Disruptive behaviour in the perioperative setting: a contemporary review
- 3.7k Downloads
Disruptive behaviour, which we define as behaviour that does not show others an adequate level of respect and causes victims or witnesses to feel threatened, is a concern in the operating room. This review summarizes the current literature on disruptive behaviour as it applies to the perioperative domain.
Searches of MEDLINE®, Scopus™, and Google books identified articles and monographs of interest, with backreferencing used as a supplemental strategy.
Much of the data comes from studies outside the operating room and has significant methodological limitations. Disruptive behaviour has intrapersonal, interpersonal, and organizational causes. While fewer than 10% of clinicians display disruptive behaviour, up to 98% of clinicians report witnessing disruptive behaviour in the last year, 70% report being treated with incivility, and 36% report being bullied. This type of conduct can have many negative ramifications for clinicians, students, and institutions. Although the evidence regarding patient outcomes is primarily based on clinician perceptions, anecdotes, and expert opinion, this evidence supports the contention of an increase in morbidity and mortality. The plausible mechanism for this increase is social undermining of teamwork, communication, clinical decision-making, and technical performance. The behavioural responses of those who are exposed to such conduct can positively or adversely moderate the consequences of disruptive behaviour. All operating room professions are involved, with the rank order (from high to low) being surgeons, nurses, anesthesiologists, and “others”. The optimal approaches to the prevention and management of disruptive behaviour are uncertain, but they include preventative and professional development courses, training in soft skills and teamwork, institutional efforts to optimize the workplace, clinician contracts outlining the clinician’s (and institution’s) responsibilities, institutional policies that are monitored and enforced, regular performance feedback, and clinician coaching/remediation as required.
Disruptive behaviour remains a part of operating room culture, with many associated deleterious effects. There is a widely accepted view that disruptive behaviour can lead to increased patient morbidity and mortality. This is mechanistically plausible, but more rigorous studies are required to confirm the effects and estimate their magnitude. An important measure that individual clinicians can take is to monitor and control their own behaviour, including their responses to disruptive behaviour.
KeywordsDisruptive Behaviour Cognitive Appraisal Frequent Instigator Correlational Research Workplace Harassment
Les comportements perturbateurs dans le contexte périopératoire: un compte rendu contemporain
Les comportements perturbateurs, que nous définissons comme des comportements qui ne montrent pas à autrui un niveau adapté de respect et qui provoquent, chez les victimes ou les témoins de tels comportements, un sentiment de menace à leur égard, sont une préoccupation en salle d’opération. Ce compte rendu résume la littérature actuelle concernant les comportements perturbateurs telle qu’elle est applicable dans le domaine périopératoire.
Des recherches sur Medline, Scopus et Google livres ont identifié les articles et monographies dignes d’intérêt, et nous avons également consulté les références de ces articles pour supplémenter nos recherches.
La plupart des données proviennent d’études hors de la salle d’opération, et comportent d’importantes limitations méthodologiques. Les causes des comportements perturbateurs peuvent être intra-personnelles, interpersonnelles et organisationnelles. Alors que moins de 10 % des cliniciens sont perturbateurs, jusqu’à 98 % rapportent avoir été témoins de comportements perturbateurs au cours de la dernière année, 70 % rapportent avoir été traités avec impolitesse, et 36 % rapportent être victimes d’intimidation. Les conséquences négatives sont nombreuses pour les cliniciens, les étudiants et les établissements. Bien que les données factuelles concernant les pronostics des patients se fondent principalement sur les perceptions des cliniciens, des anecdotes et des opinions d’expert, ces données soutiennent l’affirmation d’une morbidité et d’une mortalité accrues. Les mécanismes plausibles pour expliquer l’augmentation de la morbidité et de la mortalité comprennent le fait de saper tant le travail d’équipe, que la communication, la prise de décision clinique et la performance clinique. Les réactions comportementales des personnes exposées peuvent mitiger, de façon positive ou négative, les conséquences des comportements perturbateurs. Tout le personnel de la salle d’opération est impliqué, selon l’ordre suivant (du plus perturbateur au moins perturbateur): chirurgiens, personnel infirmier, anesthésiologistes et « autres ». La meilleure façon de prévenir et de gérer les comportements perturbateurs est incertaine, mais comprend: des cours de formation préventive et professionnelle, des formations en compétences non techniques, la formation en travail d’équipe, des efforts institutionnels pour optimiser le lieu de travail, des contrats de cliniciens décrivant les responsabilités du clinicien (et de l’établissement), des politiques institutionnelles supervisées et appliquées, des rétroactions fréquentes sur la performance, et le coaching et la remédiation du clinicien, si nécessaire.
Les comportements perturbateurs font encore partie de la culture de la salle d’opération, et s’accompagnent de nombreuses conséquences délétères. Une croyance bien ancrée veut que ces comportements perturbateurs puissent potentiellement entraîner la morbidité et la mortalité des patients, ce qui est possible d’un point de vue mécaniste. Toutefois, des études plus rigoureuses sont nécessaires pour confirmer ces effets et estimer leur ampleur. Une mesure importante que chaque clinicien peut prendre est de surveiller et de contrôler son propre comportement, y compris ses réactions aux comportements perturbateurs.
Disruptive behaviour is a term used for a range of unacceptable clinician actions, including incivility, bullying, and harassment.1 There is increasing evidence that these types of behaviour decrease the well-being of clinicians,2-14 negatively affect healthcare institutions,2,7,8,10,13-20 and may even undermine the quality of patient care.2,6,8,12,14,21-26 As a result, the Joint Commission on the Accreditation of Hospital Organizations (JCAHO) issued a sentinel alert recommending that institutions address disruptive behaviour in order to ensure high-quality care.26 Similarly, the Lucian Leape Institute recently reported that disruptive behaviour is a barrier to creating a work environment that is both safe for clinicians and facilitates good patient care.14
This review highlights how the current literature on disruptive behaviour applies to the perioperative domain and identifies experts’ recommendations to prevent and manage these behaviours. Wherever possible, we highlight the nature of the evidence that supports our understanding. Although much of the literature is based on opinion and perception, we attempt to give less credence to these sources of evidence when making recommendations.
Definitions of disruptive behaviour by some prominent healthcare associations
Canadian Medical Protective Association
Can interfere with communication between team member or with patients, and may negatively affect patient care and patient satisfaction109
• Dismissive comments
• Good faith patient advocacy
• Derogatory comments
• Professionally written alerts
• Insensitive, uncaring, callous attitudes
• Complaining to an outside agency
• Inappropriate language
• Testifying against colleagues
• Angry outbursts
• Demeaning conduct
• Condescending conduct
• Aggressive conduct
• Boundary issues
Council on Ethical and Judicial Affairs, American Medical Association
Verbal or physical conduct, that does, or may, negatively affect patient care110
• Foul language
• Good faith criticism
• Threatening language
Joint Commission on Accreditation of Hospital Organizations (JCAHO)
Conduct that intimidates others to the extent that quality and safety are compromised 111
• Verbal outbursts
• Physical threats
• Refusing to perform assigned tasks
• Quietly exhibiting uncooperative attitudes
• Reluctance to answer questions
• Condescending language26
Recognition of the inherent dignity in all people (Article 1);
Freedom from discrimination and arbitrary invasions of privacy (Article 3);
Freedom from degrading treatment (Article 5); and
Freedom from attacks upon honor and reputation (Article 12).
While some previous definitions have included a criterion that the behaviour must or may undermine patient care, we excluded this condition from our definition. “Must” would make the definition too narrow, since egregious behaviour that did not undermine care would be excluded, while “may” would not narrow the definition more than the three criteria we already included.
Ubiquity and prevalence are used to estimate the occurrence of these behaviours. Ubiquity represents the proportion of clinicians who engage in disruptive behaviour, while prevalence is the number of such behaviours reported by clinicians. The estimates of ubiquity are derived from surveys and reviews of disciplinary records,9,20,33-35 while estimates of prevalence are derived from survey studies.5,8,22,23,36-48 Most studies examining many types of disruptive behaviour focus on ubiquity.
Quantitative surveys suggest that the proportion of physicians (and other clinicians) who are disruptive is less than 10%.9,20,33,35 Reviews of disciplinary records indicate a ubiquity of 6-18%,27,34 although the percentage of these cases that are truly disruptive is debatable.27 Physicians who reviewed the cases judged that less than 1% were truly disruptive, which was partly attributed to the lack of a standard definition. There is less agreement regarding prevalence, as estimates vary depending on which types of disruptive behaviour are measured, e.g., less than 1% of nurses in Thailand report sexual harassment,47 while 91% of perioperative nurses in Ohio report verbal abuse.41 Similarly, clinicians are more likely to witness disruptive behaviour than to be subjected to such behaviour. For example, 44% of nurses reported experiencing bullying in the previous year, while 50% had witnessed bullying.4 The prevalence estimate also depends on the period of time under consideration, since almost all clinicians will experience disruptive behaviour during their career, while fewer will experience such conduct in a given year. Finally, prevalence estimates depend on whether the respondents are asked how often they have experienced specific examples of disruptive behaviour, or whether they would label themselves as victims of disruptive behaviour. For example, one survey found that 84% of junior physicians reported experiencing bullying behaviour, but only 37% affirmed being bullied.49
We recently conducted a preliminary analysis of 7,465 survey responses from operative clinicians.50 Survey results showed that 7,241/7,465 (97.7%) respondents reported experiencing or witnessing at least one episode of disruptive behaviour in the past year, with the average respondent exposed to ten out of the fourteen types of disruptive behaviour measured. The results indicated that 5,233/7,465 (70.1%) respondents affirmed experiencing incivility, and 2,755/7,465 (36.9%) affirmed being bullied.
These are personality traits, psychological conditions, and transient physiological states that increase the probability of acting disruptively. These factors can reduce a clinician’s ability to deal with conflict, e.g., reduce their capacity for empathy or impulse control. Personality traits that may increase the risk include type A personality, narcissism, and passive-aggressive tendencies.13,54,57 Disruptive behaviour may be more likely displayed by clinicians with underlying depression, addiction, stress, and burnout.24,51,54,58 Even transient physiological states, such as hunger and exhaustion,51 have been implicated.
These are the conditions within a healthcare work environment that increase clinician stress13,24 and therefore increase the probability of disruptive behaviour. These include production pressures,51,52,59 resource mismanagement, supply shortages, and administrative inefficiencies.40,41,52 Working conditions may also be responsible1; for example, the operative context may comprise unfavourable conditions, such as long hours, few breaks, and large teams in cramped conditions. These factors increase stress in an additive, if not synergistic, manner.60 In particular, work stress is compounded when a high demand is placed on workers while simultaneously limiting their control over the situation.60 This is the case when workloads are increased without consulting clinicians or including them in the decision-making process.
There are characteristics of interactions between clinicians that increase the probability of disruptive behaviour.61 Clinicians may interact with the preconception that their experience, position, or expertise is superior to that of other individuals.51 This notion may cause them to treat the supposed “lesser” clinicians with a lack of respect or to exert control over them.51 Clinicians who endorse the increasingly rejected concept of medical hierarchy may be at an increased risk of interacting in this manner.51 One such hierarchy is based on occupation, where physicians (especially surgeons) have traditionally been placed at the top of this model.11,61,62 While few studies have examined the predictors of instigation beyond profession, some hierarchies related to race and sex may also influence the occurrence.63,64 Males are more frequent instigators, and black and Asian doctors are more frequently victims.27,49,65 Certain situations also increase the risk,51,59,66 e.g., an operating room in a clinical crisis.
Who is disruptive?
Acknowledging that occupation-related hierarchies exist raises the question regarding which professions are more likely to be disruptive in the operating room and with what frequency. While there is an order to the frequency of instigation between the various groups, all operative professions have been implicated.67 Nevertheless, in both qualitative and quantitative survey research, surgeons have been identified as the most frequent instigators.23,51,68 A number of factors likely explain this outcome. Personality studies have shown that surgeons score lower on agreeability measures than other physicians.69,70 While there has been a shift to more horizontal organizational structures in recent years,62 antiquated power hierarchies linger in some operating rooms. Some individuals still perceive surgeons to be at the top of this hierarchy.71 This perception likely relates to the surgeon’s length of education, often high earnings, the perception (or fact) that they bring business to the institution, and the tradition that surgery is somewhat distinct from the rest of the medical profession.72,73 There is some evidence, including preliminary findings from our group, supporting the assertion that clinicians perceive groups thought to be higher in the hierarchy as more frequent instigators.67,74 Several studies found that nurses were also perceived to be frequent instigators.23,51,67 This departs from the simple power model that would have predicted nurses be less frequent instigators.75 This may be due to a high degree of horizontal workplace harassment between members of less powerful groups.76 While the effect of occupational hierarchy should be considered, the importance of this single antecedent should not be overstated.
The cognitive appraisal of the victims and witnesses
According to psychologist Richard Lazarus, when an individual experiences or witnesses an event such as a disruptive behaviour, they unconsciously appraise the situation before responding.77 This occurs in two steps. In the primary appraisal, the individual evaluates whether the event threatens their goals, e.g., delivering patient care or maintaining a positive self-image. If the individual perceives a threat, a secondary appraisal occurs. This involves assessing the magnitude of the threat in terms of both the harm that it has done and the harm that it may cause. The individual also evaluates how they can deal with the threat and how likely these efforts are to be successful. The cognitive appraisals are important because they can modify the psychological sequelae to victims and witnesses and can help determine how they respond.
The behavioural responses of the victims and witnesses
The continuum of behavioural responses to disruptive behaviour
Strength of opposition to disruptive behaviour
Clinician uses threats, physical violence
Clinician uses aggressive verbal confrontation
Clinician works with the instigator to find solutions that benefit all
Clinician bargains with the instigator in order to find solutions that are at least marginally acceptable to all
Clinician attempts to gain favour with the offender or makes them feel guilty
Clinician manipulates the offending party into stopping
Clinician ignores or downplays situation, or avoids interacting with others
Clinician placates to the instigator
Clinician knowingly supports the behaviour
The effect on patient care
Decreased patient care due to reduced communication and teamwork
Disruptive behaviour can undermine communication in several ways. First, clinicians may communicate less1,6,11,54,56,82,83 as a means to avoid further mistreatment.84 This response may result in a decrease in transfer of clinical information6 or a delay in communication,1 both of which threaten care. If this is the recurring response and the offender is not confronted, the behaviour that was initially considered deviant may become accepted. The airline industry labels this phenomenon as normalized deviance.85 Similarly, avoidance can lead to spirals, where the parties become progressively more distant, further reducing trust.86 The link between disruptive behaviour and compromised teamwork/communication is supported by a recent study in neonatal intensive care simulation. Study results showed that rudeness led to a decrease in diagnostic and procedural performance, especially when there was a lack of information sharing and help-seeking behaviour.87
Secondly, clinicians may intentionally miscommunicate, omit information, or be deceitful.13 A recent survey found that some surgeons and anesthesiologists admitted lying to members of the other profession, most commonly about what care had been provided.88 Anesthesiologists, but not surgeons, cited that the fear of being blamed was one reason for lying.88 This confirms the suspicion that some clinicians withhold information in order to avoid criticism.8,13
Third, clinicians may communicate in an aggressive style that damages relationships. This destructive communication may spiral upward to the point where communication shifts from problem solving to personal attacks.85 Accordingly, anger and fear will increase, leading people to retaliate1; relationships will become strained and teamwork will decrease. Clinicians who adopt avoidant, manipulative, competitive, or coercive responses as a dominant strategy are more likely to display behaviour that could undermine communication and teamwork.
Root cause analyses and observational trials support the view that there is a relationship between reduced communication/teamwork and poor patient outcomes. In their 2010-2014 assessment of 4,597 adverse events,89,90 the JCAHO identified human factors, leadership failure, and communication failure as the three most common root causes. It is notable that communication failure is present in up to 65% of events (Fig. 3). In an observational study performed at two medical centres and two ambulatory surgical centres in the USA, the investigators used an established tool to quantify operating room team function.91 Poor communication increased the risk of major complications and death, independent of the American Society of Anesthesiologist’s physical status score. While causality is difficult to establish in observational trials, study results confirmed a significant association.
Decreased patient care due to undermined clinical decision-making
Clinicians who experience disruptive behaviour may respond by placating the instigator at the expense of patient care.1,13,92 The Institute for Safe Medical Practices found that some clinicians are intimidated into compromising clinical decision-making in a number of ways.92 For example, clinicians may assume that an order is correct and allow it to stand (despite concerns about safety) in order to avoid dealing with the instigator.92 In addition, many clinicians indicated that they considered themselves inappropriately pressured to accept an order, dispense a product, or administer a medication.92
Decreased patient care due to reduced technical performance
Some clinicians perceive that disruptive behaviour can negatively affect procedural skills,17,54,84 increase medication17 and other medical errors,85 and promote substandard practice.7,10 Some clinicians also sense that these behaviours can reduce the performance of both individuals and teams.52 Technical performance could be affected in several ways. The cognitive appraisal may result in stress leading to reduced focus.6 The clinician’s attention may also shift from the patient to the instigator—to the detriment of care.83,84
The effect on clinicians
Correlational research studies using established tools with good psychometric properties, as well as expert opinion rooted in robust theory support the effect of disruptive behaviour on clinicians. Disruptive behaviour is associated with occupational stress and anxiety in those exposed,3-9 leading to increased use of sedatives and sleeping aids.3 This decline in general well-being6-8,10-13 may manifest as burnout,93 decreased self-esteem,8 or depression.4 Stressors such as disruptive behaviour are more likely to lead to disease in individuals whose cognitive appraisal leads them to adopt maladaptive coping strategies.60
The effect on students
The effect on students is supported by correlational research, qualitative surveys, and student perceptions. Disruptive behaviour certainly undermines students’ well-being.74,94,95 Disruptive clinicians are powerful negative role models,13,54 potentially leading students to adopt this type of behaviour. Such behaviour may have an effect on career choice, with some students reporting a loss of interest96 or respect83 for surgical specialties.83,84 Our group recently surveyed 563 senior medical students in Canada and the USA, and survey results showed a decrease in the probability that minority groups who were exposed to disruptive behaviour would apply to a surgical residency.97 Nevertheless, survey results also showed that some students perceived that they were also dissuaded from applying to anesthesiology training programs. As with clinicians, the effect on students is dependent on their cognitive appraisal. Students who see disruptive behaviour as a considerable threat and one that is resistant to improvement are more likely to be psychologically impacted. Additionally, students who think that a given disruptive behaviour reflects the behaviour of an entire specialty would be more likely to modify their career choice.
The effect on institutions
The effect on institutions is supported by economic analysis, expert opinion, clinician perceptions, and correlational research. Bullied clinicians are less productive.7,8,15 An analysis of data from 2,160 staff nurses reported that workplace incivility cost approximately $11,600/nurse/year due to lost productivity.16 A 400-bed American hospital showed that it could save $1 million by eliminating disruptive behaviour.17 Those exposed are less satisfied with their careers,18 are less committed to their organization,7,8,19 consider decreasing their work hours,18 may cease direct patient care,18 have increased sick time and absenteeism,8,18 and leave their employment more frequently.19,98 This turnover decreases organizational efficiency13,17,20 and makes recruiting more difficult.10
Disruptive behaviour can result in legal risk from three main sources. First, mistreated clinicians may bring legal action against the instigator and the institution.8,9,13 Institutions that are found to have tolerated this behaviour may be liable for negligent retention.56 Second, there are legal risks associated with poor outcomes.13 Third, clinicians who are dismissed for disruptive behaviour may also take legal action.8,9 Employees may also take their grievances public,9 resulting in damage to an institution’s reputation.8,10,85 Other consequences to institutions include the costs associated with non-compliance by disruptive clinicians with new practices.11
Prevention and management of disruptive behaviour
Set the expected standards for behaviour
Organizations should define the types of behaviour that are deemed disruptive (as well as those that are more appropriate)7-9,13,56,99 and should specify the appropriate behavioural responses. Work contracts should be unequivocal regarding the expectations. At the level of professional practice, standards should be disseminated through oaths, professional standards, and codes of ethics and conduct. At the institutional level, standards must be set in the bylaws,10,85 codes of conduct,85 and mandatory institutional curricula. Management should lead by example. The same behavioural expectations should apply to all clinicians, especially in light of the perception that senior clinicians who generate a large amount of business are treated more leniently.85 One study showed the importance of setting a standard by reporting that anesthesiologists working at an institution with an anti-bullying policy were less likely to report bullying than those working in an institution without such a policy.100
Equip and educate clinicians to meet the standards
All employees should be educated about disruptive behaviour and the respective behavioural responses. Professional wellness programs should identify and remediate the intrapersonal antecedents. Clinicians should consider assessing their own risks for disruptive behaviour by completing screening tools in clinician wellness programs, while institutions may also consider using employment screening tools to identify the at-risk clinicians.101 Clinicians should be made aware of resources available to them, including those in the human resources department, professional organizations, peer support and mentorship programs for new clinicians, and preventive health services and wellness initiatives. Preventing interpersonal factors requires creating a respectful culture in the operating room102 by using initiatives such as interprofessional education, soft skills training, and structured communication tools. Organizations need to identify and optimize the contributing institutional factors.102 Based on the identified organizational antecedents, this would involve keeping clinician workloads manageable, ensuring effective and efficient management of resources, supplying appropriate tools and conditions to deliver care, and engaging clinicians in decisions that affect their workloads.
Monitor compliance with the standards
There must be mechanisms to report unacceptable behaviour while retaining protection and anonymity, if required.103 Staff should have a clear understanding of the mechanisms for reporting to management,56 and it should be clear that reprisals will not be tolerated. Evaluations of interpersonal skills7,35,56 must be part of regular performance evaluations, including input from all team members, e.g., 360° evaluations.
Enforce standards and provide staged remediation when required
The responsibility of individual clinicians
Guidelines for civil behaviour
John Hopkins Rules of Civility that are applicable to the operating room112
The Ontario Medical Association’s fundamentals of civility113
• Acknowledge others: their presence, worth and effort
• Respect others and yourself
• Respect others’ opinions, time, space (physical & emotional)
• Be aware
• Speak kindly
• Communicate effectively
• Respectfully assert yourself
• Take good care of yourself
• Don’t blame
• Be responsible
• Keep it down
Disruptive behaviour is a significant problem in the operating room and originates from intrapersonal, interpersonal, and organizational issues. While only a small percentage of clinicians are instigators, other clinicians, students, and institutions may bear the consequences. Although there is a low level of evidence to support a direct effect on patient outcomes, our review presents plausible mechanisms by which such an effect could occur. The behavioural responses of those who are exposed to disruptive behaviour can positively or adversely moderate the consequences. While all operating room professions are implicated in this problem, surgeons remain the most common instigators.
Further study of operating room behaviour is essential. Much of the data comes from studies outside the operative context or with limitations related to sampling frames, statistical methods, and survey tools. More appropriate tools are beginning to proliferate.22,81,107,108
Given these data limitations, the optimal means to prevent and manage disruptive behaviour is uncertain. Clinicians must have contracts outlining the responsibilities and behavioural expectations of both clinicians and management as well as the reasonable institutional supports that clinicians can expect when performing their duties. There must also be ongoing monitoring through regular performance feedback, and institutions must enforce policies and implement graded remedial processes. An important step that individual clinicians can take is to monitor and control their own behaviour, including their responses to disruptive behaviour. It is incumbent upon institutions to support clinicians in this task by offering them resources such as coaching, professional development, and soft skills training.
Conflicts of interest
This submission was handled by Dr. Gregory L. Bryson, Deputy Editor-in-Chief, Canadian Journal of Anesthesia.
- 7.Pfifferling JH. Managing the unmanageable: the disruptive physician. Fam Pract Manag 1997; 4: 76-8, 83, 87-92.Google Scholar
- 10.Piper LE. Addressing the phenomenon of disruptive physician behavior. Health Care Manag (Frederick) 2003; 22: 335-9.Google Scholar
- 14.National Patient Safety Foundation. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA; 2013. Available from URL: http://www.npsf.org/?page=throughtheeyes (accessed November 2016).
- 26.The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety - 2008. Available from URL: https://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/ (accessed November 2016).
- 29.Huntoon LR. Abuse of the “disruptive physician” clause. Journal of American Physicians and Surgeons 2004; 9: 68.Google Scholar
- 32.United Nations. UN General Assembly, Universal Declaration of Human Rights - 1948. Available from URL: http://www.refworld.org/docid/3ae6b3712c.html (accessed November 2016).
- 36.Vessey JA, Demarco RF, Gaffney DA, Budin WC. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs 2009; 25: 299-306.CrossRefPubMedGoogle Scholar
- 39.Smith J. Bullying in the nursing workplace: a study of perioperative nurses – 2011. Available from URL: http://media.proquest.com/media/pq/classic/doc/2524265761/fmt/ai/rep/NPDF?_s=aI7DcQq3%2FaFOMFpHWFqCeq7tVdo%3D (accessed November 2016).
- 41.Cook JK, Green M, Topp RV. Exploring the impact of physician verbal abuse on perioperative nurses. AORN J 2001; 74: 317-20, 322-7, 329-31.Google Scholar
- 48.Villafranca A, Hamlin C, Jacobsohn E; Intraoperative Behaviors Research Group. Physical and psychological abuse in Canadian operating rooms. Can J Anesth 2017; 64: this issue.Google Scholar
- 50.Villafranca A, Hamlin C, Parveen D, Jacobsohn E. Bullying and incivility in the operating room: survey responses from 7,465 clinicians. Anesthesiology 2016: A3109 (abstract).Google Scholar
- 55.Hollowell EE. The disruptive physician: handle with care. Trustee 1978; 31: 11-3, 15, 17.Google Scholar
- 56.Lowes R. Taming the disruptive doctor. Med Econ 1998; 75: 67-8, 73-4, 77-80.Google Scholar
- 60.Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol 2005; 607-28.Google Scholar
- 63.Haskins J. Sexism is alive, well in the healthcare industry. Healthline 2016. Available from URL: http://www.healthline.com/health-news/sexism-is-alive-in-healthcare#1 (accessed November 2016).
- 67.Hamlin C, Villafranca A, Enns S, Parveen D, Jacobsohn E. Perpetrators of bullying and incivility in the operating room: a multinational survey of 6142 clinicians. Anesthesiology 2016: A3145 (abstract).Google Scholar
- 72.Raven BH. A power/interaction model on interpersonal influence: French and Raven thirty years later. J Soc Behav Pers 1992; 7: 217-44.Google Scholar
- 76.Duffy E. Horizontal violence: a conundrum for nursing. Collegian 1995; 2(5-9): 12-7.Google Scholar
- 77.Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer Publishing Company; 1984 .Google Scholar
- 79.Schaubhut NA. Technical Brief for the Thomas-Kilmann Conflict Mode Instrument – Description of the Updated Normative Sample and Implications for Use - 2007. Available from URL: https://www.cpp.com/Pdfs/TKI_Technical_Brief.pdf (accessed November 2016).
- 81.Villafranca A, Robinson S, Rodebaugh T, Villafranca P, Yasinski L, Jacobsohn E. Validation of a questionnaire measuring responses to negative intraoperative behaviors: 17AP2-6. Eur J Anaesthesiol 2014; 31: 253 (abstract).Google Scholar
- 85.Paskert J. Collegial intervention and the disruptive physician. Physician Exec 2014; 40(50-2): 54.Google Scholar
- 86.Wilmot WW, Hocker JL. Interpersonal Conflict. 7th ed. NY: McGraw-Hill; 2006 .Google Scholar
- 88.Nurok M, Lee YY, Ma Y, Kirwan A, Wynia M, Segal S. Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about “truth-telling practices” in the perioperative setting. Patient Saf Surg 2015; . DOI: 10.1186/s13037-015-0080-7.PubMedPubMedCentralGoogle Scholar
- 89.The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission – 2012. Available from URL: http://www.jointcommission.org/assets/1/18/2004_4Q_2012_SE_Stats_Summary.pdf (accessed November 2016).
- 90.The Joint Commission. Sentinel Event Statistics Released for 2014 - 2015; Available from URL: http://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf (accessed November 2016).
- 92.Institute For Safe Medication Practices. Results from ISMP Survey on Workplace Intimidation - 2004. Available from URL: https://ismp.org/Survey/surveyresults/Survey0311.asp (accessed November 2016).
- 96.Villafranca A, Benoit P, Jacobsohn E. Medical student exposure to negative intraoperative behaviors and post-clerkship interest in anesthesiology and surgery. Anesthesiology 2014: A3025 (abstract).Google Scholar
- 97.Villafranca A, Hamlin C, Benoit P, Jacobsohn E. Exposure to negative intraoperative behaviors alters the residency applications of some students. Anesth Analg 2016: PR079 (abstract).Google Scholar
- 100.Pisklakov S, Schoenberg C, Marcus A, Davidson ML. A survey of 5,000 active ASA members on the subject of bullying and aggressive behavior: anesthesiologists working in places with an anti-bullying policy in place are less likely to have been bullied in. Anesthesiology 2013: A3149 (abstract).Google Scholar
- 105.Ward S. What you as a manager can do to overcome verbal abuse of staff. OR Manager 2002; 18(1): 12-5.Google Scholar
- 106.Bieling PJ, McCabe RE, Antony MM. Comorbidy and CBT Groups. In: Bieling PJ, McCabe RE, Antony MM, editors. Cognitive Behavioral Therapy in Groups. NY: Guilford Press; 2013. p. 375-92.Google Scholar
- 108.Villafranca A, Robinson S, Rodebaugh T, Mashour G, Avidan S, Jacobsohn E. Validation of a questionnaire measuring exposure to negative intraoperative behaviors: 17AP2-2. Eur J Anaesthesiol 2014; 31: 251-2 (abstract).Google Scholar
- 109.Canadian Medical Protective Association. Disruptive Behaviour. Available from URL: https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/professionalism/Behaviour/disruptive_behaviour-e.html (accessed November 2016).
- 110.Council on Ethical and Judicial Affairs- American Medical Association. CEJA Opinion - (E-9.045) Physicians with Disruptive Behavior. Available from URL: http://www.ama-assn.org/resources/images/omss/cejae-9.045.pdf (accessed November 2016).
- 111.Joint Commission Resources. Defusing Disruptive Behavior: A Workbook for Health Care Leaders. Oakbrook Terrace, Illinois, Illinois; 2007. Available from URL: http://www.jointcommissioninternational.org/assets/1/14/DDB07_Sample_Pages2.pdf (accessed November 2016).
- 112.Forni P. Choosing Civility: The Twenty-five Rules of Considerate Conduct. Reprint Edition. St. Martin’s Press; 2010.Google Scholar
- 113.Rich P. Canadian physician health expert tells colleagues: “Be civil”. Canadian Medical Association - 2014. Available from URL: https://www.cma.ca/En/Pages/canadian-physician-health-expert-tells-colleagues-be-civil.aspx (accessed November 2016).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.