Chain of Command: When Disruptive Behavior Affects Communication and Teamwork

Abstract

Chain of command in healthcare refers to an authoritative structure established to resolve administrative, clinical, or other patient safety issues by allowing healthcare clinicians to present an issue of concern through the lines of authority until a resolution is reached. Frontline healthcare clinicians, who have witnessed poor performance by their peers or supervisors, may be hesitant to use this means of communication because of the fear of retaliation or uncertainty about its importance in patient outcome. Staff may also be reluctant to call a physician, supervisor, or other clinician, even in the face of the deteriorating status of a patient, fearing intimidation, confrontation, antagonistic discussion, or other disruptive behavior. This article examines the issues that surround the use of the chain of command when disruptive clinician behaviors are encountered or when there are concerns about a patient’s condition or the care they are receiving when these concerns are related to operational issues. The article discusses actions organizations can take to eliminate healthcare clinicians’ inappropriate actions and attitudes in order to boost effective communication, teamwork, and collaboration and improve patient safety.

Chain of Command

Chain of command is a system whereby authority passes down from the top through a series of executive positions or military ranks in which each individual is accountable to their direct superior. Chain of command in healthcare is the line of responsibility to both the delivery of appropriate patient care and feedback about perceived appropriateness and the impact of that care. An effective chain of command in healthcare organizations facilitates, rather than impedes, communication, teamwork, and collaboration between the decision maker and the frontline clinician. Barriers to effective and safe healthcare may include disruptive behaviors, conflicts, and lack of physician availability. The Joint Commission instituted a new leadership standard effective January 1, 2009, that requires accredited hospitals to address healthcare clinician disruptive and inappropriate behaviors.1 This standard expands the Joint Commission National Patient Safety Goal 2, which requires accredited organizations to improve the effectiveness of communication among caregivers to reduce risk, improve patient safety, and recommends standardization of communication whenever possible.2

Chain of command provides healthcare staff with a formal process to use when attempting to get satisfactory resolution or to report concerns about questionable patient conditions or care delivery. When hierarchical differences exist between healthcare clinicians, people lower in the hierarchy tend to be uncomfortable communicating problems or concerns. Individuals at the top of the hierarchy that exhibit disruptive or unapproachable behaviors may further hinder communication between healthcare clinicians.3 Delays, inappropriate care, or lack of patient care may be the byproducts of these hierarchical differences, particularly if the organization’s chain of command fails to outline a structured communication method to address disruptive behaviors or concerns about a patient’s condition or the care they are receiving. Chain of command may fail because the next person up the hierarchy “blinks,” refuses to act, has not been trained to act, fears retaliation, or falls back on enabling behaviors. Leadership for introducing chain of command only works when there is a clear and consistent demonstration of a willingness to act.

Overview of Authority Data

There were 177 events reported to the Pennsylvania Patient Safety Authority from May 2007 to October 2009 that detailed healthcare clinicians’ disruptive behaviors, many of which negatively affected patient care. Of these events, 73 (41%) were due to conflicts between healthcare clinicians, 30 (17%) to procedures not followed, 17 (10%) to absence of responses or delays, 22 (12%) were listed as other, and behaviors for the remaining 35 (20%) were not given. Some of these reported events listed disruptive behaviors that may have contributed to delays in pain control, increased risk of healthcare-associated infections, or increased risk of burns. Implementation of a chain-of-command protocol could have resulted in different outcomes. Examples follow of reports describing conflicts between healthcare clinicians, refusals to adhere to procedures, and absences or delayed responses that resulted in patient care delays and increased risks for healthcare-associated infections or burns.

Initiating a formal chain of command provides healthcare staff with guidance and examples of actions to be taken, exceptions, what to do when issues are unresolved after implementation, and documentation expectations. Thirteen (18%) of the total events based on conflicts between healthcare clinicians reported the implementation of a chain-of-command protocol when the disruptive behaviors were encountered. In 41 (56%) of the reports that did not report the use of chain of command, patient harm might have been averted if one had been implemented, while the patient outcomes on the remaining 19 (26%) reports that included healthcare clinicians’ disruptive behaviors would have remained unchanged if chain of command had been implemented.

Rosenstein and O’Daniel conducted a survey of 4,503 nurses, physicians, administrative executives, and other participants from 102 hospitals to assess the significance of disruptive behaviors, their effect on communication and collaboration between healthcare clinicians, and their impact on patient safety. The survey participants indicated the clinical areas where disruptive behaviors were reported: medical units (35%), ICUs (26%), ORs (23%), surgical units (20%), emergency departments (EDs) (7%), and others (less than 5%).4 Seventy percent of the survey respondents indicated a link between these behaviors and medical errors and poor quality patient care. More than 65% of the participants indicated that disruptive behaviors were linked to adverse events, more than 50% indicated patient safety compromise, and more than 25% of the respondents linked the behaviors to patient mortality.4

In the disruptive behavior events reported to the Authority, the care areas where the behaviors most frequently occurred were in ORs (24%), medical/surgical units (24%), ICUs (16%), EDs (8%), outpatient departments (7%), labor and delivery units (4%), behavioral health units (3%), laboratories (1%), and others (8%).

Conclusion

When hierarchical differences exist between healthcare clinicians, communication problems may occur. Those individuals that exhibit intimidating behaviors may further hinder communication between healthcare clinicians, causing delays in patient care particularly if the organization’s chain of command fails to outline structured communication techniques and clinical practice guidelines to follow when disruptive behaviors are encountered. Disruptive behaviors of healthcare clinicians have been linked to adverse events. An organization that values all healthcare clinicians is one that invests in chain-of-command policies and provides adequate investigation and follow-up of reports of disruptive behaviors. The chain-of-command policy provides healthcare staff with actions, exceptions, steps to take regarding unresolved issues, and documentation guidelines. Chain-of-command development is an essential part of healthcare organizations’ efforts to build trust, communication, collaboration, and teamwork among healthcare clinicians, all of which have positive effects on patient safety and outcomes. Education of healthcare clinicians about the chain-of-command policy can include role-playing demonstrations, which may better prepare healthcare clinicians to initiate a chain of command when they have concerns about questionable patient care or when they encounter disruptive behaviors.

Common Barriers to Interprofessional Communication and Collaboration

* Complexity of care
* Concerns regarding clinical responsibility
* Culture and ethnicity
* Differences in accountability, payment, and rewards
* Differences in language and jargon
* Differences in requirements, regulations, and norms of professional education
* Differences in schedules and professional routines
* Disruptive behaviors
* Emphasis on rapid decision making
* Fears of diluted professional identity
* Gender
* Generational differences
* Hierarchy
* Historical, interprofessional, and intraprofessional rivalries
* Personal values and expectations
* Personality differences
* Varying levels of preparation, qualifications, and status

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