When integrating change into practice, it’s important to understand the common barriers encountered in quality and safety implementation. This will allow for adequate planning and preparation. Some of the challenges include a lack of team integrity and disruptive and hierarchical behavior. Unfortunately, these factors can contribute to medical errors and patient harm. Historically disruptive and hierarchical behavior has been both accepted and normalized to an extent within healthcare culture. This article will explore these barriers in greater detail.
Team integrity includes demonstrating good moral and ethical principles and doing the right thing regardless of who is watching. Essentially, integrity is being a good person- honest, responsible, and accountable. Team integrity applies these traits collectively to the whole of the team.
For example, let’s say as part of a team training program a pre-procedure briefing process is put into place on a labor and delivery unit, in which all multidisciplinary team members come together prior to any procedural cases (i.e. scheduled/unscheduled cesarean sections) and review pertinent patient information. This includes information including but not limited to patient identity, site, procedure, consent, allergies, anesthesia plan, need for blood products, and postpartum hemorrhage risk level. The goal is to ensure that everyone is on the same page and adequately prepared for potential complications given the patient’s risk factors.
A team that demonstrates positive integrity will perform this process in the correct manner, not only on the day shift when leadership is present but also 24-7. Team members will hold each other accountable for this process. In contrast, a lack of team integrity can lead to inconsistent use of this process and potential harm to patients when key elements are missed, the team is not prepared or not on the same page. Thus, a lack of team integrity can be a barrier to quality improvement (QI) work and a culture of safety.
According to the Joint Commission (2021),
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 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 questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients (Joint Commission, 2021, p.1)
Intimidating and disruptive behaviors occur among healthcare professionals in all disciplines including nurses, physicians, pharmacists, support staff, and leadership. In addition, these behaviors create an unsafe work environment for both patients and employees, leading to medical errors, patient harm, decreased patient satisfaction, staff turnover, and litigation (JC, 2021).
Dr. Jones is a surgeon in his early 50s working in a major academic center. He has been on faculty for 10 years and is a highly regarded surgeon who obtains excellent results. However, the operating room (OR) staff prefer not to work with him, and the nurses on the floor try to avoid him. The staff have complained on numerous occasions over the past five to six years. The latest incident involved Dr. Jones throwing a piece of faulty equipment on the floor, injuring the nurse next to him. The piece of equipment gashed her foot open, hence requiring stitches. The scheduled operation proceeded successfully, and no harm came to the patient (Samenow et.al., 2013, p.119).
Disrespectful Behavior and Medication Errors
In 2021, the Institute for Safe Medication Practice (ISMP) conducted a national survey regarding disrespectful behaviors in healthcare. For context, disrespect is used to describe similar behaviors previously defined as disruptive in this article. Over 1000 practitioners responded and included nurses, pharmacists, pharmacy technicians, quality/risk/safety professionals, and physicians. Respondents shared that their experiences with disrespectful behavior changed the way they responded to medication order questions or clarifications. This included: asking colleagues to interpret orders to avoid interacting with a prescriber, asking a colleague to speak to a provider who was known to be disrespectful, and assuming an order was correct despite having concerns instead of interacting with a particular individual. Moreover, 27% of respondents described medication errors linked to disrespectful behavior, many leading to delays in care and adverse outcomes with high alert medications (ISMP, 2022).
Numerous nurses berated a pharmacist for delaying a patient therapy when she was trying to explain a safety concern with the order. The pharmacist eventually gave in and dispensed the drug. The patient received the wrong dose. The error was not corrected until the following day (ISMP, 2013, Table 3).
Causes of Disruptive Behavior
Both system and individual factors can contribute to these behaviors. System factors include the pressure resulting from the push for increased productivity and reduced costs, along with existing hierarchies, and litigation concerns. Adding to this is the continuous change in staffing, shifts, and rotations. Individual factors that can contribute to disruptive behavior can stem from a lack of effective interpersonal, coping, and conflict management skills. Stressors of the healthcare environment, involving high stakes and emotionally charged situations, combined with these aforementioned people skills, can also contribute to disruptive behavior.
In addition, different communication styles can also play a role. For example, nurses and physicians often present information in different ways, with nurses providing more detail than what providers may feel is necessary and leading to frustration. Nurses, on the other hand, may feel frustrated when they perceive a lack of interest from physicians with the information provided. The innate hierarchy that exists within the healthcare environment adds yet another layer to this (ISMP, 2014).
The hierarchical nature within healthcare can lead to disruptive behavior and a culture in which staff are unlikely to speak up. A power gradient exists when those higher up in the hierarchy are seen as holding all the power and decision-making. Typically, these are physicians. This contributes to an environment in which other team members’ contributions are not as valued and speaking up with concerns is more difficult.
Consider this example- a patient is undergoing an elective cesarean section. During a routine sponge/instrument/needle count it is discovered that the sponge count is incorrect. The process in place calls for searching the field and surrounding area, initiating a recount, repeating the wound exam, checking the sponge holders to ensure one sponge is in each pocket, notifying staff who have left the room (in the event they inadvertently left with a sponge), and lastly, performing an X-ray of the area. In this case, the surgeon opts to not follow the standard process because he is sure he did not place a sponge in the cavity. Team members are afraid to speak up given the authority gradient that exists, despite knowing the process. The end result is a retained sponge and patient harm.
A lack of team integrity along with disruptive and hierarchical behaviors all present barriers to quality and safety efforts and contribute to medical errors and patient harm. They can adversely impact staff relationships, communication, and collaboration among the team. The key to successful integration and sustainment of quality and safety work involves addressing these underlying cultural aspects along with actual implementation efforts.
Joint Commission (2021). The Joint Commission Sentinel Event Alert Issue 40. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-40-intimidating-disruptive-behaviors-final2.pdf
Institute for Safe Medication Practice (2014, April 24). Disrespectful Behaviors: Their Impact, Why They Arise and Persist, and How to Address Them (Part II). Retrieved from https://www.ismp.org/resources/disrespectful-behaviors-their-impact-why-they-arise-and-persist-and-how-address-them-part?id=78
Institute for Safe Medication Practice (2013, October 03). Unresolved Disrespectful Behavior in Healthcare – Practitioners Speak Up Again (Part I). . Retrieved from https://www.ismp.org/resources/unresolved-disrespectful-behavior-healthcare-practitioners-speak-again-part-i
Institute for Safe Medication Practice (ISMP) (2022). Acute Care ISMP Medication Safety Alert. Vol. 27, Issue 4.
Samenow, Charles P. MD, MPH; Worley, Linda L.M. MD; Neufeld, Ron LADAC; Fishel, Tobi PhD; Swiggart, William H. MS, LPC. (2013). Transformative Learning in a Professional Development Course Aimed at Addressing Disruptive Physician Behavior, Academic Medicine: Volume 88 – Issue 1 – p 117-123 doi: 10.1097/ACM.0b013e31827b4cc9
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS