Management of disruptive behaviour within nursing work environments: a comprehensive systematic review of the evidence

Abstract

Background: In an increasingly complex health care environment, where nurses are essential to the health system's capacity to respond to the challenges presented by an ageing population, creating positive work environments is fundamental for nurses, their co-workers, and their patients. Disruptive clinician behaviour, which refers to behaviours such as bullying and physical violence, but also to more subtle behaviours such as withholding vital information or gossiping, can be highly destructive within a work environment. The implications of such behaviours within the nursing workforce specifically, and to the health care system more broadly, are profound. Substantial evidence suggests that the pervasiveness of such behaviours has consequences for recruitment and retention, staff morale, job satisfaction, and staff absenteeism, as well as intra and inter-professional communication and teamwork which can ultimate also affect patient safety. The extent of the problem of disruptive behaviour in the workforce is discussed widely in the literature and nurses as a cohort have been studied extensively, however there has been no systematic review of evidence relating to how to manage these behaviours successfully.

Objective: The objective of this systematic review was to appraise and synthesise the best available evidence in relation to interventions which have been successful in managing disruptive clinician behaviour in the nursing work environment.

Inclusion criteria: Types of participants - The primary participant group of interest for this systematic review includes nurses working in any health care setting; however any other member of the health care team such as medical practitioners or allied health were also considered.Types of intervention(s)/phenomena of interest - Any study that explored behavioural, educational, managerial, organisational and personal interventions to manage disruptive behaviours in the health care setting was considered.Types of studies - Studies using quantitative and qualitative methods as well as opinion based papers were considered for this systematic review.Types of outcomes - Outcomes were assessed in relation to the effect of interventions on patient safety and quality of care, quality of team work and work environment, levels of job satisfaction and nursing staff morale as well as levels of staff retention.

Search strategy: Searches were conducted including any published and unpublished material, including grey literature, in the English language. A search of CINAHL, Medline, Medline-in Process, PsychINFO, Emerald and TRIP was undertaken using specifically defined terms and synonyms. Scirus, OpenSIGLE and Google Scholar were also searched. A search of electronic dissertations via Dissertation Abstracts was undertaken.

Methodological quality: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information' (SUMARI) developed by JBI.

Data collection: Data was identified as quantitative or qualitative data or opinion based and data extraction tools developed by the Joanna Briggs Institute were used to extract the data, where possible. Where this was not possible, findings were presented in narrative form.

Data synthesis: Data were synthesised according to their methodological approach. Qualitative data were pooled using the QARI instrument and a set of statements were developed that represented a broader overview of a specific aggregation RESULTS: A total of 24 papers, descriptive quantitative, qualitative and textual in approach, were included in the review. The majority of the papers were textual, with a variety of expert opinion provided in relation to managing disruptive clinician behaviour.

Conclusions: Comprehensive review of the literature identified that there has been very little research evaluating the effectiveness of interventions to manage disruptive clinician behaviour in nursing, or more broadly within the health care system. A handful of studies involved localised interventions followed by a qualitative evaluation, with useful but not generaliseable findings. These studies emphasised personal, peer and educational approaches to assist those nurses affected by disruptive clinician behaviour within their work teams, but none were related to specific management strategies aimed at the person exhibiting the disruptive behaviour. Most recommendations in the literature were expert opinion. These recommendations emphasised the importance of a clear and consistent organisational approaches to disruptive clinician behaviour.