Disruptive provider behavior: Nature or nurture?

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Disruptive provider behavior: Nature or nurture?


A look at the patient safety literature as well as recent popular media leaves no doubt that what is currently coined "disruptive provider behavior" is detrimental to the delivery of safe patient care. There have been numerous case studies, culture surveys, articles, and even peer-reviewed research citing disruptive provider behavior as a common contributor to, if not the cause of, many patient safety events and medical errors.

Much of the work around disruptive providers ­attributes the behavior to personal afflictions such as lack of situational awareness, perfectionism, anger management issues, and other psychological problems. While these are legitimate factors, I would argue that we don't have a sophisticated understanding of how the design and work within the care environment adds fuel to the fire, so to speak. Therefore, we may be addressing the problem incorrectly.

As inpatient acuity continues to increase, ­caregivers and professionals continue to hyper-specialize, and multidisciplinary care teams grow larger in size and complexity, I can't help but believe disruptive provider behavior will get worse before it gets better-and not on account of professionals in the field with undesirable personality traits.

Many institutions have internal definitions of disruptive provider behavior-each calling out specific words, actions, or attitudes that can impede safe patient care. Acts such as throwing surgical instruments or verbally abusing a colleague are obviously disruptive. There are also the more hidden, passive-aggressive displays such as dirty looks and cliquelike behavior. Even more subtle ­actions, such as failure to wash one's hands, could also be interpreted as disruptive provider behavior.

All of this behavior can delay or prevent ­information sharing among the team. Even worse, it can inhibit caregivers from speaking up about concerns or ­providing additional information that may be critical to patient care. Disruptive provider behavior certainly stems from cultural constructs, such as role hierarchy, age and educational differences, and attitudes and personality traits. However, I would propose that disruptive provider behavior is often a symptom of the seemingly disordered and uncoordinated care delivery environment.

The environment in which our clinicians deliver care is becoming ever more complex, chaotic, and stressful. The acute care industry is being tried-the patients entering facilities today are sicker and more medically demanding than ever. I believe that disruptive provider behavior is often not the result of unpleasant caregivers with questionable dispositions, but rather the frenzied care delivery environment-one that has little promise of settling down in the near future. When observing the commotion on any clinical unit at shift change, it's no wonder that clinicians' tempers and patience grow short with one another. Within a just culture model, and taking into consideration the challenging environment, it is often hard to listen to the stories of disruptive provider behavior and not feel sympathetic for those involved-or rather, those who have been accused of exhibiting poor behavior. Many times, these behaviors are borne out of the best intentions of doing what is right for the patient in a delivery environment that is hardly conducive to harmony among the team members.

To inject calm into chaos, programs like TeamSTEPPS have developed scripts with relevant keywords to help staff resolve conflicts and prevent a hailstorm of emotion. There are, of course, internal cultural campaigns to foster a sense of ­collegiality, camaraderie, and mutual support. There are even pushes from the academic community to form multidisciplinary programs early in medical school ­education to better prepare students for the nature of teamwork in the delivery setting. However, we still can't seem to get a handle on this increasingly problematic issue. I believe it will be impossible to curb disruptive behavior in the acute care workplace-and subsequently our patient safety issues-until we calm the chaotic environment in which our caregivers spend their time.