Disruptive physician behavior contributes to nursing shortage: study links bad behavior by doctors to nurses leaving the profession. (Doctors, Nurses and Disruptive Behavior).

IN THIS ARTICLE...

A new survey about physician-nurse relationships uncovers a strikingly high prevalence of disruptive physician behavior that's affecting nurse retention.

RESULTS OF A NEW SURVEY show that disruptive behavior by physicians is helping to fuel the nationwide nursing shortage, heavily impacting job satisfaction and morale for nurses.

The survey results reveal the seriousness of the issue and highlight a lack of physician awareness, appreciation, value and respect for nurses.

Over 90 percent of the survey participants reported witnessing disruptive physician behavior. While disruptive events seem to involve only a small percentage of the medical staff, more than one-third of the participants reported knowledge of a nurse leaving an institution because of disruptive behavior by physicians.

Also disturbing is that more than two-thirds of the survey participants reported that their organizations had codes of conduct in place, but less than 50 percent felt they were effective.

Conducted by VHA, Inc.--a network of community-owned, non-profit health care systems and associated physicians--the 24-question survey was designed to assess the overall status of physician-nurse relationships.

The survey focused on four areas:

1. The overall status and significance of nurse-physician relationships at the hospital level

2. Specific issues related to disruptive physician behavior

3. Common trends, barriers and inciting events associated with disruptive behavior

4. Suggested strategies for support and resolution

A total of 2,562 respondents from 142 acute care, not-for-profit hospitals from 11 VHA regions across the country participated in the survey. Of the participants, 389 listed their title as physicians, 104 as senior level executives and 1,615 as nurses.

Survey highlights

The survey asked about the types of disruptive behavior witnessed or experienced. The most frequent responses included:

* Disrespect

* Berating colleagues

* Use of abusive language

* Condescending behaviors

What were the issues or events that precipitated disruptive behavior?

Nurses felt that the most common circumstances involved placing calls to physicians to clarify physician orders. Physicians indicated that orders not being carried out correctly or in a timely manner were the biggest problems.

The survey found that disruptive outbursts occurred most frequently in operating rooms, medical-surgical units, intensive care units, emergency departments and obstetrics areas.

When asked about disruptive behavior by physician specialty, general surgery ranked number one, followed by cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics, obstetrics and anesthesia.

Another survey question asked how serious an issue disruptive physician behavior was at the hospital. The overall response to this question was 6.77 on a scale of 1-10, with 10 being extremely serious.

When asked how important a factor disruptive behavior is for nurse satisfaction and morale, the total group response was 8.01--the highest score in the survey.

Nearly 37 percent of the survey participants indicated that nurses were leaving their hospitals as a result of disruptive behavior. Of those who responded positively, the average number of nurses reported leaving per year was 2.5.

About 44 percent of the participants indicated that barriers to reporting disruptive behavior existed. The most common barriers included:

* Fear of retaliation

* The fact that nothing ever changes

* Lack of confidentiality

* Lack of administrative support

* Physician lack of awareness or unwillingness to change

Survey participants also suggested ways to improve the working relationship between nurses and physicians.

Nurses want more opportunities for collaboration and communication, closely followed by the need for education and training for nurses and physicians with programs that foster improved working relationships. Also mentioned was the desire to hold open forums and group discussions.

Physicians listed increased education and training and more opportunities for collaboration as their top recommendations, followed by the need to foster more open forums and group discussions to improve relationships.

Both physicians and nurses said it was only a few physicians who gave the rest of the physicians a bad reputation. They also agreed that disruptive behavior is a two-way street, with nurses sometimes guilty of exhibiting disruptive behaviors toward physicians.

Roots of the problem

One of the key findings in the survey is that perceptions differ dramatically between physicians, nurses and executives when it comes to the causes, responsibilities, barriers and solutions surrounding physician-nurse relationships.

Some of the contributing factors--such as individual personalities, training, gender biases, historical behaviors and environmental forces--may not be easy to alter. Other factors like cultural tolerance, leadership support and the development of appropriate policies, roles and responsibilities that set behavioral expectations can be changed.

For physicians, many of their behaviors are molded in medical school. Throughout their medical training, physicians learn to think on their own and take responsibility for their actions. This self-preservation fosters autonomy, independence and an autocratic, domineering behavior pattern that is the antithesis of team building and collaboration.

This also sets up a tiered hierarchal model of care that establishes a subservient role for nurses. While medical training does little to nurture the development of certain "people skills," the problem is further accentuated by the lack of formal training in management and leadership skills.

Another factor influencing physicians is increasing external pressures such as:

* Lower compensation

* Demands for greater accountability and productivity

* Governmental oversight

* Managed care restrictions

* Consumerism

* Increasing liability risks

As a result, many physicians feel demoralized and harbor a victim mentality. All of these issues may increase their predilection for disruptive behavior.

The working environment influences nurses' behaviors and perceptions, as well. Their stressors include time demands, irregular schedules, shifting roles and historically inadequate levels of compensation. Nurses, like physicians, also are trained in a hierarchical system. Once again, this model is antiquated.

Administration also plays a significant role, with administrators often creating a hospital culture that has a powerful impact on the nurse-physician relationship. Attitudes, tolerance, equality, receptiveness and staff interactions help mold the culture. In many organizations, inadequate time and resources are dedicated to leading and refining the culture.

If clear behavioral expectations based on shared values are not implemented by the administration, then individuals resort to their own "natural" behaviors that can result in disruptive outbursts.

One key to success is to have physicians, nurses and administrative leaders come together to set acceptable behavior expectations by implementing a zero-tolerance policy for abusive physician behavior. But, as the survey showed, policies alone may not necessarily ensure proper behavior.

Collaboration will only fully evolve when shared goals pertaining to patient care and professional values are revealed and discussed openly among physicians and nurses. This cultural change requires informed and courageous leaders who exemplify respect, commitment and partnership based on shared core values.

Improving the relationships

Given the enormous complexity of the problem, the approach to improving physician-nurse relationships must come from several different perspectives.

Issues related to scheduling, staffing, workload requirements, job responsibilities, job benefits and amenities all need to be addressed, but nothing impacts a nurse more than feeling valued and respected for the type of patient care they provide.

Their day-to-day duties and peer interactions have a strong influence over their perceptions and attitudes about their job. Relationships with physicians are one of the factors influencing this perception.

Some ways to increase physician awareness and sensitivity to this issue is with lectures and newsletters. But the greatest success comes when a physician champion embraces the issue and spreads the word to colleagues.

Another step is to create opportunities for communication among physicians and nurses. This can be done through informal meetings and discussions (during rounds or phone contacts) or more formally through projects, meetings or committee work where physicians and nurses can come together.

More formal educational opportunities will help, too. Programs focused on team building, joint collaboration, conflict management, time management, stress management and even something as simple as phone etiquette for both physicians and nurses, have proven very successful for improving lines of communication.

Of course, a strong, consistent, well-enforced code of conduct that outlines appropriate behavior for staff and physicians is critical to success. The ideal policy should emphasize the right of all employees to enjoy a harassment-free working environment.

Those who do not follow appropriate behavior guidelines must be approached and counseled by a designated group of peers who are trained and prepared to offer specific recommendations. The team must insist that the physician get help.

The process needs to be consistent, but at the same time it needs to be flexible. A single explosive episode from a temporarily overworked physician during summer vacations should have a different response than a physician with a long history of unprovoked abusive behavior.

The intervention team must emphasize that they are most interested in changing the behavior so that the physician can continue to function--not in ending the physician's career.

For those individuals who are unable or unwilling to improve their behavior, the organization must be ready to take appropriate actions. More severe or repeated cases may require counseling or specific education programs. Immediate suspension of privileges must always be an option when faced with recalcitrance from a physician whose behavior directly endangers either staff or patients.

Obviously, health care is not the only industry with problem personalities. Disruptive behavior in any organization destroys the morale of the workers, negatively affects product/service quality and drives away talented employees.

Nurse/Physician Hospital Relationships: Impact on Nurse Retention and
Satisfaction Percent of respondents that have witnessed or experienced
disruptive behavior from a physician

Overall                  91.0
Nurses-All               95.1
Nurses-Admin            100.0
Nurses-Direct Care       94.8
Physicians-All           75.3
Physicians-Admin        100.0
Physicians-Direct Care   75.1
Executives               90.5

Note: Table made from bar graph

Nurse/Physician Hospital Relationships: Impact on Nurse Retention and
Satisfaction What type of disruptive behaviors have you witnessed or
experienced?

                       Top Bar   Middle bar   Bottom Bar
                       = Nurses  = Physicia  = Executives

Physical Abuse           22.2        9.5         12.5
Conderscension           68.6       43.4         52.9
Insults                  43.2       24.9         47.1
Disrespect               79.9       52.7         66.4
Abusive Anger            43.2       32.4         64.4
Berating-Patients        46.4       30.3         55.8
Berating-Colleagues      71.5       42.9         55.8
Berating-Private         52.4       30.9         46.2
Yelling/Raising Voice    59.8       40.4         43.3
Abusive Language         69.4       48.6         67.3

Note: Table made from bar graph

Nurse/Physician Hospital Relationships: Impact on Nurse Retention and
Satisfaction Overall Analysis of Questions 10 & 11

How frequently does disruptive behavior occur?

1-5 Times/year          24%
Never                    2%
Daily                    7%
Weekly                  24%
1-2 Times/month         29%
6-10 Times/year         14%

What precentage of the Medical
Staff exhibit disruptive behavior?

More than 10% of staff  12%
None                     2%
1% of Staff             18%
2-3% of staff           31%
4-5% of staff           21%
6-10% of staff          16%

Note: Table made from pie chart

Resources

For more details about this study see: Rosenstein, A. "Nurse-Physician Relationships: Impact on Nurse Satisfaction and Retention." AIN, June 2002, Vol. 102, No. 6, pp. 26-34.

Alan H. Rosenstein, MD, MBA, is vice president and medical director of VHA West Coast in Pleasanton, Calif. He can be reached by phone at 925/ 730- 3003 or by e-mail at [e-mail].

Henry Russell, MD, is vice president of clinical affairs at VHA Central Atlantic in Charlotte, N.C. He can be reached by phone at 704/557-7213 or by e-mail at [e-mail]

Richard Lauve, MD, MBA is vice president and medical director at VHA Gulf States in Baton Rouge, La. He can he reached by phone at 225/922-4020 or by e-mail at [e-mail].