Chain of command in healthcare refers to an authoritative structure established to resolve administrative, clinical, or other patient safety issues by allowing healthcare clinicians to present an issue of concern through the lines of authority until a resolution is reached. Frontline healthcare clinicians, who have witnessed poor performance by their peers or supervisors, may be hesitant to use this means of communication because of the fear of retaliation or uncertainty about its importance in patient outcome. Staff may also be reluctant to call a physician, supervisor, or other clinician, even in the face of the deteriorating status of a patient, fearing intimidation, confrontation, antagonistic discussion, or other disruptive behavior. This article examines the issues that surround the use of the chain of command when disruptive clinician behaviors are encountered or when there are concerns about a patient’s condition or the care they are receiving when these concerns are related to operational issues. The article discusses actions organizations can take to eliminate healthcare clinicians’ inappropriate actions and attitudes in order to boost effective communication, teamwork, and collaboration and improve patient safety.
Chain of Command
Chain of command is a system whereby authority passes down from the top through a series of executive positions or military ranks in which each individual is accountable to their direct superior. Chain of command in healthcare is the line of responsibility to both the delivery of appropriate patient care and feedback about perceived appropriateness and the impact of that care. An effective chain of command in healthcare organizations facilitates, rather than impedes, communication, teamwork, and collaboration between the decision maker and the frontline clinician. Barriers to effective and safe healthcare may include disruptive behaviors, conflicts, and lack of physician availability. The Joint Commission instituted a new leadership standard effective January 1, 2009, that requires accredited hospitals to address healthcare clinician disruptive and inappropriate behaviors.1 This standard expands the Joint Commission National Patient Safety Goal 2, which requires accredited organizations to improve the effectiveness of communication among caregivers to reduce risk, improve patient safety, and recommends standardization of communication whenever possible.2
Chain of command provides healthcare staff with a formal process to use when attempting to get satisfactory resolution or to report concerns about questionable patient conditions or care delivery. When hierarchical differences exist between healthcare clinicians, people lower in the hierarchy tend to be uncomfortable communicating problems or concerns. Individuals at the top of the hierarchy that exhibit disruptive or unapproachable behaviors may further hinder communication between healthcare clinicians.3 Delays, inappropriate care, or lack of patient care may be the byproducts of these hierarchical differences, particularly if the organization’s chain of command fails to outline a structured communication method to address disruptive behaviors or concerns about a patient’s condition or the care they are receiving. Chain of command may fail because the next person up the hierarchy “blinks,” refuses to act, has not been trained to act, fears retaliation, or falls back on enabling behaviors. Leadership for introducing chain of command only works when there is a clear and consistent demonstration of a willingness to act.
Overview of Authority Data
There were 177 events reported to the Pennsylvania Patient Safety Authority from May 2007 to October 2009 that detailed healthcare clinicians’ disruptive behaviors, many of which negatively affected patient care. Of these events, 73 (41%) were due to conflicts between healthcare clinicians, 30 (17%) to procedures not followed, 17 (10%) to absence of responses or delays, 22 (12%) were listed as other, and behaviors for the remaining 35 (20%) were not given. (See Table 1.) Some of these reported events listed disruptive behaviors that may have contributed to delays in pain control, increased risk of healthcare-associated infections, or increased risk of burns. Implementation of a chain-of-command protocol could have resulted in different outcomes. Examples follow of reports describing conflicts between healthcare clinicians, refusals to adhere to procedures, and absences or delayed responses that resulted in patient care delays and increased risks for healthcare-associated infections or burns.
Table 1. Disruptive Behaviors Reported from May 2007 to October 2009
The primary surgeon walked out of the OR [operating room] suite, and the assistant surgeon completed the surgery. The event was a result of an altercation between surgeon, assistant surgeon, and anesthesiologist.
Physician was notified of a critical lab value. Physician asked why he was being called. Staff informed physician of hospital protocol for critical value reporting. Physician repeated the same statement and hung up the phone.
A call [was made] to a physician to clarify a medication reconciliation form. He stated he would not address the form. Nurse again asked [the physician] to review medications and reminded him that it was part of the admission and discharge instructions. Doctor stated he would not address the form and hung up [the phone].
A patient vomited immediately prior to [admittance to the] OR. The anesthesia clinician refused to do the case due to a concern for the patient’s airway. The surgeon dismissed the anesthesia clinician and elected to perform the surgery utilizing IV [intravenous] sedation monitored by himself. The case was done in this manner. The patient’s vital signs and airway [remained] stable during the procedure.
Refusals to Adhere to Procedures
Physician dropped ET [endotracheal] blade and ET tube on the floor. Asked if he wanted a clean replacement, no answer was given. [The physician] used the ET tube from the floor to intubate the patient.
Surgeons, resident, and medical student were asked to change gloves, and they refused. An implant was inserted with contaminated gloves.
Staff were about to apply [a topical anesthetic] cream to a baby’s penis when the baby’s physician entered the room and stated that he was ready to do the circumcision. The physician was told that he would have to wait 30 minutes until after the cream was applied. He stated that he would not wait 30 minutes and that it would be done now. Baby had a pain score of 4/7 [after the procedure].
Dentist wanted to remove additional teeth from the patient. He gave the patient local anesthetic where he wanted to remove the teeth. He was informed he was not permitted to do this in the PACU [postanesthesia care unit]. He continued with the procedure despite being informed that he could not.
The physician was in [the patient’s room] to place a lumbar drain. The nurse informed the physician that he would have to place the drain in monitored unit; the physician refused. The physician called another physician and was told by nursing supervisor and nurse [that the] patient had to be done in monitored unit. Both physicians brushed by the nurse, shut the door, and started to place the lumbar drain. Also, the preprocedure checklist was done after the procedure. Both doctors were rude to the nurse and ignored policy.
The nurse noted the physician was using the warm touch warmer without the appropriate blanket. She had the hose hooked under the blanket at the right shoulder. When nurse told her [she was] not allowed to do that due to documented burns, she shook her head, “yes,” she was aware of that. The physician did not remove the hose or turn the warmer off.
A patient arrived in PACU with an oral temperature of 99.7°F. The patient complained of being cold, and warm blankets were applied. Later, the patient began shivering. The anesthesiologist was contacted and ordered the nurse to place a bair hugger on the patient. I informed him [that the] patient’s temperature was 99.7°, which [had been] reassessed. The physician said to place bair hugger on patient anyway. I informed him this is not usual practice of bair hugger use and stated we use Demerol when a patient has a high temperature. He said, “No, do as I say.” I then notified [the nursing supervisor and] the charge nurse, both of whom told me to just do as he wants and not to argue. The physician came into PACU to reassess patient, increased the settings on the bair hugger, and ordered it in writing. After he left, I reassessed, orally, the patient’s temperature, which was 100.8°. I notified the physician, and he discontinued treatment of bair hugger.
The gastroenterology service was consulted for bowel issues on a patient (ileus versus obstruction). The physicians came to floor and failed to notify a nurse of doing a procedure. The physicians wanted to do conscious sedation; however, staff made the physicians aware that this procedure is not to be done on the floor. The physicians proceeded with procedure and no sedation. The charge nurse entered [the patient’s room] and told the [physicians] to stop the procedure; the patient was in a lot of pain. [A higher ranking physician and the nursing supervisor] were notified. The patient was transferred to [a higher level of care] for the procedure to be properly monitored.
Absences or Delayed Responses
A patient’s blood glucose increased to 583 without treatment for 13 hours. [There were] delays with multiple physicians in having the issue addressed. Patient [was transferred] to the ICU [intensive care unit] for an insulin drip.
A patient in active labor was complaining of severe pain. The anesthesiologist was notified of request to re-bolus [the patient’s] epidural. Physician stated that someone could not come to [labor and delivery department] for an hour to medicate patient. After one and a half hours, the nurse called again and was told that lunch breaks were being given and to call a different physician. When called, physician stated that she was not on call for obstetrics, and no one was available to help patient. Patient was finally injected two hours after the initial request.
Initiating a formal chain of command provides healthcare staff with guidance and examples of actions to be taken, exceptions, what to do when issues are unresolved after implementation, and documentation expectations. Thirteen (18%) of the total events based on conflicts between healthcare clinicians reported the implementation of a chain-of-command protocol when the disruptive behaviors were encountered. In 41 (56%) of the reports that did not report the use of chain of command, patient harm might have been averted if one had been implemented, while the patient outcomes on the remaining 19 (26%) reports that included healthcare clinicians’ disruptive behaviors would have remained unchanged if chain of command had been implemented. (See Table 2.)
Table 2. Chain of Command Listed in Reports of Conflict,
May 2007 to October 2009
Rosenstein and O’Daniel conducted a survey of 4,503 nurses, physicians, administrative executives, and other participants from 102 hospitals to assess the significance of disruptive behaviors, their effect on communication and collaboration between healthcare clinicians, and their impact on patient safety. The survey participants indicated the clinical areas where disruptive behaviors were reported: medical units (35%), ICUs (26%), ORs (23%), surgical units (20%), emergency departments (EDs) (7%), and others (less than 5%).4 Seventy percent of the survey respondents indicated a link between these behaviors and medical errors and poor quality patient care. More than 65% of the participants indicated that disruptive behaviors were linked to adverse events, more than 50% indicated patient safety compromise, and more than 25% of the respondents linked the behaviors to patient mortality.4
In the disruptive behavior events reported to the Authority, the care areas where the behaviors most frequently occurred were in ORs (24%), medical/surgical units (24%), ICUs (16%), EDs (8%), outpatient departments (7%), labor and delivery units (4%), behavioral health units (3%), laboratories (1%), and others (8%). (See Table 3.)
Table 3. Disruptive Behaviors by Care Area,
May 2007 to October 2009
Related External Principles
The Joint Commission instituted a new leadership standard effective January 1, 2009, for all accredited hospitals to address disruptive and inappropriate clinician behaviors according to two elements of performance. These elements of performance mandate (1) that each hospital develop a code of conduct that defines acceptable, disruptive, and inappropriate behaviors and (2) that the organization’s leadership create and implement a process to manage these behaviors within each facility.1
According to Joint Commission, a facility’s code of conduct is to include educating all healthcare team members, holding the entire team accountable for the code of conduct, establishing a zero-tolerance policy for disruptive behaviors within the facility, developing a system to detect disruptive behaviors, and receiving reports of disruptive behaviors.1 The Joint Commission encourages organizations to develop nonconfrontational interaction strategies to address disruptive and intimidating behaviors and to outline disciplinary actions to deal with these behaviors.1 In addition to these new elements, the Joint Commission’s medical staff standards chapter has been organized to follow six core competencies: medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism, which are to be addressed in the physician credentialing process.1,5
In April 2009, the American College of Physician Executives (ACPE) and the American Organization of Nurse Executives (AONE) formed a physician/nurse collaborative, the main concentration of which is to deliver safe care to patients and families while managing disruptive behaviors. ACPE and AONE share specific core principles that include building collaborative relationships, creating specific systems for rewards and recognition, and emphasizing patient-focused care and better patient outcomes as their major priorities.6
Relationships among healthcare staff can have a powerful influence on how well important information is communicated. Disruptive behaviors may be displayed as aggressive, which is an easier type of behavior to observe, but may also be demonstrated as passive or passive aggressive. These behaviors may threaten patient safety and quality of care. It is not only physicians who exhibit disruptive behaviors, and the challenge for organizations is to address disruptive behaviors by all healthcare clinicians.1,7 Nurses and other frontline clinicians who witness these behaviors may be hesitant to point them out because of the fear of retaliation. Furthermore, nurses may be reluctant or may refuse entirely to communicate with a disruptive clinician, even in the face of the deteriorating status of a patient. Reasons for not reporting these behaviors may include intimidation, fear of conflict, perceived lack of reporting confidentiality, fear of being labeled as a troublemaker, and concern that nothing ever seems to change in the organization. Intimidating treatment of healthcare clinicians, lack of confidence, and an unresponsive administration all contribute to a difficult situation for frontline healthcare staff and set the stage for catastrophic patient care in present and future institutions, as well. Delays in patient care, disruptive behaviors, and recurring communication problems may occur due to ongoing or unresolved disputes between clinicians, which may be related to personality conflicts or different communication styles.
ACPE conducted an electronic survey on the doctor-nurse behaviors of more than 2,100 physicians (33%) and nurses (67%). The survey results indicated a fundamental lack of respect between the two groups, which affected every aspect of their jobs, including staff morale, patient safety, and the public perception of healthcare. Nearly 85% of the survey participants indicated that degrading comments and insults were the most common complaints. Lack of respect and communication were cited as the worst behavioral problems that most adversely affected patient care and staff morale.8
In the disruptive behavior events reported to the Authority, 35 (57%) were associated with physicians (nonsurgeons), 5 (8%) were identified specifically as surgeons, and 3 (5%) listed anesthesia clinicians as having the disruptive behaviors. Two (3%) of the reports listed nurses, 2 (3%) indicated medical students, and 14 (23%) associated other healthcare clinicians with the disruptive behavior. (See Table 4.) It is important to note that, typically, facility staff who report events to the Authority are not physicians, which may bias the data.
Table 4. Disruptive Behaviors by Healthcare Clinicians,
May 2007 to October 2009
Forty-four events reported to the Authority indicated that the disruptive behaviors or inappropriate interactions occurred between healthcare clinicians from different disciplines. Thirty-nine (89%) of these interactions occurred between physicians and nursing staff, 3 (7%) occurred between surgeons and anesthesia clinicians, and 2 (5%) occurred between nurses and medical students. (See Table 5.)
Table 5. Disruptive Behaviors between Healthcare Clinicians,
May 2007 to October 2009
Organizations should expect professionals to behave as professionals. Nonresponsive health systems or dysfunctional organizations provide the antecedent for disruptive behaviors. There is a history of tolerance and indifference to intimidating and disruptive behaviors in healthcare, and organization leaders may fail to address healthcare clinicians’ disruptive behaviors for many reasons.7 One reason may be ignorance of the problem. Disruptive behaviors often take the form of intimidation, and in some instances, individuals who engage in these behaviors may be very powerful in the organization. This may discourage other healthcare clinicians from reporting the problem, and the lack of such reports may be incorrectly interpreted by organizational leaders as absence of the problem.9 Still other organizations may value financial stability above all else and tolerate disruptive behaviors by revenue producers. The major concern about disruptive behaviors is how frequently they occur and the potential negative effect on patient care.3
According to a 2002 survey about physician-nurse relationships by Rosenstein et al., nurses indicated that placing calls to physicians to clarify physician orders was the most common precipitant to disruptive behaviors.10 Physicians indicated that orders that were not carried out correctly or in a timely manner were the largest problems. Forty-four percent of all participants indicated that barriers to reporting disruptive behaviors existed, including fear of retaliation, the concern that nothing ever changes, lack of confidentiality and administrative support, and physician lack of awareness or unwillingness to change. The survey listed contributing factors to disruptive behaviors, including differences in individual personalities, education, gender biases, historical behaviors, and environmental factors, which may not be easy to change. The overall findings of the survey indicated that perceptions between physicians and nurses differ when it comes to the causes, responsibilities, barriers, and solutions that surround these complicated yet essential relationships.10
Some Pennsylvania facilities that submitted disruptive behavior reports to the Authority listed the contributing factors of these events as follows: 44% were organizational/management factors (i.e., procedures not followed, unclear or ambiguous policies and procedures), 19% were team issues (i.e., communication problem between clinicians), 14% were task factors (i.e., training issue, emergency situation, inexperienced staff), 11% were staff factors (i.e., issue related to proficiency), 8% were patient characteristics, and the remaining 5% were related to work environment. (See Table 6.)
Table 6. Contributing Factors Listed in Disruptive Behavior Reports,
May 2007 to October 2009
Communication and Collaboration
Effective communication encourages successful collaboration and teamwork among healthcare clinicians, helps to prevent errors, and promotes patient safety. Communication, collaboration, and teamwork may not always occur in clinical settings.3 The Joint Commission lists problems with communication as the root cause in over 60% of all sentinel events studied since 1995.10-13 A culture of low expectations has developed in some healthcare settings, with healthcare clinicians anticipating poor communication and teamwork. Such a culture can lead to faulty or incomplete exchange of patient information and patient safety compromise due to ignored alerts or clinical discrepancies.3 Healthcare clinicians must know how to effectively communicate with each other so that vital patient information can be shared promptly.12 While nurses and physicians share the common goal of taking care of patients, differing communication styles can impact patient health and safety.
Schmalenberg and Kramer tested the construct validity and psychometrics of the Essentials of Magnetism tool, based on 5 types of nurse-physician relationships, identified by 3,602 staff nurse interviews from 26 Magnet* and comparison hospitals. This tool measures the nurse-physician unit climate and the proportion of positive relationships to neutral or negative relationships, all of which impact effective communication, success collaboration, and teamwork. The five types are as follows:14
- A collegial relationship, in which nurses and physicians have equal trust, power, and respect and in which nurses are asked by physicians for their input about patients
- A collaborative relationship, marked by mutual trust, power, respect, and cooperation based on mutuality rather than equality
- A student-teacher relationship, in which the physician or nurse takes on the teacher/guidance role
- A friendly-formal relationship, which is based on a neutral feeling and tone and the formal exchange of information
- A hostile/adversarial relationship type between the nurse and physician, which is marked by anger, verbal abuse, or resignation
* “The American Nurses Credentialing Center (ANCC) Magnet Recognition Program® recognizes healthcare organizations that provide the very best in nursing care and professionalism in nursing practice. The program also provides a vehicle for disseminating best practices and strategies among nursing systems. The ANCC Magnet Recognition Program is the gold standard for nursing excellence.” (American Nurses Credentialing Center. About ANCC [online] 2010 [cited 2010 Jan 13]. Available from Internet: http://www.nursecredentialing.org/FunctionalCategory/AboutANCC.aspx.)
Another issue is passively ignoring the input of other team members. Interestingly, nurses interviewed indicated that all five relationship types can be found on any patient care area, simultaneously. Participating nurses from Magnet hospitals consistently reported more collegial and collaborative relationships than nurses from non-Magnet hospitals.14
Featherstone et al. identified communication between healthcare clinicians as the largest problem in all reported deaths in United Kingdom acute hospitals.15 Structuring the content of communication can facilitate a more thorough patient information transfer, particularly when complex information needs to be communicated quickly.3
As the person with the greatest exposure to the patients, the nurse often has the ultimate responsibility of making the crucial assessment of the patient’s status and effectively communicating this to the physician. When this essential line of communication fails, tragic events may follow. Effective communication between nurses, physicians, and other healthcare clinicians is essential to patient safety. That said, communication patterns are highly variable and influenced by multiple factors.11 There are many reasons for poor communication, one of which is the difference between what kinds of patient information nurses and physicians communicate to each other. (See “Common Barriers to Interprofessional Communication and Collaboration.”) Collaboration between nurses and physicians is vital to create and sustain a healthy work environment.16 Even though nurses and physicians interact numerous times each day, they often have different perceptions of their roles and responsibilities regarding patient needs and differing goals for patient care.3
Nurses tend to describe a situation in broader terms, are often process- and outcomes-driven, and build relationships using democratic leadership styles. Nurses also tend to avoid disagreements and, as a result, may compromise when conflicts arise.16 Most nurses in healthcare facilities are assigned to one care area, making their concerns unit-based. Physicians, on the other hand, are action-oriented, outcomes-driven, and generally have a commanding leadership style. They typically desire only the main subject matter of the problem, so action can be taken promptly; they may regard other healthcare workers as assistants.12,16,17 Physicians may be adversarial when conflict arises.16 Physicians are frequently service-based, so their patients and responsibilities may be spread over the organization’s entire geographic area.16
The nurse is expected to implement standards of care and advance the chain of command when needed. As a patient’s advocate, if the nurse determines that a patient may be in peril when unsafe or inadequate care is administered, the chain of command must be instituted.13 Those healthcare environments that are characterized by a vertical hierarchical culture often institute physicians at the top. In these environments, physicians may believe that the environment is a collaborative one, but other direct healthcare clinicians frequently perceive communication difficulties with physicians.3 While collaborative interactions may help to ensure that the proper treatments are being delivered appropriately to patients, hierarchical differences may diminish these exchanges between healthcare clinicians.
Manning divides communication failures into three categories: (1) system failures, (2) message failures, and (3) reception failures. System failures are those in which there are no formal channels for communication (e.g., nonfunctioning page system). Message failures are those in which the formal channels are present, but the necessary information is not transmitted (e.g., incomplete information given). Reception failures occur when there are formal channels present, the correct information is transmitted, but the information is either misinterpreted or arrives too late (e.g., written order not discovered for several hours).11 Of the reports of disruptive behaviors to the Authority, 5 were identified as having system failures, while 41 reports fell into the category of reception failure. The differences in communication styles have the potential to make disruptive behaviors erupt. It is important for organizations to hold all healthcare clinicians, regardless of seniority or clinical discipline, accountable for modeling desirable behaviors including basic business etiquette and phone and people skills, with an emphasis on respect.
Featherstone et al. indicated that nurses have a greater chance of getting a helpful response if a structured call for assistance is used when contacting a physician about a deteriorating patient’s condition.15 A structured communication tool conveys a patient’s change in condition with a clear statement that indicates the purpose for the contact or call. The call content provides the physician with a brief summary of how the patient presents by providing a convincing and succinct way to communicate how the patient’s condition has changed and to request assistance for the acutely ill patient.15
There are several cross-discipline communication methods available for healthcare clinicians. According to Nadzam, any structured verbal or written communication tool should be simple enough to complete quickly, convey patient information efficiently, promote multidisciplinary collaboration, and limit the likelihood of miscommunication. Such structured communication tools that promote good communication may include interdisciplinary assessment forms, medication order forms, progress notes, time-outs, read-backs, and briefings.12
One of the Joint Commission’s National Patient Safety Goals requires facilities to improve the effectiveness of communication among healthcare clinicians. This goal recommends the development, use, and implementation of standardized communication, coordinated teamwork, and defined roles and responsibilities.2
The Center for Medical Simulation and 40 anesthesia trainees affiliated with Harvard Medical School participated in simulated clinical case scenarios to practice the management of obstetric emergencies and improve teamwork skills. The scenarios simulated challenges between the trainees and the resident’s faculty anesthesiologist, faculty surgeon, and circulating nurse. Cases included three clinical problems presented to the trainees in a fully simulated OR. The “two-challenge rule” was the first communication method used by the trainees to speak up when actions of the team members seemed incorrect. Each team member shares responsibility for a safe outcome. The “advocacy and inquiry method” was the second technique used to obtain additional help. This was instituted in acute clinical situations in which speaking up and taking action were indicated: a form of chain of command.18 Trainees had difficulty recognizing opportunities to challenge the circulating nurse during the simulations and may not have fully
appreciated the importance of the nurses’ role when critical events occur. The study revealed that simulated educational interventions can be can be learned and applied, and are significant in clinical settings.
The University of California developed a four-hour educational program on teamwork that combined teaching strategies to practice effective communication skills and team behaviors. The program created a shared forum for healthcare clinicians to learn about and discuss interdisciplinary communication and teamwork. The communication methods used in this program included the Situation, Background, Assessment, Recommendation tool (SBAR), which is used to convey critical information between healthcare clinicians, as well as the words, “I’m Concerned, I’m Uncomfortable, this is a Safety issue (CUS),” which are said to get healthcare providers’ attention to stop what they are doing and listen.19 The program was rated highly by all disciplines that attended, and the participants reported that it likely changed the way they communicate with each other.19
Support of professional behaviors is not possible without a commitment to address disruptive behaviors whenever they occur.20 Hickson et al. describes several collaborative approaches used by the Vanderbilt University Medical Center’s (VUMC) and Vanderbilt University School of Medicine (VUSM) to promote professional behaviors for all faculty, staff, and students. One approach developed in 2004 is the VUSM’s Academic Leadership Program, which focuses on physician leadership training and includes a foundational introduction on disruptive behaviors and ways to address them. This process includes the use of the Disruptive Behavior Pyramid, which identifies, measures, and addresses unprofessional physician behaviors (available online at http://www.studergroup.com/DB). The pyramid provides guidance on how and when to intervene when physician disruptive behaviors are encountered. Those physicians that exhibit disruptive behaviors represent a threat to patient quality care and safety and require authoritative intervention, such as a tiered intervention process, beginning with informal, nonjudgmental feedback and progressing to an awareness intervention. If a disruptive behavior persists and becomes a pattern, the intervention is set up to advance to a more authority-based intervention. Persistent patterns of disruptive behaviors that fail to respond to interventions may be disciplined with privilege restriction or termination with reporting to government entities. Those that exhibit a single unprofessional act may require a less formal intervention, such as a conversation.20
All VUMC employees and students are required to sign and follow the Credo Behaviors creed (available online at http://www.mc.vanderbilt.edu/root/pdfs/elevate/8_5credo.pdf) developed by VUMC leadership, which outlines elements relating to respect of patients and staff, privacy and confidentiality, employee and/or student ownership, effective communication, professional conduct, and a commitment to colleagues. VUMC also has a Patient Advocacy Reporting System (PARS), a surveillance system designed to recognize patterns of unprofessional behaviors based on patient complaint records from the institution’s database. PARS operate under an oversight committee of physicians that provide applicable peer review and interventions to those physicians who exhibit patterns of unprofessional behaviors. VUMC reports an approximate 60% improvement in complaint scores after an informal level one awareness intervention.20
The benefits of programs, such as VUMC’s, that work to eliminate disruptive behaviors include improved staff satisfaction and retention, enhanced institution and leadership reputation, creation of a culture of professionals who are role models for staff and students, improved patient safety due to staff willingness to speak up when unprofessional behaviors are encountered, reduced liability exposure and risk, improved teamwork, and, overall, more productive, civil, and desirable work environments.20
Another program designed to advance the quality, safety, and efficiency of healthcare by improving communication and other teamwork skills is Team Strategies and Tools to Enhance Performance and Patient Safety™ (TeamSTEPPS™), which was developed by the Agency for Healthcare Research and Quality and the Department of Defense. TeamSTEPPS is a teamwork system based on 20 years of experience and lessons learned from high-reliability organizations. The skills emphasized in this program contribute to important strategies that enable teams to adapt to changing situations, share an understanding of the patient’s care plan, develop positive attitudes towards teamwork, provide reliable and efficient patient care, and to reach the desired outcome of safer care. The program’s success depends on enhancing the organization’s culture to focus on teamwork.21 (Some Pennsylvania facilities have successfully used the program to help improve communication within their facilities and reduce errors; see the article “Patient Safety is Enhanced by Teamwork” in this issue.)
Risk Reduction Strategies
Some events reported to the Authority listed recommendations to prevent future events due to disruptive behaviors. These include the need to rectify system communication problems, encourage all staff to comply with hospital policies, improve documentation issues, investigate any pending accusations of disruptive behaviors, refer the event to interdepartmental meeting or chair, discuss the event with the involved healthcare worker, reeducate the healthcare worker, track the events, or look for trends within the organization. (See Table 7.)
Table 7. Recommendations Listed in Reports to Reduce Disruptive
Behaviors, May 2007 to October 2009
Other risk reduction strategies found in the clinical literature include the following:
Develop an organizational chain-of-command policy that includes an administrative commitment and expectation that staff are responsible for ensuring that patients receive quality care and are expected to implement the chain-of-command policy when the quality of care or patient safety is in question. Having a set chain-of-command policy means that all involved personnel will be familiar with the delineation of care and responsibilities. Policies detail the levels of management that should be contacted and the order in which the contact should occur. (Organizations have developed algorithms for chain of command and deterioration of patient condition.) Educate all staff about the organizations’ chain-of-command policy. Provide regular chain-of-command demonstrations for staff that include simulated scenarios to better prepare healthcare clinicians when initiating a chain of command or when concerns about questionable patient care are encountered. Policies should also include documentation guidelines and outline alternatives and instances when an inappropriate chain of command is implemented.22
Develop an organizational code of conduct that includes training in basic business etiquette and phone and people skills with an emphasis on respect. Educate all physicians, nurses, and other staff, including contract workers, about appropriate professional behaviors as defined by the code of conduct. Define and establish an organizationwide safety culture. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, and medical staff. Make the organization’s overall safety performance a key, measurable part of the evaluation by the chief executive officer and all leadership. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).1,7
Institute an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization to create an environment in which it is safe for everyone to talk about vulnerabilities and failures without fear of reprisal. Hold all healthcare clinicians accountable for modeling desirable behaviors. Enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline. Provide reinforcement of the code in a positive fashion.1,7,20
Develop and implement policies and procedures and processes appropriate for the organization that address “zero tolerance” for the most egregious disruptive behaviors. Incorporate this policy into medical staff bylaws, all staff employment agreements, and administrative policies. Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a healthcare organization should be complementary and support the organization’s policies pertaining to nonphysician staff. Protect those who report or cooperate in the investigation of intimidating, disruptive, and other unprofessional behaviors. Include nonretaliation clauses in all policy statements that address disruptive behaviors and how and when to begin disciplinary actions.1,8
Regularly hold open discussions with the patient safety officer; risk management, performance improvement, physician, nursing, and pharmacy leaders; and all healthcare clinicians who are caring for patients to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care may provide the ideal opportunity for these discussions, which focus on learning and improvement, rather than blame or retribution.1
Create and communicate a policy that defines the behaviors that will be referred for disciplinary action; include the timeframe in which the disciplinary action will take place. Develop an organizational process to address intimidating and disruptive behaviors that solicits and integrates substantial input from an interdisciplinary team of medical and nursing staff, administrators, and other employees.1,7
Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice that includes skills for providing feedback about chain of command, unprofessional behaviors, and conflict resolution. Cultural assessment tools can also be used to measure changes in attitude over time.1
Assess staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive, and timely. Ensure that staff have the opportunity to fully participate in the investigation and in risk identification and mitigation activities that will prevent future adverse events.1,7
Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behaviors. Include patient advocates who provide important feedback from patients and families who may experience intimidating or disruptive behaviors from healthcare professionals. Monitor system effectiveness through regular surveys, focus groups, and peer- and team-member evaluations. Learn whether intimidating or disruptive behaviors exist or recur through multiple and specific strategies, such as direct inquiries at routine intervals with staff, supervisors, and peers.20
Support surveillance with tiered, nonconfrontational interventional strategies that start with informal conversations directly addressing the problem and move toward detailed action plans and progressive discipline, if patterns persist. These interventions may initially be nonadversarial, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety. Make use of mediators and conflict coaches when professional dispute resolution skills are needed.1,7,20
Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, with adequate resources to support individuals whose behaviors are caused or influenced by physical or mental health pathologies.1,20
Encourage interdisciplinary dialogues across a variety of forums as a proactive way to address ongoing conflicts, to overcome them, and to move forward through improved collaboration and communication. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.1,7
When hierarchical differences exist between healthcare clinicians, communication problems may occur. Those individuals that exhibit intimidating behaviors may further hinder communication between healthcare clinicians, causing delays in patient care particularly if the organization’s chain of command fails to outline structured communication techniques and clinical practice guidelines to follow when disruptive behaviors are encountered. Disruptive behaviors of healthcare clinicians have been linked to adverse events. An organization that values all healthcare clinicians is one that invests in chain-of-command policies and provides adequate investigation and follow-up of reports of disruptive behaviors. The chain-of-command policy provides healthcare staff with actions, exceptions, steps to take regarding unresolved issues, and documentation guidelines. Chain-of-command development is an essential part of healthcare organizations’ efforts to build trust, communication, collaboration, and teamwork among healthcare clinicians, all of which have positive effects on patient safety and outcomes. Education of healthcare clinicians about the chain-of-command policy can include role-playing demonstrations, which may better prepare healthcare clinicians to initiate a chain of command when they have concerns about questionable patient care or when they encounter disruptive behaviors.
- Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40 [online] 2008 Jul [cited 2009 Nov 13]. Available from Internet: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.
- Joint Commission. Accreditation programs: hospital. National Patient Safety Goals [online]. 2009 [cited 2009 Nov 13]. Available from Internet:
- O’Daniel M, Rosenstein AH. Chapter 33: Professional communication and team collaboration [online]. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. 2008 Apr [cited 2009 Nov 13]. Available from Internet: http://www.ahrq.gov/qual/nurseshdbk/docs/O’DanielM_TWC.pdf.
- Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm Qual Patient Saf 2008 Aug;34(8):464-71.
- Schyve PM. Leadership in healthcare organizations: a guide to Joint Commission leadership standards [online]. 2009 Winter [cited 2009 Nov 13]. Available from Internet: http://www.jointcommission.org/NR/rdonlyres/48366FFD-DB16-4C91-98F3-46C552A18D2A/0/WP_Leadership_Standards.pdf.
- American Organization of Nurse Executives (AONE). ACPE and AONE collaborate on improving nurse/physician relationships [online]. 2009 Apr [cited 2009 Dec 21]. Available from Internet: http://www.aone.org/aone/about/2009PressReleases/041009.html.
- Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to safety [online]. Patient Saf Qual Healthc 2006 Jul-Aug. Available from Internet: http://www.psqh.com/julaug06/disruptive.html.
- Johnson C. Bad blood: doctor-nurse behavior problems impact patient care. Physician Exec 2009 Nov-Dec; 35(6):6-11.
- Porto G, Deen J. Drawing the line: effective management strategies for disruptive behavior. Patient Saf Qual Healthc 2008 Nov-Dec;20-8.
- Rosenstein AH, Russell H, Lauve R. Disruptive physician behavior contributes to nursing shortage. Study links bad behavior by doctors to nurses leaving the profession. Physician Exec 2002 Nov-Dec;28(6):8-11.
- Manning ML. Improving clinical communication through structured conversation. Nurs Econ 2006 Sep-Oct;24(5):268-71.
- Nadzam DM. Nurses’ role in communication and patient safety. J Nurs Care Qual 2009 Jul-Sep;24(3):184-8.
- Zimmerman PG. Preventing lawsuits by noting and acting on key aspects in a patient’s condition. Orthop Nurs 2008 Jan-Feb;27(1):31-5.
- Schmalenberg C, Kramer M. Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Crit Care Nurse 2009 Feb;29(1):74-83.
- Featherstone P, Chalmers T, Smith GB. RSVP: a system for communication of deterioration in hospital patients. Br J Nurs 2008 Jul;17(13):860-4.
- Benner AB. Physician and nurse relationships, a key to patient safety. J Ky Med Assoc 2007 Apr;105(4):165-9.
- Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009 Dec;18(6):424-8.
- Pian-Smith MC, Simon R, Minehart RD, et al. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc 2009 Summer;4(2):84-91.
- Sehgal NL, Fox M, Vidyarthi AR, et al. A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience. J Gen Intern Med 2008 Oct;23(12):2053-7.
- Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: indentifying, measuring, and addressing unprofessional behaviors. Acad Med 2007 Nov;82(11):1040-8.
- Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS™: national implementation [online]. 2010 [cited 2010 Jan 13]. Available from Internet: http://teamstepps.ahrq.gov.
- Jones JS. Chain of command: a risk management perspective. Compass 2004 Mar;2(2):1-4.
Common Barriers to Interprofessional Communication and Collaboration
- Complexity of care
- Concerns regarding clinical responsibility
- Culture and ethnicity
- Differences in accountability, payment, and rewards
- Differences in language and jargon
- Differences in requirements, regulations, and norms of professional education
- Differences in schedules and professional routines
- Disruptive behaviors
- Emphasis on rapid decision making
- Fears of diluted professional identity
- Generational differences
- Historical, interprofessional, and intraprofessional rivalries
- Personal values and expectations
- Personality differences
- Varying levels of preparation, qualifications, and status
Source: O’Daniel M, Rosenstein AH. Chapter 33: Professional communication and team collaboration [online]. In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. 2008 Apr [cited 2009 Nov 13]. Available from Internet: http://www.ahrq.gov/qual/nurseshdbk/docs/O’DanielM_TWC.pdf.