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I. What is Disruptive Behavior in the Workplace?
Disruptive behavior is an enduring pattern of conduct that disturbs the professional’s day-to-day interpersonal surroundings. The disruptive professional employs certain types of behaviors (conscious and unconscious) as a means to use their position of power for personal gain and/or to avoid blame or responsibility. Often times, disruptive behavior is byproduct of professional burnout rather than exclusively anchored in a personality disorder or formal psychiatric problem. It is always important to diagnostically discriminate to what degree the individual’s difficulties stem from professional burnout (which is typically an adjustment disorder), significant psychiatric stressors (atypical depression, an anxiety disorder such as untreated PTSD), and/or personality disorder dynamics.
Disruptive behavior is almost always justified in the name of patient care. Although the physician may have legitimate concerns about questionable care, there is a gross logical error embedded in the assumption that angry, potentially dangerous, and devaluing behavior can positively improve the dissemination of medical care.
1. Behavioral Characteristics:
a. Conscious or unconscious expression of destructive anger or resentment:
• Intimidation
• Use of abusive language
• Oppositionality
• Shaming or humiliating others when unfavorable outcomes occur
• Enactments of vengeance
• Making disparaging remarks
• Public displays of temper (e.g., throwing charts or instruments, yelling)
• Placing inappropriate or unrealistic demands on co-workers
• Passive-aggressive enactments (i.e., not returning pages to certain nurses, placing subordinates in double-bind situations)
• Inability to respond constructively to feedback
• Failure to heed corporate compliance requirements
b.Inappropriate comments or behaviors directed toward others
• Unwanted sexual overtures, jokes or innuendo
• Ethnic, racial or socioeconomic slurs
• Disregarding, or being insensitive to, the personal space of others
• Displays of physical abuse or violence
• Sexual harassment and innuendo
c.Inconsiderate responses to patient needs, staff requests, or organization requirements
• Displays of arrogance or disrespect
• The use of avoidance or undependability
• Uncooperative or rigid conduct
• Poor communication
• Being disrespectful of other peoples’ dignity
• Significant deviations from hospital/clinic protocols (e.g., not adhering to a schedule, making rounds at inappropriate times, not adhering to established procedures)
• Exhibiting a pattern of delinquent documentation
• Role confusion
2. Disruptive Behavior can also be defined according to a series of related factors that can be either the result of conscious intention, unconscious neglect, and/or a lack of knowledge:
a. The presence of negative attitudes, communications, and behaviors that result in other people feeling threatened, belittled, devalued, humiliated, frightened, intimidated, demoralized, and criticized as a person rather than having their performance objectively assessed
b. The absence of positive behaviors including encouragement, direction, guidance, explanation, goal-setting, positive reinforcement for a job done well, teaching, communicating expectations clearly and in detailed fashion, patience
c. The relative absence of empathy and communication – the inability to appreciate other people’s perspectives, insensitivity to the feeling states of others, and not taking into account each individual’s strengths and limitations when engaged in interpersonal interactions
d. The absence of a feedback loop that might allow the professional to take in negative information about their performance as a leader; i.e., the message is given to colleagues and subordinates that the leader is unwilling and/or unable to accept reports that his/her behavior, facial expressions, attitudes, and/or communications are negatively impacting the performance of others
II. The Impact of Disruptive Behavior on the Medical Team:
• Increased workplace stress
• In order to avoid anxiety, team members may spend time avoiding or appeasing the disruptive physician
• Splitting in the team (good doctors vs. bad doctors)
• Co-workers feel manipulated, controlled, hassled, mistreated
• Diminished team morale
• Deterioration in communication
• Increased risk of mistakes, oversights, diminished patient care, and malpractice claims
III. Etiological Considerations:
1. Individuals who display disruptive behavior typically lack the ability to be introspective and, thus, are often blind to the way in which their conduct impacts others. The disruptive physician can be understood as having certain deficits with regard to self-regulation. Self-regulation is defined as one’s capacity to manage and contain anxiety and process emotional states, maintain balance in self-esteem, respect other peoples’ points of view, and remain engaged in productive goal-oriented occupational activity with others. Deficits in one’s ability to effectively self-regulate are often multi-determined and usually involve the intermingling of:
• Underdeveloped social skills
• Unresolved trauma from childhood (e.g., battling against authorities who are perceived as threatening)
• An undiagnosed Axis I disorder (e.g., ADHD, mood, anxiety, intermittent explosive, or psychotic disorder)
• Substance abuse
• Professional burnout: Stressors that remain unresolved. For example, high mental workload and low decision latitude (M. Gendel)
• Personality disorders (narcissistic, antisocial, obsessive-compulsive, borderline character pathology)
• Unresolved intra-psychic conflicts
• Problems in organization systems and processes – the intersection of the physician’s particular dysfunction/deficits and the organization’s dysfunction (i.e., the dysfunction junction)
• Financial stress
• Family discord (displaced onto the work environment)
• Stressors associated with malpractice litigation
• Unresolved career identity crisis
• Exposure to a subculture of dysfunctional behavioral norms modeled in medical school and residency
IV. Detecting the Early Signs of Disruptive Behavior:
• The physician begins to get a reputation regarding inappropriate conduct
• Medical staff, office staff, or partners must provide real-time feedback in all cases of disruptive behavior (regardless of the political power of the physician involved)
• The physician begins to manifest behaviors that are out of character
• Feedback from colleagues and/or co-workers that indicates the presence of a problem
• Impatience
• Irritability
• Swearing
• Tardiness
• Rigidity
• Difficulty taking appropriate responsibility for adverse outcomes
• Expecting special treatment from others
• Late or inappropriate responses to pages/phone calls
V. Guidelines for Intervention:
• Clearly define the problem(s)
• List documented incidents of disruptive behaviors
• Be compassionate, nonjudgmental, but firm
• Demonstrate staff solidarity and the expectation of change
• Demonstrate how the physician’s conduct is impacting staff and/or patient care
• Offer help
• Make anticipated changes explicit
• Review the consequences of not changing
• Document carefully
• Summarize the intervention in a follow-up certified letter
• Be diligent with follow-up and ongoing accountability (assign a mentor)
• Use of a behavioral agreement document
VI. The Conditions Under Which People Can Change:
• When the physician has come to recognize that his/her behavior is a problem, despite any organization dysfunction
• After the physician’s problematic behaviors, and probable origins of the same, have been accurately identified, e.g., the construction of an explanatory hypothesis that helps the physician and concerned parties to understand the physician’s difficulties within a context that is not punitive
• A commitment and willingness on the part of the physician to change
• The provision of education and applied opportunities for skill building
• Acquired ability to internalize accurate feedback from peers
• When acceptable outcomes have been specifically defined
• Multiple opportunities to observe colleagues engaged in functional problem-solving behaviors. This can often occur in a treatment setting with peers
• The development of empathy, which emerges as a byproduct of being able to identify, make meaning out of, and integrate one’s emotions
VII. Prevention:
• Education
• Provide behaviorally specific performance appraisals and expectations with consistent and timely feedback
• Contiguity between the physician’s disruptive behavior, feedback, and documentation in the physician’s record
• The cultivation of a culture of appropriate behaviors initiated by the medical staff and/or partnership leadership figures
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