Running head: DISRUPTIVE BEHAVIORS

Disruptive Behaviors and Nursing

Maggie M. Fabry
California State University Stanislaus
Date Submitted: 3/31/15

DISRUPTIVE BEHAVIORS

Disruptive Behaviors and Nursing

The large majority of prospective nurses choose to enter into the field of nursing
because they are eager to provide care to those in need. What many of these prospective
nurses will discover, though, is that an intimidating and aggressive work environment can
undermine this goal. The unfortunate reality is that, sometimes, nurses can aggress,
rather than help, their own. These disruptive behaviors can yield undesirable effects for
both the nurse and the patient.
The Problem
Violence amongst co-workers is disruptive, intolerable, and inappropriate. It can
include behavior such as intimidation, ostracizing, backstabbing, sabotaging, disregard
for anothers privacy, using innuendo, bickering, and withholding information (Coursey,
Rodriguez, Dieckmann, & Austin, 2013). The Joint Commission states that this
behavior, can foster medical errors, contribute to poor patient satisfaction and to
preventable adverse outcomes, increase the cost of care, and cause qualified clinicians,
administrators and managers to seek new employment in more professional
environments (Lachman, 2014, p. 39). Although the exact pervasiveness of intimidating
behaviors in the workplace is yet to be discovered, there is evidence to support the fact
that it is a problem. According to Lachman, a recent survey revealed that 39% of novice
nurses witnessed bullying in their first year of practice, and 31% experienced bullying
themselves (2014). An additional, statewide survey conducted in South Carolina found
that 85% of participants reported being a victim of horizontal violence, and many
identified experienced nurses as the perpetrators (Lachman, 2014). In addition to this
lateral violence amongst nurses, there can also be conflict between physicians and nurses.

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One study revealed that 95.7% of physician directors that were interviewed, reported
knowledge of disruptive physician behavior, (Saxton, 2012, p. 603-604).
Context: Conflict
Conflict can, most simply, be defined as a disagreement between two or more
individuals (Shuss, Kelton, Lockhart, & Davis, 2015). According to the Assessment
Technologies Institute, it is often, the result of opposing thoughts, ideas, feelings,
perceptions, behaviors, values, opinions, or actions, (2013). There are two different
types of conflict: intrapersonal and interpersonal. Intrapersonal conflict is the type that
occurs within the individual, and often involves conflicting morals and/or desires.
Interpersonal conflict takes place between two or more individuals who may have
conflicting morals, goals, and/or points of view. Intergroup conflict is a type of
interpersonal conflict that involves two or more groups of, individuals, departments or
organizations, (Assessment Technologies Institute, 2013, p.22).
According to Shuss et al., there are five different types of conflict resolution
styles used by individuals: collaborating, competing, avoiding, accommodating, and
compromising (2015). The style of collaborating often involves assertiveness and
cooperation, and aims to arrive at a solution that is viewed as a win by both sides. This
style focuses on deeply exploring the concerns and insights of both parties, and using
creativity to arrive at the best possible solution. Competing is a direct style of conflict
management that involves both assertiveness and aggression, and generally lacks a
concern for the opinions of others. It can be effective and efficient in situations where a
quick decision needs to be made, but can leave others feelings unsatisfied and powerless.
The avoidant style will often seek to escape conflict, leaving the underlying issues

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unresolved. It can be useful in situations where a solution appears impossible, but can
leave team members feeling dissatisfied. The compromising style is similar to the style
of collaboration in that it involves cooperation and assertiveness, and aims to find middle
ground. This style aims to quickly solve problems by searching for a solution that it
partially acceptable to both parties. Lastly, the accommodating style is one in which one
individual puts aside their own needs and desires in order to keep the peace. This style
can be useful because it is usually positively perceived by the other individuals, but can
result in one-sided decisions that arent necessarily the best choices (Shuss et al., 2015).
After reviewing these five styles, I believe that my style of conflict management most
closely matches the compromising style. I often lack the patience to utilize collaboration
and find the best solution, but still aim to please all individuals involved. I would say
that there are specific times in which I can remember using each one of the styles in
different situations. Even still, I would consider compromising to be my typical style.
The Impact of Disruptive Behaviors on Patients
Lateral violence and conflict amongst nurses can have devastating effects on
patient outcomes. According to McNamara, one study concluded that, disruptive
behavior is related to an increase in medical errors, a decrease in patient safety,
compromised quality of care, and even an increase in patient mortality (2012). An
additional study showed, that out of the 1500 respondents, 17% reported that disruptive
behavior resulted in, patients experiencing pain or prolonged pain, delays in treatment,
misdiagnosis, mistreatment and death, (McNamara, 2013, p. 538). A separate study
conducted by Rosenstein and Naylor using 237 respondents revealed that 32.8% of
respondents felt as if disruptive behavior could be the cause of an adverse event and

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12.3% thought it could be linked to a patient death (2012). In addition, the majority of
respondents indicated that they believed patient satisfaction was strongly affected by
these behaviors. A particularly interesting question that was posed examined whether the
respondents knew of a specific circumstance in which disruptive behavior resulted in an
adverse patient event. Thirteen percent of the group responded positively to the question
(Rosenstein & Naylor, 2012). What many of these studies failed to address is the fact
that the patient can also be robbed of therapeutic communication and positive nursepatient interactions due to these behaviors.
The Impact of Disruptive Behaviors on Nurses
Although the argument to stop lateral violence in the hospital setting is perhaps
best won through looking at its impact on the patient, its impact on nurses is nothing less
than substantial. According to Embree and White, lateral violence can result in, low
self-esteem, depression, self-hatred, negative patient outcomes, and feelings of
powerlessness, (2010, p. 171). Additional consequences include damaged relationships
and a decrease in cooperation (Embree & White, 2010). Workplace bullying can also
cause nurses to feel angry, to have increased absences from work, and even to engage in
suicidal behaviors (Becher & Visovsky, 2012). The cost of these behaviors are
estimated to be between $30,000 and $100,000 each year per individual due to increased
turnover, decreased performance in the workplace and absenteeism. These high costs and
turnover rates have devastating effects to the profession, as it contributes to the nursing
shortage and can cause financial complications for hospitals (Becher & Visovsky, 2012).
A Personal Story

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During one of my rotations to the neonatal intensive care unit (NICU), I witnessed
a conflict between two registered nurses while report was being given. On this particular
day, I had been assigned to extern with Nurse Betty during the morning shift. Towards
the very end of our shift, a nurse who was very new to the unit, Nurse Paula, arrived and
awaited report on the three infants. Upon seeing Nurse Paula, Nurse Betty turned around
and walked toward the babies to do her final assessments. It was instantly clear to be that
a friendly relationship did not exist between the two nurses. Nurse Betty did not sit down
to give Nurse Paula report until just five minutes before she was due to be off the clock.
The report was unemotional, short, undetailed and listed several duties that Nurse Paula
was to perform. One of these tasks included taking a baby down for a diagnostic
procedure that would last approximately 20 minutes. Hospital policy requires a
registered nurse to stay with infants from the NICU at all times, which, in turn, requires
another nurse to watch over the two additional babies in the assignment. Nurse Paula
was instantly frustrated, and asked Nurse Betty to stay in the unit while she took the baby
down for the procedure. Nurse Betty stood up, began to walk out of the room, and stated
that she is not going to stay because its not her job to do so.
About one month after this shift, I returned to the NICU to find that Nurse Paula
resigned, and found employment elsewhere.
Solutions
The elimination of disruptive behaviors and conflict in the health care setting
cannot be achieved until a solution is established and implemented. The following are
proposed solutions that correspond with the budget that is attached below. The
approximate cost of the proposed solutions will be $42,430.

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The 2008 Sentinel Event released by the Joint commission requires all hospitals
and organizations to create, a code of conduct that defines acceptable and disruptive and
inappropriate behaviors, and to, implement a process for managing disruptive and
inappropriate behaviors, (The Joint Commission, 2008, Existing Joint Commission
requirements section, para. 1). The first step in eliminating disruptive behavior is to
create and manage this code of conduct. This code of conduct needs to contain a
detailed account of all of the behaviors that will be considered disruptive by the
institution (Longo, 2010). In addition, it needs to address every employee of the
institution as well as nonemployees such as physicians, and must be directed towards
each and every situation, where there is a possible preach, (Longo, 2010, Addressing
disruptive behaviors section, para. 3). All management team members must model the
standards set by the code and enforce it when necessary. It is also essential that the
employees be made aware of the fact that the code of conduct will contain zero-tolerance
policies for certain behaviors. This awareness is important because all employees must
understand the expectations of the organization in order to be held accountable for
breaching them (Longo, 2010). To achieve this understanding, handouts of the code of
conduct should be printed out and distributed into employee mailboxes, and be posted in
conference rooms, and other areas of gathering. Once the code of conduct is created, a
process must be established for dealing with situations in which the code of conduct is
breached. A group of physicians and nurses should create guidelines for confronting
disruptive behaviors. According to Longo, one of the most important aspects of
developing a code of conduct is the enforcement and follow through aspects that are to be
used when codes are breached (2010).

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An additional solution will involve educational programs for individuals holding

management positions that will cover how best to deal with disruptive behaviors. One
study revealed that many nurses do not feel that they have the support of their managers
in dealing with disruptive circumstances (Longo, 2012). Managers must be approachable
and create a trusting environment in which nurses do not fear retaliation for reporting
disruptive behavior. These classes can help managers in facilitating this atmosphere of
trust. Hospital managers can work to create a consistent and well-organized approach for
reporting these behaviors (Rosenstein & Naylor, 2012). Rosenstein and Naylor
recommend creating an interdisciplinary team who will be responsible for reviewing the
reports, and taking appropriate action (2012). Managers must also be trained in coaching
and mentoring strategies for dealing with the behavior. According to Longo, coaching
involves addressing behaviors through, communicating the need for change, and by
having the person commit to change, (Longo, 2010, Addressing disruptive behaviors,
para. 6). In addition, acting as a mentor can offer reinforcement and support for
employees going through the intervention (Longo, 2010). The proposed educational
programs will address the above information and encourage input from all attendees.
A third and final solution will involve an educational program regarding effective
communication for all staff. The Joint Commission states, in their sentinel even
regarding disruptive behavior, that safe and high quality care are dependent on
collaboration, communication and fellowship in the workplace (The Joint Commission,
2008). In addition, this sentinel event encourages, inter-professional dialogues, and,
moving forward through improved collaboration and communication, (The Joint
Commission, 2008, Other Joint Commission suggested actions section, para. 10). The

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proposed educational program will involve communication training, aimed at improving

effective communications in order to improve team functioning (Saxton, 2012).
According to Longo, there are eight skills that are crucial in communication: active
listening, the use of open-ended questions, the use of closed-ended questions, gaining
clarification, paraphrasing to interpret meaning, the use of facilitators, assessing the use
of non-verbal language, and using silence when appropriate (2010). Part of this
education can involve performing self-evaluations to increase awareness of ones
personal communication skills, and also of ineffective skills, so that they can be approved
upon. Longo also notes that in addition to possessing the essential communication skills,
ones must have a desire to communicate. He goes on to note that, specifically, nurses and
other health care team members often have concerns confronting co-workers and
physicians (Longo, 2010). These educational classes can also address this aspect of
communication and assertiveness skills can be fostered through creating awareness. If
the use of assertiveness is displayed in friendly and safe environments, perhaps
employees will feel more comfortable using them in the workplace.
Conclusion
Disruptive behavior has become a common practice in health care environments.
The reasons behind these behaviors differ from individual to individual, but are all
completely unacceptable. To eliminate these behaviors, which result in adverse
outcomes for patients and emotional distress for nurses, we must implement a code of
conduct, and educate both our nursing leaders and the rest of the staff regarding ways to
deal with them. Much can be learned through examining the faults of our current nursing
environment, and we can use this knowledge to implement a change for the future.

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References

Assessment Technologies Institute. (2013). Nursing leadership and management (6th

ed.).
Becher, J. & Visovsky, C. (2012). Horizontal Violence in Nursing. MEDSURG Nursing,
21(4), 210-214.
Coursey, J. H., Rodriguez, R. E., Dieckmann, L. S., & Austin, P. N. (2013). Successful
implementation of policies addressing lateral violence. AORN Journal, 97(1),
101-109. doi:10.1016/j.aorn.2012.09.010
Embree, J., & White, A. (2010). Concept analysis: nurse-to-nurse lateral violence.
Nursing Forum, 45(3), 166-173. doi:10.1111/j.1744-6198.2010.00185.x
Lachman, V. D. (2015). Ethical Issues in the Disruptive Behaviors of Incivility, Bullying,
And Horizontal/Lateral Violence. Urologic Nursing, 35(1), 39-42.
Longo, J. (2010). Combating disruptive behaviors: Strategies to promote a healthy work
environment. Online Journal of Issues in Nursing, 15(1).
McNamara, S. A. (2012). Incivility in nursing: unsafe nurse, unsafe patients. AORN
Journal, 95(4), 535-540. doi:10.1016/j.aorn.2012.01.020
Rosenstein, A. & Naylor, B. (2012). Incidence and impact of physician and nurse
disruptive behaviors in the emergency department. Administration of Medicine,
3(1), 139148. doi: 10.1016/j.jemermed.2011.01.019
Saxton, R. (2012). Communication skills training to address disruptive physician
behavior. AORN Journal, 95(5), 602-611. doi:10.1016/j.aorn.2011.06.011
Shuss, S., Kelton, D., Lockhart, L., Davis, C. (2015). Resolve conflict with style.

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Nursing Made incredibly Easy!, 26-32. doi: 10.1097/01.NME.0000460362.73

422.52
The Joint Commission. (2008, July). Behaviors that undermine a culture of safety (Issue
brief No. 40).

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Appendix A

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