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Helen Hillier, RN, assistant nurse manager at Mount Auburn Hospital in Cambridge, Mass., has witnessed her share of disruptive behavior in her 30 years as a perioperative nurse. Over the years, she has heard surgeons cursing and has watched them throw instruments onto the floor.

“Sometimes a surgical case is bumped because of an emergency. This causes some surgeons to become vocal and disruptive,” says Hillier. “We try to explain what caused the delay, but surgeons are sometimes difficult to deal with.”

Disruptive behavior among surgeons, nurses, and anesthesiologists is a frequent occurrence in many perioperative settings. Such behavior increases levels of stress and frustration, which impairs concentration, impedes communication, and adversely affects staff. It’s a culture that has developed over the years in the high-stress areas of hospitals across the nation.

One common cause of conflict in the OR, according to Hillier, is surgeons’ lack of access to their preferred supplies. Surgeons may become agitated when they don’t have their preferred sutures, for example. “The surgeon yelled and carried on, as nurses frantically called other hospitals in search of the suture,” says Hillier as she recalls an incident. “A courier delivered the desired supplies, but the damage had already been done. The disruptive behavior had a profound effect on team dynamics, morale, and communication flow.”

Communication as a learned skill

Nurses sometimes lack the communication skills necessary to thrive in high-stress environments. Leslie Schneiderhan, RN, BSN, MEd, a clinical nurse specialist in perioperative services at Mount Auburn Hospital, teaches assertiveness and communication skills to nurses working at all levels.

“Nurses focus on safety and are pulled in many directions,” says Schneiderhan. “They concentrate on getting everything right and sometimes forget the niceties like ‘please’ and ‘thank you.’ I try to teach nurses what to say and how to say it.”

But what’s a nurse to do when an overbearing surgeon’s behavior borders on abuse? Schneiderhan recalls an incident earlier in her career at the main surgery desk. “A burly surgeon threw his scrub shirt on the counter, shook his forefinger at the nurse in charge, and yelled, ‘I won’t wear this scrub top for surgery. It’s not my size and I’m uncomfortable.’”

The nurse at the desk responded calmly, saying, “There’s no need to raise your voice. I’ll send to OB to pick up another scrub top.” Schneiderhan advises all nurses to stand up for what they believe is right and feel confident they are supported by their organizations.

Zero-tolerance for disruption

Today, Mount Auburn Hospital prides itself on creating an environment in which nurses want to work. The hospital’s “zero tolerance” for disruptive behavior doesn’t allow for toxic personalities in the organization.

Deborah Baker, RN, MBA, vice president of patient care services and chief nurse executive at Mount Auburn, explains the hospital’s physician application process. “When physicians are hired, they are asked to sign a code of conduct. Each time they are re-appointed, they must read through an updated version and sign off. When physicians have problems with nurses, there is no yelling or throwing of instruments. Instead, they go through the proper channels to rectify the situation.”

Mount Auburn has worked to create a culture in which surgeons and nurses work together. “It’s a relationship that builds confidence,” Schneiderhan says. She remembers her first OR experience as a student nurse. “The nurses put me in a room and told me ‘don’t move and stay out of the way.’ This type of behavior intimidates nurses and drives them away from the profession.”

An employee assistance program (EAP) at Mount Auburn offers trained professionals who address issues such as stress, conflict resolution, professionalism, and change. “Many of our staff members have benefited from EAP presentations because they allow them to problem-solve in a constructive way,” says Schneiderhan. “By having plenty of resources, we are able to keep our nurses happy and our hospital well-staffed.”

The patient safety tie-in

On Sept. 11, l999, the Institute of Medicine (IOM) released the pivotal report “To Err Is Human.” According to its findings, between 46,000 and 100,000 Americans die in hospitals each year as a result of medical errors. The report also advocates cultures of safety, a decrease in lateral violence and disruptive behavior, and an increase in therapeutic communication.

Disruptive behavior is defined as any inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical and sexual harassment. Communication mishaps can cause sentinel events, minor injuries, near-misses, low morale, and high turnover rates for nurses everywhere, according to a 2004 AORN Journal article. Clinicians and safety experts must address the problem of intimidation and minimize its effects on processes of care and potential for medical errors.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) proposed several new National Patient Safety Goals (NPSGs) for 2007. Goal l6 discourages disruptive behavior. JCAHO based its proposal on a study conducted by the Institute for Safe Medication Practices, which found that 88% of respondents had encountered some form of disruptive behavior on the part of physicians and staff members.

On June 12, 2006, JCAHO announced that Goal 16 didn’t make the grade. One argument against it: “It is unenforceable, punitive and not appropriate as a NPSG. Management of disruptive staff and physicians should be handled through existing peer review and supervision processes, or through the appropriate licensing board.”

Richard J. Croteau, MD, executive director for patient safety initiatives of the Joint Commission International Center for Patient Safety, expects Goal 16 will be addressed next year. Croteau says respondents representing health care organizations expressed similar comments. “They thought it might be counterproductive to add new requirements while they still struggled with older goals,” says Croteau. “The result was to limit an expansion of the 2007 goals and spotlight Goal 16 in 2008.”

A HealthDay News for Healthier Living article, “Nurses Give Surgeons Poor Grades on Teamwork in the OR, reveals that operating rooms have historically been governed by a pecking order in which members of the operating team have been discouraged from confronting the surgeon on patient-care issues.

“Nurses are generally trained to work on teams with each other in combination with other disciplines,” says Fran Griffin, project director at the Institute for Healthcare Improvement, Cambridge, Mass., in the HealthDay News for Healthier Living article. “The teamwork begins even before the surgeon walks into the room, whereas the surgeons are trained to rule the roost.”

Paula Graling, RN, MSN, CNOR, CNS, clinical nurse specialist of perioperative services at Inova Hospital, in Fairfax, Va., believes in creating a culture of respect within the health care system. “Whether it’s called disruption in the OR, lateral violence in the OR, or just communication in the OR, it’s all the same,” Graling says. “It’s the old hierarchy — a doctor-nurse relationship that sets people up for failure.”

Graling, who also is the national president for the Association of periOperative Registered Nurses (AORN), believes teamwork is an attitude that can be taught. Graling lectures incoming residents and medical students on the roles, rules, and responsibilities of physicians and nurses. “Integrating team members in a collaborative setting not only breaks down the barriers, but creates an attitude of teamwork,” she says.

Common ground in the air

Some health organizations are looking to the commercial aviation field for guidance and inspiration. The human factor concept, taken from the Aviation Model in Healthcare, looks at how teams relate to each other and how teamwork affects patient outcomes.

“What human factor shows is how teams work with each other during times of stress,” says Graling. “Its goals include decreasing errors and gaining communication skills among members of the team.”

Aviation and health care share similarities — employees in both fields must function in high-risk, stressful, error-intolerant environments. Both settings require quick responses to adverse events, cross-checking of behaviors, and the ability to make effective decisions during stressful situations and while avoiding errors. A major difference between the two fields: Commercial aviation is federally regulated — surgery and medicine are not.

Inova Hospital has designed a “boarding pass” checklist to document completion of tasks such as confirming identification band accuracy, obtaining signed consent, taking a complete history and physical, and marking the surgical site.

Solutions embedded in culture

Alma Baird, RN, BSN, executive director of perioperative facilities at Stamford Hospital in Stamford, Conn., believes in communities built on respect. Early in her career, Baird experienced disrespect as a new nurse; she considered leaving the facility at which she worked but soon realized it was the overall culture that had to change.

At Stamford Hospital, assertiveness and conflict management training are incorporated into staff meetings. Baird doesn’t believe in raising her voice or using inappropriate language. “I teach a broad range of communication techniques, as some people respond to quiet and others respond to humor,” says Baird. “Assertiveness training must consider the spectrum of differences between nurses: genders, generations, tenure, nationalities, and cultures.”

Stamford Hospital provides its staff with the skills needed to create a culture of effective communication throughout the facility. Inappropriate behavior directed toward patients or staff members results in suspension or termination. “Respect is one of our core values,” says Baird. “If staff members don’t follow our values, they don’t belong in our organization.”

Barbara Thompson, MSN, RN, CNOR, director of surgical services at Middlesex Hospital in Middleton, Conn., says Middlesex prides itself on good communication and teamwork among staff members. Some new physicians, according to Thompson, require an orientation to the Middlesex culture. “If something isn’t going the way surgeons want it to go, their knee-jerk reaction is to do exactly what they want to do,” says Thompson.

Middlesex Hospital has come a long way. “Years ago, nurses didn’t know how to respond to conflicts within their environment,” says Thompson. “Now we have a ‘generic screen,’ a process that enables nurses to write anecdotes about hospital incidents that interfere with patient care.” Thompson reads the text that is entered there and presents it to the appropriate party for discussion. “If it’s serious enough, it goes to the medical executive committee,” says Thompson. “If it’s a physician, it’s dealt with on a peer level.”

Management at Middlesex pays attention to nurses’ concerns. “Just because someone is a physician displaying disruptive behavior doesn’t mean he or she receives a free pass,” says Thompson. “Good communication between management, nurses, and physicians is what makes the system work.”

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