Addressing Disruptive Behavior from a Leadership and Organizational Perspective

How can you address disruptive behavior from a leadership and organizational perspective?

Until The Joint Commission established a performance standard in 2008, disruptive behavior was largely tolerated, ignored, and even condoned. The sentiment about what to do about disruptive behavior is changing in the boardroom and executive suite. This is good news. With this changing attitude, organizational interventions are being designed and implemented, ranging from management to training programs to establishing processes for reporting disruptive behavior. For busy healthcare executives and board members, several best practices will be shared as illustrative cases. Furthermore, specific lessons learned from these cases will be highlighted as the foundation for developing your own organization-wide disruptive behavior plan.

I. LEADERSHIP

Healthcare executives need the knowledge and skill to establish an organizational culture that supports prevention and management of disruptive behavior. Where does this come from? Who’s responsible for implementing these strategies? The ultimate fulfillment of your organization’s policy objectives requires an organization-wide development and commitment to:

1. Routinely disseminating your code of conduct and monitoring compliance.

2. Reviewing and learning lessons from collected data on previous incidents of disruptive behavior, i.e., post mortem analysis.

3. Developing leadership skills for managing disruptive behavior.

4. Creating processes for managing disruptive behavior.

5. Maintaining leadership unity on interventions and fostering a team approach in your organization.

6. Encouraging individuals to report disruptive behaviors and having simple means for reporting and investigating all allegations promptly and thoroughly.

7. Giving timely feedback on all complaints submitted.

8. Conducting periodic surveys on the organizational climate or culture.

As a leader of an organization, you are continually communicating your ethics, values, and beliefs. This occurs by modeling the mission and reinforcing the cultural norms you have set and reinforced in your life. Your ability to collaborate and validate individuals allows others to be in relationship with you and assist in defining the shared purpose of the organization. This ultimately creates your expectations, communicates your tolerance and forgiveness within your system, rewards inter-dependency, and enhances growth.

You must maintain your focus on your mission to make your organization safe. Members and other institutional forces can create tension that can lead you to being distracted. For example, others may sabotage your goals or interventions by not following through with your directives or responding to your policies in a passive-aggressive manner. You may begin to unconsciously delegate tasks you are less comfortable with or those for which you possess the least skill set. Remember, if you are unsure of yourself given the high level of emotional energy required when dealing with disruptive behaviors, always fall back on your written policies/procedures and consult. You are not alone. You may need to commit extra effort, resources, and energy to the tasks that reinforce and demonstrate your principles. Your persistent motivation to disseminating organizational expectations will create a system-wide acceptance of your continuously defined mission.

Try these:

• You could attend or facilitate, in person not via technology, some portion of the code of conduct sessions and enact a role play with a staff member.

• You could share data of the number of hours committed to prevention and a flowchart on the management of disruptive behavior.

• You could offer examples of both victories and failures during the past year.

• You could communicate the established norms of routinely monitoring all members and introduce the support for all, given the pervasive impact of these behaviors.

• You can integrate current monitoring cases/events, data/research, and the latest technology when reinforcing your policies.

• You can validate the complex nature and communicate the changes expected of each member’s core beliefs and values. You will be challenging them to grow by having them interpret, define, effectively regulate themselves, manage their beliefs, and act in positive/controlled manner despite being confronted with these stressful situations.

• You can practice life balance in your professional and personal life, e.g., respect time boundaries, manage meetings efficiently, practice being ”in the moment” throughout the day, balance nutrition and exercise, actively listen and respond, etc.

Some of these may seem irrelevant, but remember you are the main communicator and catalyst for all to “buy in.” Sticking with your leadership guidelines and holding everyone accountable is one of the core expectations people/employees have of you and illustrate the effectiveness of your leadership. Encourage others to remain engaged and connect with members of your leadership team who support your efforts. Practicing these leadership qualities is an arduous task that can be divisive of your team and can lead to your feeling alienated from others. Therefore, accept that you need assistance, support, and guidance at times. You may need to rely on experts in times of crisis or when restructuring your organizational behavioral systems. Again, you will be modeling acceptance of feedback and openness to outside resources to troubleshoot systemic impasses.

In The Joint Commission’s publication, Defusing Disruptive Behavior: A Workbook for Healthcare Leaders, numerous elements of performance (EPs) provide you as a leader with clear expectations and guidelines for the management of disruptive behavior. For example, “Each leadership component contains active members who are competent, or the components have access to individuals with such competency, in the following…” This includes:

• Identifying and resolving conflict.

• Assessing processes from a system-based perspective.

• Working with team-based concepts.

• Making decisions based on evidence.

• Fostering an environment of mutual respect for other team members.

Here is where your leadership gets tested, as you are required to make sure “training is made available to all leaders for each of these skills.” This requires you and your executive team to model productive and respectful communication, congruency, cultural expectations, a commitment to tasks, accountability of all members, interdependency, and healthy confrontation/conflict resolution skills. These are not simple skills to master.

You will struggle when encountering some of these situations as you bring a lifetime of habits and experiences to the table. Your response often will be automatic. You are influenced by your developmental experience with conflict, your observational learning of conflict, your historical sympathetic responses to conflict, your history of negotiating conflict, and your current mental health status. You are expected to be prepared and capable of appropriate responses at all times. This is a formula for failure, as all leaders are vulnerable. The stressors associated with the human life cycle have no boundaries or champions. Therefore, continually monitor your process of responding and be open to external feedback. Be prepared to make mistakes and to be presented with situations or scenarios you have never encountered before. Consider these common leadership errors from the Defusing Disruptive Behavior Workbook when responding to disruptive behaviors:

1. Hoping the problem will work itself out without any active effort. “Let’s just wait a while to see what happens; maybe it’ll work itself out.” Do not act prematurely, but once you are sure a staff member is being disruptive, act immediately.

2. Not taking the first step. Before you do anything else, determine the cause of the disruptive behavior. Like depression and dementia, disruptive behavior is a descriptive catchall term. Sudden outbursts of uncontrollable anger can be due to a brain tumor. They can also be caused by high-liability insurance premiums or a heavy-handed executive management style. Design strategies to deal with the causes of disruptive behavior.

3. Trying to prove that the disruptive staff member is incompetent. When the problem is substandard clinical performance, collect data about clinical practice. When the problem is disruptive behavior, carefully document the time and details of incidents judged to be disruptive. There is a difference between the two, and it may not be possible or advisable to try to link the two together.

4. Inadvertently using pejorative language when trying to deal with the behavior. Resolving an issue can be especially difficult if the language used to deal with the problem becomes a barrier in and of itself. For ex-ample, saying something like “Look, Doc, we’re just trying to help you here” could be seen as pejorative or demeaning and inflame an already tense situation. For many physicians, for example, “Doc” is a disrespectful term.

5. Going to the medical staff bylaws or staff guidelines/policies and/or using legal means to deal with the problem. While a disruptive person may eventually leave you no choice but to impose administrative and legal remedies, the first step in dealing with disruptive behavior should be constructive confrontation.

6. Giving certain kinds of staff special treatment. “Yes, I know he pushed one of the nurses the other day in the OR, but he’s one of our best surgeons.” If some employees or staff are given wide latitude and tolerance for types of disruptive behavior, while others are immediately penalized (and even terminated) for the same or similar behavior, it can create a demoralizing work environment that sends the message that some staff are “above the law.” It also communicates to colleagues of the staff members who get special treatment that they may also be afforded the same privilege, which can perpetuate the broader acceptance of disruptive behavior.

7. Trying to conceal the problem from the board. While the presence of a disruptive staff member may not reflect negatively on performance, hiding information from the board can. Advise the board about the problem as soon as possible, before they learn about the problem from elsewhere.

8. Bringing in external consultants and turning the whole matter over to them. It may be necessary to look outside the organization for skills and expertise to help assess, advise on, resolve, and solve the problem, but this must be combined with leadership support and active involvement. Outside resources may be a great help in solving a problem, but the driving force and leadership to really resolve the issues must come from within the organization.

9. Believing that disruptive behavior is forever. It is possible that some staff members’ behaviors or actions are so egregious or damaging that it is not suitable or possible for them to practice or work at the organization again. But for the most part, many staff members can work through their issues and successfully remain on staff and viable to the organization. An organization’s policy and approach to disruptive behavior should take into consideration reinstatement, rehabilitation, and reintegration into the work environment. It should also acknowledge when behavior is overcome and improved upon.

II. ORGANIZATION

What is your organization’s comfort level with conflict? Is it similar to your style? How is blame attributed within your system? Are there certain types of conflicts that are repeated? Does this tension lead to emergent change regarding patient care, productivity, morale, etc.? Are individuals the focus of change when conflict is present? These are some of the means by which your organization communicates its values. Ideally your organization should accept and embrace conflict because this defines growth. Your organization’s feedback loop is a sign of life and vitality. Imagine a living cell where nutrients are passed through the membrane and growth and adaptation are required for survival. This disruption leads to new insights, creativity, awareness, and freedom.

You are creating a level of comfort and placing expectations on the members of your organization. Each individual has a job description. The organization has policies and procedures with accompanying flowcharts. The leaders have dashboards and strategic plans as their set of core competencies. This sets the vision and defines desired behaviors. The ability to deal with conflict has been clearly communicated through training sessions, and individuals are informed about their choices. This repertoire of conflict prevention, management, and resolution should be integrated into your core competencies. You are required to offer ongoing structural support by having good listeners and those that can offer procedural advice. Some staff may need direction provided to handle difficult situations and rehearse responses. Finally, you must provide rewards and consequences for everyone with a monitoring of performance when you expect change. You will have greater leverage and higher expectations for conflict management when you are tracking outcomes. Ultimately this leads to earlier resolutions and healthier systems.

You may consider external mediation services available for both individuals and teams that are experiencing conflict. They can offer skills training in the areas of communication, negotiation and conflict resolution, team building, branding, coaching, and team management. This may challenge your appreciation for the value of conflict and force you and your stakeholders to reframe this as an opportunity.

Excerpted from Taming Disruptive Behavior by Marty Martin, PsyD, MPH and Philip Hemphill, PhD, LCSW.

References

1. The Joint Commission. (2007). Diffusing Disruptive Behavior: A Workbook for Healthcare Leaders. Oak Brook Terrace, IL: The Joint Commission.