip may sound like schoolyard antics, a new survey of more than 2,100 physicians and nurses found these and other examples of bad behavior occur frequently on the front lines of health care -- in our nation's hospitals.

Barry Silbaugh, MD, chief executive officer of the American College of Physician Executives, hopes his organization can take a leading role in eliminating bad behavior in the health care industry.

"We were surprised this doesn't seem to be getting better, despite talking about it for years," said Barry Silbaugh, M.D., chief executive officer of the American College of Physician Executives (ACPE), which conducted the survey. "Our goal is to have zero tolerance for disruptive communication and behavior, because that affects the safety of the patients. And it presents problems in the workforce."

ACPE sought to learn the current status of interactions between practitioners and to take steps, including offering courses, in an effort to eliminate bad behaviors from the health care industry.

"We wanted to put a spotlight on the current state of the problem and hope people will agree to get down to the business of fixing it," Silbaugh said.

About 67 percent of respondents were nurses. Nearly 98 percent of survey respondents indicated behavior problems between physicians and nurses exist at their organizations and they had witnessed it within the past year, with 85 percent reporting degrading comments and insults, and 74 percent reporting yelling. That everyday lack of respect leads to poor staff morale, patient safety and public perceptions, the participants said.

Maureen Swick, RN, PhD, NEA-BC, vice president of patient care services at Saint Peter's University Hospital in New Brunswick, N. J., expressed surprise that the percentage reporting bad behavior was so high.

"I have seen such a change. Organizations are more team focused for process improvement, and there's much more collaboration on quality projects," Swick said. Although people often think about poor physician-nurse interactions, arguments among nurses also create tensions and difficulties. Nearly half of the ACPE survey respondents, 48 percent, described an even mix of both doctors and nurse exhibiting behavior problems, with the balance heavily blaming physicians, 45 percent, while 7 percent put the blame on nurses.

Alan Rosenstein, M.D, M.B.A., indicated successful programs to change behavior require a multifaceted approach.

The ACPE study found higher rates of disruptive behavior than a VHA West Coast survey of 4,520 nurses and doctors conducted from January 2004 through March 2007. More than three-quarters, 77 percent, of respondents to that study reported witnessing disruptive behavior, and 67 percent agreed that disruptive behaviors were linked with adverse events, 71 percent for medical errors and 27 percent for patient mortality.

"Not only is it a problem with satisfaction and morale, but we've demonstrated bad things happen to patients," said coauthor Alan H. Rosenstein, M.D., MBA, vice president and medical director, VHA's West Coast office in Pleasanton, Calif. He called having such data crucial to convincing people at every level of the organization to change disruptive behavior.

Michelle O'Daniel, MHA, MSG, suggested emphasizing the patient safety ramifications of bad behavior when trying to change the culture.

Rosenstein and Michelle O'Daniel, MHA, MSG, director of member relationships for VHA's West Coast office, have worked with VHA hospitals to initiate behavioral policies. They offered 12 recommendations to prevent bad behaviors, which include creating policies to deal with it; standardizing reporting of incidents; evaluating initiating factors; education and training, from diversity and sensitivity topics to conflict management; providing communication tools, such as SBAR and structured team building; developing intervention strategies with a multidisciplinary team reviewing the incident; and supporting the individuals who speak up when something happens that could affect patient care.

O'Daniel recommended focusing on the reason change is needed--to improve patient safety.

"We focus on a human factor and behavioral approach to patient safety," Rosenstein said.

The Joint Commission has recognized the danger of bad behavior, issuing a sentinel event alert in 2008 and requiring by January 1, 2009, all accredited programs 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.

"There have to be programs in each institution, and they have to be workable programs that can be integrated into the daily lives of busy people," said Dianne M. Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a professor at the University of Cincinnati, Ohio, College of Nursing. "The programs need to be reinforced, as often as CPR and fire safety are reinforced and supported by administration."

Felblinger added that memorable reminders, such as an acronym or a pin or something else worn, can help remind people of the suggested interventions in certain situations.

"We are in a culture that could benefit from an increase in civility and it could start with us," Felblinger said. "When it starts with us in health care, the patient benefits."

Kristin Baird, RN, advocates a commitment to a healthy culture, which values all contributors and promotes better communication and safer care.

Kristin Baird, RN, president of Baird Consulting of Fort Atkinson, Wis., and author of Raising the Bar on Service Excellence: The Health Care Leader's Guide to Putting Passion into Practice, suggested hospitals promote a healthy culture, which fosters positive physician-nurse relations and better patient outcomes and satisfaction.

"We need strong leadership to say a healthy culture is a priority, and we cannot permit certain behavior and draw the line," Baird said. "Part of the problem with doctor-nurse relations is when expectations are laid out and no one enforces them."
 

Baird advocates zero tolerance for bad behavior and consequences for people who act out anyway.

"In incendiary situations, what you permit, you promote," Baird said.

Swick added that support from the medical executive level helps to foster the culture change to zero tolerance and mutual respect. "For years, physicians were not in tune to how they were perceived. People never addressed the issues," Swick said.

O'Daniel suggested rolling the program out in one department at time, building on successes. Champions respected by all levels of the organization can promote the change. In addition she recommends addressing operational issues, such as staffing concerns and broken equipment, that often provoke inappropriate outbursts.

Silbaugh said nurses and physicians will need to work together to talk about the differences in culture and training that contribute to the problem.

"Some of these problems, perhaps, start in the academic center, and it doesn't get better unless there are role models of physicians and nurses who know how to communicate even when they disagree about something," Silbaugh said.

Gail Gazelle, MD, FACP, FAAHPM, assistant clinical professor of medicine at the Harvard Medical School in Boston, agreed and added, "Much of this stems from the different ways doctors and nurses are trained. Doctors are taught from the beginning that they are the head of the team, that they are better than nurses, that the skill set of nurses is inferior to their own. This leaves them feeling entitled to put down nurses and mistrust their judgment."

The Joint Commission directive and the movement toward patient-centered care has helped foster a more collaborative climate, Gazelle said.

"Nurses need to feel empowered to take on the over-arching authority of physicians and see themselves as equal partners in the care of patients," Gazelle added. "Some of this can be in the nursing curriculum and much is on-the-job. Obviously, for the latter, nurses need institutional backing for this to be successful and, fortunately, a number of initiatives have come to the fore."

Aurela O'Connell, RN, PhD, ACNP, BC, CCRN, meets with students as part of a collaborative physician-nurse education curriculum at UCLA.

The UCLA School of Nursing and the David Geffen School of Medicine at UCLA have launched a pilot program to develop both professions' team-building skills.

"Nursing students participate in the medical school's third-year doctoring program, which uses role-playing, narrative writing and small group discussion to teach students the communication and interpersonal skills they need to deliver the human side of medicine," said Laura Petty, director of communications at the UCLA School of Nursing.

Baird also recommends nurses reconnect with their purpose and the profession.

"People that are connected to that purpose are going to look for opportunities for collaboration and be more engaged in the work they do," Baird said. "If we put the patient at the center and work side by side with the physician, we will have the best result all around."

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