Disruptive physician behavior has been defined by the American Medical Association as “personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively.” It specifically includes “conduct that interferes with one’s ability to work with other members of the health care team.” Of course, it is not only physicians who exhibit disruptive behavior, and the challenge is to find a way of addressing any disruptive behavior in health care whether by health care workers or patients.
It is assumed that disruptive behavior by health care workers impacts quality of care and patient safety. How best to respond to disruptive behavior is less clear. This article explores the utility in framing disruptive behavior as a conflict management systems challenge.
Health Care as a Complex Adaptive System
I start by exploring the context for the disruptive behavior-health care as a complex adaptive system in which individual agents (physicians, nurses, administrators, medical staff, patients, families, insurers) have certain freedoms to behave in ways that are not always totally predictable, and whose actions are interconnected such that one agent’s actions changes the context for other agents. (Zimmerman BJ, Lindberg C, and Plsek PE. 1998.)
Conflict is an inevitable feature of relationships between agents in a complex adaptive system. Conflict is a sign that there are different perceptions about needs and how they will be met. It may intensify as a behavioral dispute with explicit disagreement. It is certainly a sign that the system has moved away from equilibrium and has reached a bifurcation or change point.
Change occurs both through design (and implementation), and also through self organization. However, the ability to facilitate change in a direct and controlled manner through design is limited. Typically, change occurs through self organization after the system has moved to a more volatile state-what some call conflict, and what some authors have described as the productive edge of chaos. (Milleman, Goya Surfing the Edge of Chaos, 2003)
If change does emerge through self organization it is reflected in the structure, process and pattern of the system. Making a change to a structural element-a new building, a new policy, etc, is relatively easy to achieve using a directive design and implementation approach. Working on processes-the domain of organizational development-such as communication, collaboration and teamwork is harder but can be accomplished through coaching and skills training. However, hardest, is changing the pattern of organization, especially those embedded in the organizational culture through mental models. In the context of health care this includes the beliefs that conflict is by definition a negative experience.
The idea that conflict is a negative is deeply rooted in most people’s mental models. It results in distancing behavior (around 50% of the time) and unproductive fighting for 30%. Only 20% of the time do we use it productively. (Milleman, Goya Surfing the Edge of Chaos, 2003)
Disruptive Behavior as Conflict
I have already shared the ‘in use’ definition of disruptive physician behavior as provided by the American Medical Association. It is explicitly behavioral and links to health care outcomes: negative patient care and interference with teamwork. Does it encompass conflict?
I define conflict as “differences about how expected needs will be met, usually manifesting in emotional tension and relational separation or combative behavior.” As such it encompasses a cognitive, emotional and behavioral dimension. When we think of conflict resolution we are normally thinking about the behavioral aspect. So it is not surprising that that the AMA focus is on the behavioral aspect. And yet, getting to a lasting resolution of a conflict typically requires that in addition to the behavioral dimension, we address both the emotional and cognitive aspects as well.
I also draw a clear distinction between a conflict and a dispute. A dispute is a disagreement after a demand has been made and rejected, in respect of the real or perceived differences.
The AMA does not list what behaviors are disruptive. However, it does encourage documentation of the behaviors in a policy with due process safeguards. Even without a list, this step represents a relatively easy structural change that can be managed and controlled to a high degree. Building on the work of Neff (2000), authors Porta and Lauve list the following as potentially disruptive behaviors:
- Profane or disrespectful language
- Demeaning behavior, such as name calling
- Sexual comments or innuendo
- Inappropriate touching, sexual or otherwise
- Racial or ethnic jokes
- Outbursts of anger
- Throwing instruments, charts, or other objects
- Criticizing other caregivers in front of patients or other staff
- Comments that undermine a patient’s trust in other caregivers or the hospital
- Failure to adequately address safety concerns or patient care needs expressed by another caregiver
- Intimidating behavior that has the effect of suppressing input by other members of the healthcare team
- Deliberate failure to adhere to organizational policies without adequate evidence to support the alternative chosen
- Retaliation against any member of the healthcare team who has reported an instance of violation of the code of conduct or who has participated in the investigation of such incident, regardless or the perceived veracity of the report
(Porto, G, Lauve, R, 2006)Disruptive Clinician Behavior: A Persistent Threat to Safety, July/August 2006, Patient Safety and Quality Healthcare)
For each item on the list there is an implicit expectation about how health care personnel should behave. When there is behavior that contradicts that expectation or when there is a perception to that effect, we have conflict. It is possible to infer that for each item on the list that there were differences about expectations. The Doctor wants to operate now. A nurse has concerns. The nurse asserts her concerns with some anxiety. The doctor responds in anger, and demeans the nurse. Even if it does not rise to the level of a dispute-the nurse demanding and the doctor refusing-it does not seem a stretch to argue that disruptive behavior can be defined as a conflict.
Historic Responses to Disruptive Behavior
Current organizational development efforts to address disruptive conduct still tend to focus on the actual behavior. Good behavior is rewarded. Poor behavior, punished. In contexts where there is a power imbalance between the organization and the disruptive employee, the historical trend has moved from the free use of power, to restraint through right based interventions (laws, policy, contract), and most recently through a collaborative mental model, to a focus on interests, needs and concerns.
In healthcare the relationship between hospitals and nurses typically exhibits a rights based approach: at will employment is subject to basic legal and contractual rights that cover working conditions and workplace behavior. Even where at will employment is in place, disciplinary codes are often progressive and provide some due process rights. In some states Unions play a role in the negotiation of disciplinary standards and procedures. Sporadic adoption of a collaborative approach to relationships with nurses is on the rise.
By contrast, doctors are often not employees and are often viewed as customers by hospitals. As such there is less of a power imbalance than is the case with nurses, and in some instances it can be argued that the doctors have more power.
Some aspects of the relationship between doctors and hospitals is clearly rights based with legal and contractual provisions governing the relationship. A license to practice medicine subjects doctors to specific legal standards and general standards such as the law of tort. Beyond that there are the criminal provisions that deal with behavior that in other contexts would be construed as assault!
It is also collaborative to the extent that mutual and competing interests are addressed through communication. The behavioral aspects of the relationship are not typically governed directly in the relationship with the hospital.
To the extent that disruptive behavior is motivated by a discriminatory intent or has a discriminatory impact it is unlawful under federal law, and most states have augmentary local legislation.
If we accept that disruptive behavior can be considered as conflict, what can the field of conflict management teach us?
Integrated Conflict Management Systems
In their seminal work, “Designing Conflict Management Systems”, Costantino and Merchant (1996) proposed that how organizational conflict is actually experienced should “be viewed as a subsystem within a larger system.” Until that book’s publication, the ways in which organizations dealt with conflict had not been recognized in terms of systems theory or named as discreet systems.
In 2000, the Society for Professionals in Dispute Resolution issued a report on organizational conflict management, titled Guidelines for Designing Integrated Conflict Management Systems. (SPIDR Guidelines) The SPIDR Guidelines advocated an integrated systems approach to the management of all organizational conflict.
An integrated conflict management system (ICMS) is evidenced as an ideal that exists through a coordinated and supportive method for dealing with all types of conflict, through multiple access points, providing a variety of rights and interest-based options, and creating a culture that welcomes dissent and supports collaborative negotiation to resolve conflict at the lowest level of intensity possible.
In an ICMS, the various parts of the system are not operating in isolation or indifference to one another. The tension inherent between the actual structure of the organization (manuals, handbooks, policies, etc.), and the living pattern of relationships (the shadow culture, blame, repeating types of conflict, etc.), is used and integrated through a variety of supportive processes (dialogue, negotiation, mediation, etc.). Most importantly, the tension is integrated in such a way that the emergent properties (such as reduced costs and claims, good morale, organizational learning, and patient safety) are productive.
To resolve conflicts early (before they become full blown disputes) participants need the skills to recognize the fact that there is a conflict, skills to respond respectfully, and skills to resolve the real differences that do sometimes exist. However, it is important to appreciate the different levels at which one chooses to focus. Ultimately, I argue, that focusing on conflict management at a systems level rather than on ad hoc individual situations is key.
Using the criteria of culture, expectations, skills and knowledge, support structures, rewards and consequences, and procedures and options I tease out the various aspects of an integrated conflict management system: Culture: Ideally an organization embraces conflict as a reality and rather than demonizing it, sees conflict as a sign of vitality and an opportunity for new insights and growth. Conflict is not avoided by the organization, and individuals feel comfortable giving feedback and having difficult conversations.
Expectations: Ideally the organization and its individuals know what is expected of them. Conflict management is recognized as a core competency and behaviors that are supportive and productive are incorporated in job descriptions. Employees conflict management roles are described and they have a sense of how their responsibilities mesh with the organizations-through clearly communicated vision, mission and value statements that are both general and conflict management specific.
Skills and Knowledge: Employees need to know how to deal with conflict from a communication skills perspective. They also need to be oriented to their conflict management options, and be able to make informed choices about which option to use and when. Conflict prevention, management and resolution should be recognized as a core competency.
Support Structures: Employees need easy access to support, especially when it comes to handling difficult conversations or challenging situations. Support can be provided in many ways and includes having people to listen, give procedural advice, and intervene to provide direction or to help a solution emerge. An organization that has a senior level conflict management champion is very fortunate indeed.
Rewards and Consequences: It is one thing to say what is expected, another to give employees the skills to reach those expectations, but if no system is in place to monitor performance on an ongoing basis change is unlikely. On the other hand, once a performance review system starts tracking conflict management, the leverage for change is great.
Procedures and Options: A healthy conflict management system provides a variety of procedures for employees to deal with all conflicts. Interest-based options such as discussion, negotiation, and mediation are used most of the time. Rights based options like investigations, arbitration and litigation are used as a back up. Power plays are the last resort. Importantly, procedures and options are provided to employees but also to vendors and clients. The fact that Doctors are not employees does not prevent the negotiation of a dispute resolution procedure.
Integrated Conflict Management for Health Care?
Health care organizations are exploring more interest based approaches to managing employee, but also medical malpractice disputes. As regards the latter, disclosure policies, early resolution, mediation and ombuds programs have started to emerge as adaptive responses both in large health care systems such as Kaiser Permanente, but also in smaller community hospitals.
In the arena of employee or workplace disputes, organizations are revising their policies to introduce progressive disciplinary steps, making in house and at times, external mediation services available both for individuals and teams that are experiencing conflict. Importantly they are providing more and more soft skills training in the areas of communication, negotiation and conflict resolution and team management.
As I have already noted the situation is complicated by the fact that doctors are often not employees. However, that does not mean their relationships with health care organizations exist in a vacuum. In addition to the contractual relationship there are laws that govern their behavior.
As Porto and Fauve note, responses to disruptive behavior is often seen as ineffective because “organizations have not implemented a comprehensive and consistent plan that addresses all the pertinent issues and provides sufficient options for intervention.”
In many ways that is the thrust of an integrated conflict management system. All conflict is welcome. Failure to provide a place to go is considered a fatal error. Saying that we will address certain conflicts but not others sends the wrong message and typically the lack of a forum does not make conflict go away. The other aspect that deserves recognition is the appreciation that a variety of options for intervention must be provided. In organizations with a rights based emphasis this means that the formal investigation will not always be appropriate. Equally, mediation, coaching and other interest based interventions must be available but only used when appropriate.
Organizations that appreciate the value of a different relationship to conflict, that recognize that conflicts are excellent learning opportunities, and that using a combination of avoidance and power plays is not the way to develop a culture of respect, mutual support and learning, will typically start by reviewing all policies and procedures in place that have something to do with conflict management.
Based on the review of their own practices and best practices from Health care and other related industries, a new procedure for managing conflict is drafted with input from as many stakeholders as possible.
Best practices from the field of organizational conflict management offer integration and coordination strategies vital to a program’s success. This article has focused on the elements of an integrated conflict management system as a way of managing disruptive behavior. What differs from organization to organization is the extent to which members are conscious of their conflict management systems. There is a sense that health care is ready to embrace conflict management as an ally for patient safety.
John,
If the model discussed becomes the accepted intervention, are there enough trained providers to provide?
George Anderson
Posted by: George Anderson | May 01, 2009 at 08:11 AM