Disrespectful Behaviors: Part 1

Disrespectful behavior chills communication and collaboration, undercuts individual contributions to care, undermines staff morale, increases staff resignations and absenteeism, creates an unhealthy work environment, and causes some to abandon their profession—all of which ultimately harm patients. These behaviors have been linked to errors, compromises in patient safety, and even patient mortality.^1,2

Disrespect causes patients to experience fear, anger, shame, uncertainty, isolation, self-doubt, and depression, and physical ailments such as insomnia, fatigue, nausea, and hypertension.³ These feelings diminish patients’ abilities to make sound judgments and make it less likely they will ask questions, voice concerns, or provide important information. Disrespectful behavior is also at the root of difficulties encountered in developing team-based approaches to improving care.³

Why Disrespectful Behaviors Arise

Disrespectful behaviors can arise in any health care setting and are often “survival” behaviors gone awry.⁴ Both the stressful nature of the environment and human nature play roles in this destructive behavior. Although personal frustrations and system failures are no excuse for disrespectful behavior, they often push an individual, physician and patient alike, over the edge. Personality characteristics, such as insecurity, anxiety, depression, aggressiveness, and narcissism, can serve as a form of self-protection against feelings of inadequacy.³ Cultural, generational, and gender biases, and current events influencing mood, attitude, and actions, also contribute.² Practitioner impairment, including substance abuse, mental illness, or personality disorder, is often at the root of highly disruptive behavior.²

The hierarchical nature of health care and a sense of privilege and status can lead those at the top to treat others with disrespect. Power dynamics and different communication styles also play their part.^3,5 For example, physicians may get frustrated when nurses present information in more detail than they believe is necessary, and nurses may get frustrated when physicians do not seem interested in the information provided. A sense of autonomy, such as a resistance to collaborate with others or follow procedures that promote safety, can also underlie passive disrespect. Unfortunately, the victims of disrespectful behavior may feel they have no choice but to become perpetrators themselves.³

Why Disrespectful Behaviors Persist

Health care organizations have fed the problem of disrespectful behavior for years by ignoring it—thereby tacitly accepting such behaviors.⁴ The health care culture has permitted a certain degree of disrespect and “aggressive crudity,” considering this a normal style of communication.³ Studies have, in fact, shown that disrespectful behaviors are tolerated most often in unfavorable work environments, although it is unclear whether poor working conditions create an environment where the behaviors are tolerated or if the disrespectful behaviors create the unfavorable environment.^6,7

Organizations have largely failed to address disrespectful behavior for a variety of reasons. First, the behavior typically occurs daily, often going unreported due to fear of retaliation and the stigma associated with “whistle blowing.” Disrespectful behaviors are often difficult to measure, so leaders may be ignorant of the problem.⁸ Second, leaders may be unaware of the behavior if managers, viewing it as a personal failure, shield them from this information.⁸ Even if they do know about disrespectful behavior, leaders may be reluctant to confront individuals if they are powerful or high-revenue producers, or if they do not know how to handle the problem. It’s not a topic taught in training programs, so leaders may hesitate to take on a problem for which there is no obvious solution.⁸ Recommendations to help address this longstanding problem will be provided next month in part 2 of this article.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.

References

• Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471.
• McNamara SA. Incivility in nursing: unsafe nurse, unsafe patients. AORN J. 2012;95(4):535-540. doi: 10.1016/j.aorn.2012.01.020.
• Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-852. doi: 10.1097/ACM.0b013e318258338d.
• Zimmerman T, Amori G. The silent organizational pathology of insidious intimidation. J Healthc Risk Manag. 2011;30(3):5-6,8-15. doi: 10.1002/jhrm.20055.
• Gessler R, Rosenstein A, Ferron L. How to handle disruptive physician behaviors. Am Nurs Today. 2012;7(11):8-12.
• Lamontagne C. Intimidation: a concept analysis. Nurs Forum. 2010;45(1):54-65. doi: 10.1111/j.1744-6198.2009.00162.x.
• Budin WC, Brewer CS, Chao YY, Kovner C. Verbal abuse from nurse colleagues and work environment of early career registered nurses. J Nurs Scholarsh. 2013;45(3):308-316. doi: 10.1111/jnu.12033.
• Porto G, Deen J. Drawing the line: effective management strategies for disruptive behavior. Patient Safety & Quality Healthcare website. http://psqh.com/effective-management-strategies-for-disruptive-behavior. Published June 11, 2009.