Disruptive behavior and patient safety - President's Message

AORN Journal,  August, 2002  by Donna S. Watson

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A nurse disagrees with a surgeon's opinion and is told she no longer is allowed to speak when present in the surgeon's room. A new graduate nurse walks into the OR without a mask, and the surgeon yells at her to get out of the room. A surgeon yells at the charge nurse in the hall about slow room turnover and poor work by staff members. Many perioperative nurses have experienced scenarios like these. They recognize the feeling they have when they report in for the day, look at the surgery schedule assignment, and immediately realize it is going to be a very long and demanding shift. This feeling is not based on the work that lies ahead; instead, it is based on previous experience with the mix of personalities on the surgical team, anticipated interactions, and likely personal conflicts.

FAMILIARITY BREEDS CONTEMPT

The perioperative surgical suite is an environment unlike other areas of a hospital, clinic, or private office. In the surgical suite, team members may spend eight hours or more together on any given day. This provides an opportunity for individuals to learn more about their coworkers than they may want. Relationships among team members develop because of this unique situation and can result in family-like interactions. Surgical team members frequently become so comfortable with each other that they discuss topics and issues most coworkers might feel uncomfortable addressing. This comfort level among team members can result in inappropriate remarks that lead to tension between team members.

Most perioperative nurses have experienced their share of lewd jokes, comments about coworkers' anatomies, innuendoes, verbal temper tantrums, throwing of instruments, and even physical abuse. (1) This type of behavior has been tolerated and often viewed as part of the OR culture; however, this behavior is considered offensive to many, and perioperative nurses need to know where to draw the line. When does a push of the hand or shove of the body become physical abuse? When does a sexual joke become a form of sexual harassment? When does this type of behavior have implications for recruitment and retention of nurses in the surgical suite?

THE NECESSITY OF A SUPPORTIVE ENVIRONMENT

The nursing shortage is based on many issues, including an aging nurse workforce and fewer individuals interested in nursing as a career. Issues contributing to nursing being considered a less desirable career choice include lower compensation, mandatory work hours, stress, increased levels of burnout, less time for direct patient care, increased patient acuity levels, verbal abuse, and less than optimal management teams. Recruitment and retention relies on more than a decent pay scale; nurses today are demanding supportive workplace environments.

Nurses are more selective as to where they choose to provide patient care, and they are seeking out supportive workplace environments with strong management teams.

Unfortunately, there are institutions that choose to contribute to the nursing shortage by providing less than optimal workplace environments with poor management support, especially when it comes to disruptive physician behavior. In one recent study, 92% of respondents observed disruptive physician behavior; (2) however, physicians and nurses had significantly different perceptions about the effect of disruptive physician behavior on nurse morale and patient outcomes.

Disruptive behavior is defined as "any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical and sexual harassment." (3) Disruptive behaviors may occur between physicians, nurses, surgical technologists, ancillary staff members, managers, patients, family members, and visitors. One study of OR managers reports that disruptive behavior in the OR was an issue, and 21% of the sample reported at least a weekly occurrence, 36% reported a monthly occurrence, and 35% reported an occurrence of less than once per month. (4)

Disruptive behavior that occurs among team members results in unnecessary anxiety and stress among people who are required to function skillfully as a high-level team. Disruptive behavior between two members of the surgical team often affects the entire team, resulting in a strained mood among team members and potentially affecting patient care negatively. I know of cases where both nurses and physicians have refused to work with certain members of the surgical team. This results in complexities related to staff member assignments and running an efficient surgical suite. A nurse who feels intimidated by an individual surgeon may delay notifying him or her about critical patient information because the nurse may worry that the surgeon will be irate and verbally insult or yell at him or her. One study reports that nurses who were subjected to disruptive behavior by a physician had resulting behaviors, such as failure to notify the physician when the patient's condition warranted it and hesitancy to make recommendations that could improve the care of the patient, out of a desire to avoid confrontation. (5)