Running head: DISRUPTIVE BEHAVIORS IN NURSING

Disruptive Behaviors in Nursing

JoAnne Saba
December 11, 2015
California State University, Stanislaus

DISRUPTIVE BEHAVIORS IN NURSING

Disruptive Behaviors in Nursing

Disruptive behaviors are not uncommon amongst hospital personnel; research proves that
they occur on a daily basis (The Joint Commission [TJC], 2008; McNamara, 2012). These
behaviors are described by McNamara (2012, p. 536) as incivilities and include "verbal abuse,
nonverbal abuse, sexual harassment, passive aggressive behavior, and bullying." Furthermore,
disruptive behaviors inhibit individuals from utilizing his or her skills to their highest capability
(College of Physicians and Surgeons of Ontario, 2008). This paper will discuss the problem of
disruptive behaviors in nursing, the impact they have on patients and nurses, a specific example
of the conflict these behaviors create, and possible evidence-based solutions to improve this
issue.
The Problem: Disruptive Behaviors in Nursing
Nurses have the highest susceptibility to disruptive behaviors in comparison to all other
professions (Small, Porterfield, & Gordon, 2015). One study, completed by Small, Porterfield,
and Gordon (2015), found that 86.8% of nurses have been verbally abused, 11.5% electronically
abused, and 22.8% physically abused at some point in his or her career. However, of these cases
only 54% of victims reported the abuse to superiors. Reasons that most fail to report such
occurrences include the following: fear of retaliation, fear of confrontation, fear of being shamed
by colleagues, belief that those of higher power will be reprimanded leniently, and belief that
hospitals do not adequately handle these cases (TJC, 2008; Stewart, Wyatt, & Conway, 2011).
Several root causes contribute to the continuance of disruptive behaviors amongst nurses
(Granstra, 2015). Hierarchical systems and seniority promote feelings of empowerment over
newer nurses causing senior nurses to bully others. Conversely, insecure nurses are also inclined
to use disruptive behaviors to magnify his or her own worth. Differences in education, such as

DISRUPTIVE BEHAVIORS IN NURSING

bachelor's degree prepared nurses versus associate's degree prepared nurses, can also foster
hostile actions due to a perception that the other does not have the required knowledge to
practice effectively.
The Evidence
Impact on Nurses
Hostile work environments can have physical and psychological effects on nurses
(Johnson, 2011; McNamara, 2012; Granstra, 2015). Habitual exposure to disruptive behaviors
causes an increase in stress and cortisol production, which inherently creates other negative
physical manifestations (Johnson, 2011). Nurses can experience gastrointestinal upset, sleep
disturbances, pain, fatigue, decreased cardiovascular functioning, and weight changes
(McNamara, 2012; Granstra, 2015). Likewise, psychological symptoms may emerge which
include depression, anxiety, hopelessness, and decreased self-esteem.
Dissatisfaction in one's current position can cause him or her to seek a new position
elsewhere (TJC, 2008; Johnson, 2011; McNamara, 2012; Granstra, 2015). High nurse turnover
requires the hospital to increase efforts to retain and recruit new nurses (Johnson, 2011; Granstra,
2015). This is particularly expensive for the hospital to endure and leaves units understaffed. As
a result, nurses have difficulty completing tasks within a reasonable timeframe, which,
consequently, can cause more disruptive behaviors (Yildrim, 2009).
Interpersonal communication, collaboration, and teamwork are also largely affected
(McNamara, 2012; Granstra, 2015). Relationships are damaged due to habitual mistreatment,
which reduces the amount of communication amongst colleagues and therefore inhibits nurses
from providing productive collaborative care (Ganstra, 2015). This not only makes the nurses'
jobs more difficult, it also decreases the quality of care provided to patients. Therefore, nurses

DISRUPTIVE BEHAVIORS IN NURSING

cannot effectively do their job.

A study conducted by Espeland (as cited in Brinkert, 2010) found burnout to also be a
consequence of disruptive behaviors. Causes of burnout were identified as role overload, role
conflict, poor camaraderie between colleagues, interpersonal conflicts, and perceived unfair
treatment of employees. Furthermore, a study of transplant nurses determined several negative
effects of burnout that included: emotional exhaustion, depersonalization, and a lack of perceived
personal accomplishment (Jesse, Abouljoud, Hogan, & Eshelman, 2015). All of these outcomes
can further manifest in to the psychological symptom described previously.
Impact on Patients
Disruptive do not only affect nurses but have an impact on patients as well. Of the
participants of the study conducted by Rosenstein and O'Daniel (2008), 70% believed that
disruptive behaviors cause poor-quality care and medication errors, 50% associated these
behaviors with decreased patient safety, and 25% thought disruptive behavior increased patient
mortality. Research proves nurses are likely to make medication errors, carry out unsafe orders,
and have other adverse outcomes when these behaviors were prominent in the workplace (TJC,
2008; Johnson, 2011; Stewart, Wyatt, & Conway, 2011). This is a direct result of reduced
communication amongst nurses due to nurses withholding critical patient information (Ganstra,
2012). Stewart, Wyatt, and Conway (2011) have also found that disruptive behaviors result in
increased patient dissatisfaction, more patient complaints, and a higher risk for indictment.
Context
Conflict
Knippa et al. (2011, p. 23) describes conflict as "an inevitable part of professional, social,
and personal life" which occurs as a "result of opposing thoughts, ideas, feelings, perceptions,

DISRUPTIVE BEHAVIORS IN NURSING

behaviors, values, opinions, or actions." Conflict can be further classified in to one of four
categories that include: intrapersonal conflict, interpersonal conflict, intragroup conflict, and
intergroup conflict (Evans, 2013). These varying levels differ due to the number of people or
groups involved in the conflict. Intrapersonal and interpersonal conflicts take place within a
single individual or between two individuals, respectively. Similarly, intragroup conflict and
intergroup conflict, correspondingly, happen when there are disturbances within a single team or
amongst several different teams within an organization.
Conflict Management
Each individual has his or her preferred style of dealing with conflict (MTD Training,
2010). The results produced from each conflict resolution style differ greatly. These five
conflict resolution styles include: avoiding, competing, accommodating, compromising, and
collaborating (MTD Training, 2010; Cross, 2015). Solutions of these styles can be described as
lose-lose, lose-win, win-lose, or win-win dependent on which party benefits and which does not
due to the conclusion made (Knippa et al., 2011).
Avoiding. Avoiding occurs when the parties involved are aware a conflict exists but
neglect to resolve it (Knippa et al., 2011). This poor strategy, considered a lose-lose solution, is
not often beneficial because the conflict can resurface or escalate with time (MTD Training,
2010; Knippa et al., 2011). However, in situations where conflict is minor or can resolve itself
this style may be appropriate (Knippa et al., 2011).
Competing. This conflict resolution style is most effective when decisions need to made
quickly or when the decision made may not be favorable (MTD Training, 2010). Competition
occurs when an individual comes to a solution at the cost of another, often leaving them angry
and dissatisfied (Knippa et al., 2011). Solutions are referred to as win-lose when competition is

DISRUPTIVE BEHAVIORS IN NURSING

used.
Accommodating. Contrary to competitive conflict resolution, accommodation occurs
when one party forfeits their desires to allow the opposing party to receive what they wish
(Knippa et al., 2011). The conflict remains unresolved and may resurface in the future. This
solution is considered a lose-win resolution.
Compromising. In order for compromise to be successful, both parties must give up
something of equal value to find a solution that is satisfactory for all (MTD Training, 2010;
Knippa et al., 2011). This style of conflict resolution is not optimal if a strict deadline must be
kept due to risk of a time-consuming process (MTD Training, 2010). Compromising is
considered a win-lose/win-lose solution.
Collaborating. Collaborating is considered a win-win solution and the optimal conflict
resolution style (MTD Training, 2010). This style incorporates all parties' ideas and attitudes
because they are believed to be equally important (MTD Training, 2010; Cross, 2015).
Ultimately, all final solutions are negotiated to satisfy all that are involved.
Personal Experience
Disruptive behaviors occur daily to all nurses regardless of the length of his or her career;
however, research shows that new nurses take the brunt of the abuse (Yildirim, 2009). During
my rotation in the neonatal intensive care unit (NICU), I witnessed this firsthand when an older,
more experienced nurse spoke inappropriately to a newly licensed float nurse orienting to the
unit. It was the new nurse's second day orienting in the NICU so she was still learning hospital
procedure and proper routine. The older nurse, who had much to do herself, was impatient,
spoke rudely with her trainee, and would roll her eyes at some of the questions she was asked.
In this example, the new nurse utilized the conflict resolution style of avoiding. The

DISRUPTIVE BEHAVIORS IN NURSING

newer nurse never confronted the older nurse about her actions, causing her to become reluctant
to ask the nurse orienting her for assistance. This interrupted the new nurse's routine due to not
being oriented with the environment and floor protocol, as well as reduced the quality of care she
could provide her patients. By not addressing this issue, the new nurse has left conflict
unresolved and it can evolve into a larger conflict when she floats to the NICU in the future.
My "Typical" Conflict Resolution Style
Everyone has a choice of which conflict resolution style will work best for the problem at
hand (Cross, 2015). Though varying styles may be appropriate at different times, each person
has a conflict resolution style that he or she typically attempts to use. In most situations, I prefer
to use collaboration because I believe that all parties affected by a decision should be equally
satisfied. I have also observed that people are more likely to comply to changes if they agree
wholeheartedly with them.
Possible Solutions
It is apparent that conflict within the workplace has serious repercussions on staff and
patient. Though it would be simplest to ignore the issue, the cost to replace a single nurse ranges
between $22,000 to $64,000 (Granstra, 2015). This shows that turnover is quite costly to the
hospital and it is fiscally better to fix the problem. The literature shows that multiple
interventions, which may not be effective on their own, prove to be the best options in fostering
improved employee dynamics (Coursey, Rodriguez, Dieckmann, & Austin, 2013). Outlined
below are four evidence based interventions that could potentially alleviate such an extensive
issue. These include: applying a zero tolerance policy, providing conflict management training,
implementing a nurse mentors program, and providing all staff with an effective communications
and assertiveness skills workshop. A proposed budget(see Appendix) is included to view

DISRUPTIVE BEHAVIORS IN NURSING

supplies and costs related to each intervention.

Zero Tolerance Policy
The Joint Commission (2008) suggested implementing a zero tolerance policy as measure
to decrease the incidences of disruptive behaviors. A study conducted by Dimarino (2011) found
that a culture of respect can be created when clear expectations are outlined. Once a strong code
of conduct was in place, the institution sampled did not experience any staff turnover and had no
reports of disruptive behaviors.
To initiate, a committee of five nurses and five hospital directors would need to be
created to write the zero tolerance policy. These individuals would collaborate on expectations
of employees, guidelines of how to handle conflicts, how to report disruptive behaviors, and the
consequences associated with violating this policy. The policy would then be presented to the
hospital board to be voted in to the hospital bylaws. Once the policy is accepted, each employee
will be trained on how to report disruptive behaviors then issued a copy of the policy to sign for
their personal file. A justice committee will be formed during this time to evaluate each report
submitted. Reports will include: employee used disruptive behavior, what the actions were, and
events that lead to the incident.. This data will serve to identify what types of interventions may
need to be implemented in the future to continue working toward a peaceful work environment.
They will also evaluate each occurrence and issue the appropriate consequence to offenders.
Conflict Management Training
It is stated that lack of conflict management skills is a contributing factor to disruptive
behavior (TJC, 2008; Stewart, Wyatt, & Conway, 2011). Thus, to address the cause of the
problem, conflict management training would be a beneficial intervention. According to a study
completed by Haraway and Haraway (2005), conflict management training is successful in

DISRUPTIVE BEHAVIORS IN NURSING

reducing role overload, role boundaries, psychological strain, and interpersonal strain.
Nurses should have better management and balance over the demands of their job
following intervention (Haraway & Haraway, 2005). In addition, there should be an increased
capability of applying more positive conflict resolution strategies while in the workplace. Nurses
should be able to discuss conflicts, express emotional understanding of the opposite point of
view, and be empathetic and respectful toward opposing positions (Rosenstien, Dinklin, &
Munro, 2014).
This intervention, which is currently applied by few hospital campuses, is designed to
teach newly hired nurses how to deal with conflict as a preventative measure (Lux, Hutcheson, &
Peden, 2012). In an on-campus classroom during new hire orientation, a credentialed instructor
would teach a three-hour course regarding several aspects of conflict resolution and conflict
management. Topics included would be the different reasons for conflict, the threat associated
with unresolved conflict, responses to conflict, conflict resolution styles, and conflict resolution
strategies (Haraway & Haraway, 2005). Learning techniques that would be utilized are videos,
handouts, reflection, and role-playing.
Nurse Mentor Program
Transitioning from student to new nurse can be a difficult process, but using a mentor
system can facilitate a smoother adjustment to the workplace (Lux, Hutcheson, & Peden, 2014).
It was found that these mentor-mentee relationships improved nurses' perceptions of each other,
the perception of nurses by other hospital workers, provided additional support, and improved
patient care outcomes (Latham, Hogan, & Ringl, 2008; Brinkert, 2010). Overall, nurse mentor
programs assist in creating a supportive work environment, reducing turnover, and increasing
patient safety (Brinkert, 2010).

DISRUPTIVE BEHAVIORS IN NURSING

10

The goal of a mentorship program is to pair newly graduated nurses with experienced
nurses to have an additional resource to teach valuable intrapersonal and interpersonal skills that
go beyond the duties of a preceptor (Lux, Hutcheson, & Peden, 2014). Mentors act as a role
model of effective assertive communication, how to make personal goals, how to work in a team,
and how to handle their work environment. Ultimately, they assist new graduates to properly
socialize into the nursing profession (Latham, Hogan, & Ringl, 2008).
This program would be implemented similar to the study completed by Latham, Hogan,
and Ringl (2008). Approximately 200 experienced nurses, a number adequate to match the
number of new hires, will be recruited by use of flyers on each unit. Each mentor volunteer
would be required to attend a brief orientation, which would outline the differences between the
roles of mentor and preceptor, the roles and responsibilities of a mentor, and goals for the
program. Mentees would learn about this program during their hiring process. Pairings are
created by mentees choosing their mentor based on his or her perceived compatibility.
Communication Workshop and Assertiveness Training
Of healthcare clinicians surveyed about the reasons to take an assertive communication
class, 65% believed that good communications skills are vital to professional development
(McVanel & Morris, 2010). Studies have also shown that improved communication between
healthcare professionals decreases disruptive behaviors (Brinkert, 2010; Saxton, 2012). Saxton's
research (2012) proved that providing a communication skills workshop, nurses' had improved
self efficacy of identifying and addressing disruptive behaviors.
This intervention is designed for nurses to increase their skill in identifying disruptive
behaviors so that they will be able to address the person carrying out the behavior (Saxton,
2012). Equally, it will provide nurses with the leadership skills required to speak up, despite

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11

traditional hierarchies, for the safety of their patients (McVanel & Morris, 2010). The overall
goal is for nurses to learn how to communicate professionally, yet assertively, with all hospital
staff.
This intervention would be a two-day communication and assertiveness skills workshop
that would take place in a conference room on the hospital campus (Saxton, 2012). A qualified
instructor will be hosted to teach the course to nurses, who will be compensated for two days of
pay. Education techniques include: videos, role-playing, personal reflection, and handouts to
take home. The workshop would begin with nurses learning how to recognize disruptive
behaviors and proceed with them learning skills on how to address these behaviors.
Assertiveness skills to be taught are use of I-messages, broken record statements, fogging,
momentary delay, and opinion exchange statements (McVanel & Morris, 2010). This
intervention would target all current, working nurses as a refresher course on proper
communication techniques.
Conclusion
Disruptive behaviors are a consequential problem that effect healthcare workers daily;
they impact nurses by causing poor retention rates, inflicting physical and psychological illness,
and decreasing job performance. Patients are equally affected because poor patient outcomes
and dissatisfaction occur as ramifications of these actions. Conflict amongst colleagues
frequently arises, most often toward newer nurses. The prevalence of disruptive behaviors must
be addressed and can be resolved through conflict management training, communication skills
workshops, and nurse mentor programs. Through contribution by all hospital employees,
reducing the frequency of incidences in the hospital to improve the workplace environment is an
attainable goal.

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12

References
Brinkert, R. (2010). A literature review of conflict communication causes, costs, benefits, and
interventions in nursing. Journal of Nursing Management, 18(2), 146-156 12p. doi:
10.1111/j.1365-2834.2010.01061.x
College of Physicians and Surgeons of Ontario (2008). Guidebook for managing disruptive
behavior. Toronto, Canada: College of Physicians and Surgeons of Ontario.
Coursey, J.H., Rodriguez, R.E., Dieckmann, L.S., & Austin, P.N. (2013). Successful
implementation of policies addressing lateral violence. AORN Journal, 97(1), 101-109
9p. doi: 10.1016/j.aorn.2012.09.010
Cross, V. (2015). Five approaches to conflict resolution. Retrieved from
http://smallbusiness.chron.com/five-approaches-conflict-resolution-21360.html
Dimarino, T. (2011). Eliminating lateral violence in the ambulatory setting: One center's
strategies. AORN Journal, 93(5), 583-588 6p.doi:10.1016/j.aorn.2010.10.019
Evans, B. (2013). Types of conflict four classifications. Retrieved from
http://www.typesofconflict.org/
Granstra, K. (2015). Nurse against nurse: Horizontal bullying in the nursing profession.
Journal of Healthcare Management, 60(4), 249-257 9p.
Haraway, D., & Haraway, W.M. (2005). Analysis of the effects of conflict-management and
resolution training on employee stress at healthcare organization. Hospital Topics, 83(4),
11-17 7p.
Jesse, M., Abouljoud, M., Hogan, K., & Eshelman, A. (2015). Burnout in transplant nurses.
Progress in Transplantation, 25(3), 196-202 7p. doi:10.7182/pit2015213
Johnson, S. (2011). An ecological model of workplace bullying: A guide for intervention

DISRUPTIVE BEHAVIORS IN NURSING

13

and research. Nursing Forum, 46(2), 55-63 9p. doi:10.1111/j.17446198.2011.00213.x

Knippa, A., Sommer, S., Ball, B., Churchill, L., Elkins, C., Janowski, M., Roberts, K.,
Wright, M.G., Prater, D., Archer, E.A., Barnes, J., Crawford, C., Groninger, H., Herre,
M., Lehman, A., Shindler, J., & Stacy, B. (2011). Nursing leadership and management
review module (5.0th ed., pp. 25-26). Stilwell, KS.: Assessment Technologies Institute.
Latham, C., Hogan, M., & Ringl, K. (2008). Nurses supporting nurses: Creating a
mentoring program for staff nurses to improve the workforce environment.
Nursing Administration Quarterly, 32(1), 27-39 13p.
Lux, K., Hutcheson, K., & Peden, A. (2012). Sucessful management of disruptive behavior: A
descriptive study. Issues in Mental Health Nursing, 33(4), 236-243 8p. doi:
10.3109/01612840.2011.647255
Lux, K., Hutcheson, J., & Peden, A. (2014). Ending disruptive behavior: Staff nurse
recommendations to nurse educators. Nurse Education in Practice, 14(1), 37-42 6p.
doi: 10.1016/j.nepr.2013.06.014
McNamara, S. A. (2012). Incivility in nursing: Unsafe nurse, unsafe patients. AORN
Journal, 95(4). 535-540 6p. doi:10.1016/j.aorn.2012.01.020
McVanel, S., & Morris, B. (2010). Staff's perceptions of voluntary assertiveness skills training.
Journal for Nurses in Staff Development, 26(6), 256-259 4p. doi:
10.1097/NND.0b13e31819b5c72
MTD Training (2010). Dealing with conflict and complaints. MTD Training & Ventus
Publishing ApS (p. 54-55).
Rosenstein, A., Dinklin, S., & Munro, J. (2014). Conflict resolution: Unlocking the key to

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14

success. Nursing Management, 45(10), 34-39 doi:

10.1097/01.NUMA0000454027.46483.4f
Rosenstein, A. & O'Daniel, M. (2008). A survey of the impact of disruptive behaviors and
communication defects of patient safety. Joint Commission Journal on Quality and
Patient Safety, 34(8), 464-471 8p.
Saxton, R. (2012). Communication skills training to address disruptive behavior. AORN
Journal, 95(5), 602-611 10p. doi: 10.1016/j.aorn.2011.06.011
Small, C., Porterfield, S., & Gordon, G. (2015). Disruptive behavior within the workplace.
Applied Nursing Research 28(2) 67-71 doi: http://dx.doi.org/10.1016/j.apnr.2014.12.002
Stewart, K., Wyatt, R., & Conway, J. (2011). Unprofessional behaviour and patient safety. The
International Journal of Clinical Leadership, 17(2), 93-101 9p.
The Joint Commission (TJC), 2011. Sentinel events alert. Retrieved from
http://www.jointcommission.org/assets/1/18/SEA_40.PDF
Yildirim, D. (2009). Bullying among nurses and its effects. International Nursing Review, 56
(4), 504-511 8p. doi: 10.1111/j.1466-7657.2009.00745.x

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15

Appendix-Proposed Budget

Budget of Measures to Improve Disruptive Behaviors

Year:

2015

Organization: Doctors Medical Center

Submitted by: JoAnne Saba
Total
Budget:

$1,641,835

Budget Planning

Line
1

Item
Nurse Mentor
Program
Communication
Workshop &
Assertiveness
Training
Room
Reserved
Hourly Pay*
Instructor
Fee
Materials
Fee
Conflict Resolution
Training
Room
Reserved
Hourly Pay*
Instructor
Fee
Materials
Fee
Zero Tolerance
Policy

Description/Justification
To establish and improve
rapport between newly hired
nurses and existing staff
To refresh and instill
interpersonal communication
and assertiveness skills

Qty.
200

Conference room on hospital

site
2-Day pay for attendees
Pay for instructor to lead
courses and workshops
e.g. paper, booklets, handouts,
etc.
Training done during job
orientation to instill conflict
resolution skills (2 hours)
Conference room on hospital
site
3-hour pay for attendees
Pay for instructor to lead
courses and workshops
e.g. paper, booklets, handouts,
etc.
Policy created and
implemented by all hospital
staff to eliminate disruptive
behaviors and create a
respectful environment

Unit
Cost/
Rate
$0

Total
$0

$1,566,350

$0

$0

2000
1

$768
$350

$1,536,000
$350

2000

$15

$30,000
$30,925

$0

$0

200
1

$144
$125

$28,800
$125

200

$10

$2,000
$44,560

DISRUPTIVE BEHAVIORS IN NURSING

Writing
Committee

Paper
Justice
committee

Committee created of hospital

nurses and directors to write
zero tolerance policy and
consequences associated with
breaking it (
Paper to print zero tolerance
policy for all nurses to sign and
file in employee file.
Committee created to
evaluate all disruptive
behaviors complaints to
evaluate magnitude of offense,
feasible consequence, and keep
data regarding disruptive
behaviors

16
10

$2,688

$26,880

200

$2

$400

$1,920

$17,280

Grand Total $1,618,815

*Hourly pay is based off of a $48 per hour salary. Rate is based on pay for each nurse for
entirety of workshop or training