While these wildly inappropriate behaviors grab headlines, there are less obvious, stealthier forms of passive-aggressive disruption that can be equally if not more threatening to patient safety and staff morale, such as:
While no single incident of any of these behaviors would be cause for alarm or intervention, over time these types of behaviors not only impede effective care and pose a threat to patient safety, they also frustrate patients and their families, lower staff morale, drive up the cost of care delivery and expose healthcare organizations to the risk of malpractice suits.
The Joint Commission’s Sentinel Alert #40 “Behaviors that Undermine a Culture of Safety” issued in 2008, states that healthcare organizations must address disruptive behaviors that threaten the performance of the healthcare team, which specifically include:
“...passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.”
“Overt eye-rolling and sarcastic behavior can be as inhibiting as a temper tantrum,” notes Liz Ferron, senior consultant and manager of clinical services for VITAL WorkLife. “A physician who makes nurses feel idiotic for asking legitimate questions is interfering with the flow of necessary information and ultimately, patient care.”
Passive-aggressive physicians with an “us versus them” attitude toward management, administration, other departments and even patients can be a significant energy drain on other team members as they attempt to share their misery and sense of victimization.
In the American College of Physician Executive’s (ACPE) 2009 Doctor-Nurse survey, a majority of participants had witnessed personal grudges interfering with patient care. In addition:
“A great many physicians might be unaware of the impact of their behavior, and they operate in an environment where staff and administrators remain largely reluctant to challenge them,” notes Alan Rosenstein, MD, MBA, medical director for VITAL WorkLife.
Many physicians lack the communication skills to deal with conflicts or voice their frustrations in a direct, constructive manner. They avoid crucial conversations, so what may be a legitimate concern or question comes out “sideways.”
“Instead of telling an OR manager about frustrations with the way scheduling is managed, a physician may deliberately slow every procedure,” notes Ferron. “He or she not only doesn’t solve the underlying problem, but makes the schedule more punishing for everyone else.”
Passive-aggressive behaviors are often considered safer and less risky by those who engage in them than direct conflict resolution. Physicians are less likely to be called on being sarcastic or talking behind others’ backs. They often have reasonable-sounding excuses for forgetting to call someone back (“It was a busy day”), working too slowly (“I’m just precise”), ignoring others (“I don’t hear well”), avoiding staff meetings (“I’m so busy, and besides nothing important is ever covered”), and failure to comply with policies and procedures (“It’s too hard to try to keep up with all the changes”).
Physicians who feel put upon and are unable to see the options and choices they have for dealing with stress and frustrations may use passive-aggressive behaviors to release anger and frustration and to feel more self-empowered.
Many passive-aggressive physicians are reacting to perceived and sometimes very real disempowerment in their work environment. For example, older physicians, used to far more autonomy and control in their early career, may not yet have fully accepted the “new normal.”
“There’s a natural desire for many administrators to think physicians should have ‘gotten over it’ by now, but healthcare organizations that aren’t providing a forum or outlet for those physicians to work through their disappointment and frustrations with their careers may very well experience a higher level of passive-aggressive behavior,” notes Ferron.
It is not uncommon at all to see passive-aggressive and aggressive behaviors in the same physician. Since passive-aggressive behavior rarely leads to true problem resolution, frustrations build and may lead to occasional explosions.
Organizations should not only make it clear in their policies around disruptive behavior that NO behavior will be tolerated that undermines patient safety and negatively impacts quality of care, directly or indirectly, they should also provide staff training about what constitutes respectful communication.
The ACPE study showed that both doctors and nurses feel more empowered to point out unsafe or unacceptable behaviors at organizations that provide support, training and encouragement for bringing those behaviors forward.
VITAL WorkLife provides training to organizations and work groups on improving and encouraging positive communication skills, dealing effectively with workplace conflict, civility training and other topics surrounding behaviors which can impact patient safety and care.
“It’s much easier to begin conversations around unacceptable behavior when the organization has clearly stated its expectations about everything from respectful communication and attendance or participation in staff meetings, to prompt attention to pages and consult calls,” notes Ferron.
Organizations should put into place mechanisms for tracking and reporting all types of disruptive behavior, in order to:
“Prior to sitting down with the physician, the administrator needs to have objective data on hand to demonstrate that the physician’s behavior is out of bounds—either in terms of stated organizational policy or in terms of performance as compared with other physicians in the organization,” notes Rosenstein.
While recognizing the different types of passive-aggressive behavior is important, it’s rarely helpful to label the behaviors as such. Rather, the administrator or manager should initiate a conversation that focuses on changing the behavior.
Here’s how one such conversation might play out:
“Many physicians will commit to modifying their behavior or attitudes after being made aware of the impact it’s having on others,” says Rosenstein. “Improvement can’t be voluntary. They have to know that the behavior has been observed, documented and will be monitored.”
In cases where physicians have issues that aren’t resolvable in a simple conversation, administrators have of the option of “reminding” physicians that the Physician Well Being Resources offers free, confidential counseling and physician peer coaching—or making a more definite suggestion.
Whether they come of their own volition or under a certain amount of guidance, The Physician Wellness Resources helps physicians to:
When physicians are non-compliant in changing or addressing their behaviors, VITAL WorkLife offers a comprehensive intervention solution designed to:
Watch the video below to learn more about our Physician Intervention solution and how it can help:
Chronic abusers or recalcitrant individuals may require formal interventions, very specific performance improvement plans and intense counseling over a lengthy period of time. In rare cases, termination may be the final course of action.
“A great many organizations prefer to outsource the intervention, counseling and performance improvement monitoring,” notes Rosenstein. “It’s often easier for physicians to continue or resume their responsibilities when they’ve been referred to an outside entity without the collegial relationships.”
Contact us online to learn how our Physician Well Being Resources can support the well being of your physicians and providers. Click here to learn about our Physician Intervention solution.