A Policy to Deal with Disruptive Staff Members

Disruptive behavior by any member of the oncology team can sabotage professionalism and has clinical, operational, and economic consequences. The interdisciplinary team becomes less productive and creative. At best, work is not as exhilarating as it could be. In the worst-case scenario, working becomes filled with anxiety. When caregivers tolerate disruptive behavior from a member of the oncology team, the patient is the loser. Patients with cancer are dealing with intense fear and feelings of isolation. If their caregivers are emotionally unavailable and distracted by the behavioral ups and downs of a colleague, that sense of isolation will be intensified. The possibility also exists that important clinical information will be missed because the attention of the staff is not where it should be.
Cancer caregivers cannot develop strong therapeutic teams without a policy for dealing with disruptive behavior. The delivery of cost-effective, humane cancer treatment requires the healing or removal of disillusioned, angry, or “disruptive” professionals from direct patient care.

While no single definition of disruptive behavior exists, most authorities agree such behavior undermines practice morale, increases staff turnover, sabotages effective teamwork, increases the risk of ineffective care, and causes distress to peers, staff, patients, or others in the practice.

Disruptive behavior includes bullying, abusive language, shaming others for negative outcomes, criticizing team members in front of others, and threatening a team member with retribution, litigation, violence, or job loss.(See case studies on page 20). Disruptive individuals rely on intimidation to accomplish their goals and refuse to honor cultural differences. A disruptive staff member may also violate personal boundaries or refuse to comply with clinical practice standards.

The consequences to the disruptive individual may be severe,2 including loss of privileges, employment, and employability. He or she may be at increased risk of lawsuits from disgruntled colleagues and patients, or become “isolated” from colleagues and experience increased workloads because other team members will not provide assistance and support.

CAUSES OF DISRUPTIVE BEHAVIOR

Working in the field of oncology creates stress on its own, irrespective of what might be happening in a colleague’s personal life. Cancer care practices are stages on which an inordinate number of dramas are played out. Suffering, loneliness, intractable pain, and “bad things happening to good people” are all part of an oncology staff’s daily lives. This stress may aggravate pre-existing personality traits so that, for example, distrust evolves into hypercritical behavior or perfectionism.

Oncology practices need to acknowledge the stress inherent in dealing day after day with the needs of critically ill and dying people, and should offer their staff members ways to deal with these stressors.

Do not assume that an alleged disruptive professional has a psychiatric or psychological problem. Disruptive behavior can also be caused by stress syndromes or physical diseases, such as poorly-controlled diabetes, thyroid disorders, undiagnosed tumors, hearing loss, and so on.

Cultural differences are also worth exploring. For instance, personal space boundaries are smaller in the South than in the northern part of the country. A practitioner from a southern state may unknowingly offend northern coworkers without meaning to by standing “too close” to them.

PREVENTIVE STRATEGIES

Preventing disruptive behavior is as important as learning how to manage the problem once it occurs. Hiring outside experts to teach interpersonal skills and conflict management is a good investment for any oncology facility. The most cost-effective way to prevent disruptive behavior is to address the root causes of the behavior. One valuable method to help professionals cope with occupational stress is to get them to participate in facilitated staff support groups. Support groups have proved to be one of the best ways to prevent burnout and keep behavioral problems from becoming toxic.

Unfortunately, physicians tend to be so fearful of self-disclosure among peers that they don’t take advantage of such groups, even litigation support groups. When oncologists don’t receive the natural relief and revitalization provided by collegial support, this lack of respite may result in unresolved distress and resentment being discharged on their staff.

The problem needs to be addressed in your work culture. Clear messages should be communicated to your physicians that, within the confines of the cancer program or practice, self-disclosure, expressing fears, and asking for support will be considered healthy behaviors and will be met with caring and concern.

DIFFICULTIES IN HANDLING DISRUPTIVE BEHAVIOR

In spite of these efforts, there will always be people whose personal problems make difficulties between them and their coworkers.

Since many disruptors refuse to acknowledge the harmful impact of their behavior on others and do not respond to timely, private, and direct feedback, confrontation usually becomes necessary. Most people don’t want to confront a disruptive individual because they are afraid the disruptor’s anger will escalate or, if the disruptor is high in the institutional hierarchy, that the disruptor will abuse his or her power and terminate the confronter’s employment. Fear of an increased workload if the disruptor is fired also encourages tolerance.

Tolerating disruptive behavior usually results in a higher turnover rate in the clinic staff and a poorer quality of patient care. For the sake of the patients alone, each workplace must create and implement standardized ways of dealing with individuals that cause problems for the practice.

DEVELOP PROFESSIONAL BEHAVIOR GUIDELINES AND POLICIES

A cancer program that focuses on professionalism and sets up positive standards of behavior lets staff members know what is expected of them. These standards should focus on both interpersonal and professional/practice expectations, and should be reviewed by the staff members who will be expected to comply with them. The agreed-upon standards should also be clearly communicated to all members of the staff, including new staff when they arrive, and should be enforced fairly and on a regular basis.

The following is a partial list of reasonable professional behavior guidelines for staff members. Add to them according to the values of your practice culture. Staff members should:
 Comply consistently with practice standards for professionalism
 Communicate with colleagues clearly and directly, displaying respect for their dignity
 Support policies promoting cooperation and efficient teamwork
 Use conflict resolution and mediation skills to manage disagreements
 Address concerns about clinical judgments with team members directly and in private
 Address dissatisfaction with practice policies through appropriate grievance channels
 Routinely offer and accept constructive feedback.

In a cancer center, the first step in developing a disruptive behavior policy is to decide what behaviors are considered disruptive, what consequences should be imposed on people who indulge in these behaviors, and how the consequences will be enforced. Answering the following questions will help you define what kind of policy your practice wants to implement.

 What single incident or patterns of behavior warrant use of the policy?
 Who should be responsible for initiating contact with an allegedly disruptive person?
 What consequences are available for dealing with disruptive individuals at each level in your staff hierarchy, and in what order do you want to apply them?
 How will you consistently enforce these consequences?
 Will you use performance appraisals as opportunities to discuss interpersonal behavior?
 In the hospital setting, how will you work with disruptive independent contractors, such as contract radiation oncologists?
 In the practice setting, is there an equitable professionalism policy for all staff members?
 Does your policy allow and reinforce mediation?
 Does your policy allow and fund efforts to find rehabilitation resources?
 Is the existence of outside resources for rehabilitation known to allegedly disruptive staff members?
 Are consistent rules in place to handle an alleged or verified disruptor who refuses help?
 After rehabilitation, is there a policy in place for reentry transitioning?
 Has your grievance policy been reviewed by your legal counsel and interpersonal skills correction experts?
 Is there enough money so that the practice can defray the cost of corrective services if they become necessary?

The answers to these questions will help shape a sound disruptive behavior policy. Many of our clients have found it helpful to read sample policies from similar practices or cancer care centers when they are trying to establish their own standards, but do not assume that another practice or center’s policy can automatically be transferred to your facility. Your definition of professionalism and policy transgressions is a culturally intimate decision. Just make sure the policy deals with behavioral expectations, methods of confrontation, the grievance process, assessment tools, treatment choices, sanctions, and re-entry into the system.

When fair disruptive behavior policies exist, disruptive professionals are helped to correct their behavior through a variety of mechanisms, including peer counseling, reading, support groups, and outside professional help. They usually respond to these aids and become functioning members of the practice once again.

SAFEGUARDS

Any system, no matter how well set up, is open to abuse. In our work, we have seen too many cases where disruptive behavior policies were used by jealous economic competitors, estranged spouses, or angry partners to harm innocent individuals. We were once involved in a case where a hospital administrator manipulated an investigative board to force a powerful, competing physician off the staff. It is not at all uncommon for litigious physicians to use the threat of a lawsuit to thwart or delay confrontation about their behavior.

Talk to your risk manager and legal counsel to develop a good disruptive behavior assessment policy with adequate due process protection.4 Whether you add up incident reports or interview complainants, make sure your process is fair.

If necessary, call in outside help. We recall several cases where serious allegations were made and outside assessment discredited the allegations.

Outside assessments can occur on site or off site. Our organization, the Center for Professional Well- Being (CPWB), is a 501(c)3 non-profit educational organization devoted to promoting well-being among health care professionals through educational, consulting, and advisory programs and services. Visits are made to groups and practices, and services and programs are tailored to the needs of clients. Off-site programs include retreats, lectures, seminars, and consulting services. CPWB assesses and helps remediate “disruptive” behavior using a supportive, non-psychiatric, skills development model. Among other services, we offer seminars and workshops on anger management, assertive communication, conflict resolution, and medical partnership relationship building.

At CPWB, we usually collect data on site when major discrepancies exist between the stories of the complainant and the alleged disruptor, or the denial of the alleged disruptor is so great that a neutral party must be called in to mediate.

An equitable and effective grievance procedure must be structured into the framework of your policy, and both sides of a problem must be explored.4 If a physician believes his or her outburst was triggered by the administration’s intractable resistance to legitimate requests for equipment, this allegation must be looked into and corrected.

Treating each alleged case of disruptive behavior as a special entity is no longer acceptable. Many risk managers can relate stories replete with aggravation, staff anger, unexpected job turnover, and threatened litigation. The problem is pervasive and emotionally and financially costly.

Of course facility leaders must investigate and correct the aggravating aspects of their cancer program or practice that promote frustration and acting out; but the best way cancer care centers can prevent or reduce difficult behavior on the job is by creating and enforcing strong, positive professional behavior standards and crafting fair disruptive behavior policies to manage, confront, and rehabilitate people who interfere with the healthy functioning of a work group.

Within professional groups one must 1) define reasonable and competent interpersonal behavior; 2) offer educational opportunities to improve communication, increase interpersonal skills, and learn how to manage conflict; and 3) fairly assess, offer feedback, confront, and attempt to correct interpersonal deficiencies when they cause problems in the workplace.

by John-Henry Pfifferling
Oncology Issues
May/June 2003
Volume 18, Number 3