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Spring/Summer 2012

A Renewed Call to 'Do No Harm'

Date: May 14, 2012

A Renewed Call to 'Do No Harm'

Taking the form of incivility, psychological aggression, and physical violence, disruptive behavior is a persistent and complex problem among doctors and nurses, according to a recent clinician study aimed at understanding the causes of such misconduct at Johns Hopkins.

While disruptive clinicians at Hopkins Hospital don’t pose an immediate physical threat to patients, the study found a link between poor workplace manners and poor patient and staff well-being, note co-investigators Deborah Dang, director of nursing at Hopkins Hospital; Jo Walrath, an associate professor in the School of Nursing; and Dorothy Nyberg, a study coordinator in the Department of Nursing.  

In the 12 months prior to taking the Web-based survey, 85 percent of the doctors and nurses who responded had personally experienced disruptive behavior and 73 percent had seen a coworker fall victim to treatment that ranged from passive aggressive conduct to physical violence. Perhaps surprisingly, physicians and nurses reported the highest levels of misconduct within their own professional ranks. In response to the survey, for example, one physician described a senior faculty member’s routine conduct: “rude, condescending, abusive, throws things … yells at patients and staff.”

The multi-phase Hopkins study is the first to bring a systematic approach to identifying and rectifying bad behavior among clinicians, say the researchers. “What we found from the literature and our research is that the phenomenon can’t simply be explained as an off-the-cuff occurrence without a discernible root cause,” says principal investigator Dang.

Ignited by triggers such as high-stress working conditions, and fatigue, disruptive behavior is perpetuated by the silence of both victims and bystanders, the study found. Even when poor conduct puts a patient’s condition at risk, 18 percent of survey respondents said they didn’t speak up. Also notable: Of 1,559 respondents, 40 percent indicated that acceptance of the bad behavior of others was part of their job.

This tacit “code of silence” practiced by physicians and nurses protects errant clinicians, hampers communication, and allows hazardous conditions to escalate, the investigators say. To crack the code, the investigators presented their findings to top leaders at the School of Medicine and the Hospital, who gave the green light to develop a broad-based plan that would require managers at every level to “set expectations and act as role models to their staffs,” Nyberg says. 

Convened in response to the study, the Professionalism in Practice Steering Committee (PIP), composed of clinical and administrative leaders as well as frontline caregivers, has been charged with developing a series of interventions to make it safe to speak up in the face of disruptive clinician behavior, provide staff with the necessary communication skills for doing so, and establish a culture of mutual accountability, respect, and collegiality.  Stephanie Shapiro