Disruptive behaviour
– symptom, cause or both?
Professor Alastair Scotland – Medical Director
Dr Jenny King – Chartered Psychologist
Dr Gwen Adshead – Consultant Forensic Psychotherapist
What you think you are looking at
may not be what you are seeing
– ten years experience at NCAS
Professor Alastair Scotland – Medical Director
NCAS Annual Conference 2011 - Disruptive Behaviour
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Overview
•
What NCAS sees – what we are told
•
•
So what might be underlying this
•
•
•
Alastair Scotland – “What you think you are looking at may not be
what you are seeing: ten years experience at NCAS”
Jenny King – “Disruptive behaviour: what lies beneath”
Gwen Adshead – “Clinicians behaving badly: conduct and behaviour”
But first – some definitions
•
Conduct
•
•
a specific
ifi iincident
id
which
hi h b
breaches
h operating
i rules
l and
d may llead
d to
disciplinary action – eg “He attacked him”
Behaviour
•
How an individual typically acts and interacts with others at work – eg “He
is bad-tempered”
Who contacts NCAS and why
•
1 doctor in 200 and 1 dentist in 250 referred to NCAS each year
•
•
•
•
•
•
•
c1000 referrals yearly
3 in 4 NHS organisations refer at least once a year
M
More
than
th half
h lf working
ki with
ith us att any time
ti
Used equally, regardless of type or ‘organisational rating’
Small but consistent self-referral rate – about 3%
Overlap with professional regulators very small
Certain groups more likely to be referred
•
•
•
•
•
Older
C
Consultants
lt t – and
d career grades
d more generally
ll
Men
In secondary care, non-white doctors qualifying outside the UK
Substantially more likely for single-handed than in practices of 4 or
more
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What concerns come forward
behaviour / conduct – 57%
clinical concerns including
governance / safety 62%
27%
20%
30%
4%
5%
6%
6%
health concerns 22%
Base: 2947 cases handled Dec 2007-Mar 2009
The NCAS performance triangle
Work
Context
Clinical
Knowledge
& Skill
Skills
Health
Behaviour
Adapted from Jacques et al, Québèc
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Non-clinical concerns coming forward
•
Conduct
•
•
•
Organisational
•
•
•
Theft / fraud / financial; breach of contract; breach of confidentiality
Misuse of resources / equipment
Use of legal or illegal pornography at work
Personal
•
•
•
Sexual misconduct
Assault; threatening behaviour; bullying; harassment
Unfair discrimination
Behaviour
•
•
Organisational
•
•
•
Communication; teamworking
Leadership style; decision-making; conflict management style
Workload management
Personal
•
•
Aggressive / antagonistic; erratic / unpredictable / emotionally volatile
Withdrawn / isolated / uncommunicative
Non-clinical concerns coming forward
•
Health
•
•
•
•
•
Physical or mental health or disability
•
•
Mental – eg changes in mood, concentration, energy / fatigue, memory
Physical – eg mobility, manual dexterity, lifting and carrying, sight
Potential problems with cognition – eg problem solving / planning
Specific issues affecting performance – eg mental health, alcohol or
drug misuse, anxiety / stress / burnout
Work environment
•
Teamworking – eg communication, workload management, role
definition, leadership / decision making / conflict management style
•
Support systems – eg for teamworking
teamworking, personal development ,
induction
•
Other resource issues – eg workload, accommodation, facilities
Other personal factors
•
eg relationships, family pressures, bereavement, finance
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All concerns coming forward
Behaviour other than conduct
Conduct
Health
Personal circumstances
Work environment influences
Clinical or governance
0
10
20
30
40
50
60
70
Per cent of cases
•
Health concerns more prominent
•
•
•
•
White and UK-qualified practitioners
Psychiatrists
Pharmacists (small sample)
Clinical and governance concerns more prominent
•
•
GP sector
Older and higher grade practitioners
Base: 2972 cases handled Dec 2007-Oct 2010
Behavioural concerns with age
100%
Per cent of cases with known
n age
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
<30
30-34
35-39
40-44
45-49
Not behavioural
50-54
55-59
60-64
65-69
70+
Behavioural
Base: 2347 cases
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Behaviour alongside everything else
Pe
er cent of concern groups in a
age group
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
Clinical/governance
Work environment
Personal circumstances
Health
Conduct
Behaviour
70+
Base: 3821 concerns recorded in 2347 cases
Are we simply seeing the U-bend of life?
Self-reported well-being, on a scale of 1-10
7
68
6.8
6.6
6.4
6.2
6
5.8
18-21
26-29
34-37
42-45
50-53
58-61
66-69
74-77
82-95
US data quoted in The Economist – 18 Dec 2010
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Behaviour and conduct concerns by group
Training grades (234)
Other H&C career grades (448)
Consultants (1053)
General medical practice (860)
Surgery/O&G (573)
Psychiatry (306)
General medicine (230)
Pharmacists (70)
Dentists (337)
Doctors (2565)
Qualified outside EEA (980)
Qualified elsewhere in EEA (308)
UK qualified (1357)
UK-qualified
White (1052)
Non-white (1046)
0
10
20
30
40
50
60
Per cent of cases
Behaviour
Conduct
Base: see bars – cases handled Dec 2007-Oct 2010
Are behaviour and conduct associated?
Per cent of cases with conduct con
ncerns
60
General medicine
50
Other medical specialties
40
Psychiatry
ALL CASES
Surgery/O&G
30
Dentistry
General medical practice
20
10
0
0
5
10
15
20
25
30
35
40
Per cent of cases with behavioural concerns
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What we are told – themes
•
•
Demographic
•
•
Younger and training grades – conduct issues more prominent
•
•
Ethnicity and place of qualification – perhaps more health concerns
Consultants in H&C sector – behavioural concerns more common,
rising into middle age and then declining
Women – fewer conduct issues; perhaps more behavioural concerns
Professional and specialty
•
Dentistry and pharmacy – fewer behavioural concerns but perhaps
more conduct issues
•
General medical practice – clinical / governance / safety concerns
more prominent, but fewer behaviour and conduct issues
•
General medicine – behaviour and conduct issues more prominent
but fewer clinical / governance / safety concerns
•
Psychiatry – communication concerns more prominent, but fewer
clinical / governance / safety concerns
Disruptive behaviour:
What lies beneath
Dr Jenny King DPhil CPsychol AFBPsS
Director
Edgecumbe Consulting Group Ltd
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Disruptive behaviour
“A physician [doctor] with disruptive behaviour is one who cannot or will
not function well with others to the extent that his or her behaviour, by
words or actions, interferes or has the potential to interfere with quality
healthcare delivery.”
The College of Physicians and Surgeons of Ontario, Canada
Disruptive behaviour: What lies beneath
Disruptive
Behaviours
Psychological factors
Training &Education
Workload; sleep loss
Family pressures
Organisational
culture
Health problems
Source: “Understanding Doctors’ Performance” (Eds) Cox J, King J, Hutchinson A and McAvoy P, Radcliffe Press,2006
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Personality at work – the ‘Big Five’
•
Emotional Stability
•
•
Extraversion
•
•
How open to new experiences and change?
Agreeableness
•
•
How sociable?
Openness
•
•
How resilient?
H
How
collaborative?
ll b ti ?
Conscientiousness
•
How diligent and focussed?
Source: Costa and Macrae, 1982
Analysis of 279 doctors referred to NCAS: Personality profiles
What we expected
What we found
More emotionally reactive
Somewhat more reactive
More introverted
More introverted
Less open
Less open
Less agreeable
Much MORE agreeable
Less conscientious
Similar to the working population
Under pressure: More arrogant
Under pressure: More perfectionist and more
dependent (anxious to please)
Analysis of 279 doctors referred to NCAS 2002-09; Norm group - UK working population
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Managing overplayed strengths
•
Disruptive behaviour comes from a strength overplayed
•
Eliminate the problem behaviour and you lose the strength
•
So RETAIN the strength but RESTRAIN and set limits
C.L.A.D.A. – a diagnostic framework
Factor
What is it?
Options for Resolution
Capacity
A fundamental limitation that is
y to change
g
unlikely
Change job, specialty, or career
Learning
A deficit of knowledge, skills or
experience
Training (adapted to learning style);
feedback (e.g. 360°)
Arousal
Boredom ; stress; burn-out; low morale
Coaching, counselling, mentoring;
new project/role/manager
A problem elsewhere causing a
problem here
Specialist support; set limits; make
“reasonable” adjustments
Deep rooted anger/embitterment
leading to sabotage
Move out of the
organisation/department;
therapeutic support
(Motivation)
Distraction
(including Health)
Alienation
Source: Edgecumbe Consulting Group Ltd
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The intractable problem
•
Are there some problems that never go away – if so, which, and what can
be done with these?
•
For example
•
•
•
•
Longstanding “grievance and grudge”
Some health problems
Ingrained behaviour patterns plus lack of insight
Set limits;; use a behavioural contract;; ring-fence
g
where p
possible
Clinicians behaving
g badly:
y
Conduct and behaviour
The relevance of personality
Dr Gwen Adshead
Consultant Forensic Psychotherapist
NCAS Annual Conference 2011 - Disruptive Behaviour
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Rules make social spaces work
„
„
„
„
Formal rules: laws, codes of conduct,
policy
li directives
di ti
Informal rules: implicit and explicit
agreements, based on inherent
mentalising faculty
Empathy sympathy
Empathy,
sympathy, social emotions
Recognition of boundaries between
persons
Rule breakers are boundary
breakers
„
„
„
„
Formal or informal boundaries
The boundary and distance between
people: hence moving toward or away or
against
Social boundary breaking causes alarm in
groups
People who break the rules get excluded
from groups
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Relevance of personality
„
„
„
„
Each person’s personality marks the
b
boundary
d
off the
th space between
b t
people
l
SO people with personality problems
struggle with interpersonal stress
Personality function has fixed and dynamic
elements
Behaviours communicate the mind of the
personality: so also fixed and dynamic
What good personality traits does
the medical culture select for?
„
„
„
„
„
„
„
Extraversion: being positive, taking charge
Cooperativeness
Conscientiousness and diligence
Agreeableness
Open-ness
Commitment and persistence
Mild obsessionality
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What less good personality traits
does the medical culture select for?
„
„
„
„
„
Narcissism: I am the greatest
Perfectionism: I must do this right and
mistakes are intolerable in me/others
Compulsiveness: I have to do this, and I
can’t give up till I finish
Denigration of vulnerability: People who
need help are failures
Shame: if I am in need, I am a failure
What less good personality traits
does the medical culture select for?
„
„
„
„
„
Narcissism: I am the greatest
Perfectionism: I must do this right and
mistakes are intolerable in me/others
Compulsiveness: I have to do this, and I
can’t give up till I finish
Denigration of vulnerability: People who
need help are failures
Shame: if I am in need, I am a failure
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Personality: disorder, dysfunction
and disorganisations
Disorders (4%)
Clinical dysfunctions
Disorganised stress reactions
Mild dysfunctional
y
stress reactions
Functional responses to
stress
Personality disorder ( PD)
„
„
„
„
„
Only 4% in the community overall
Only 1% of the most severe kind
Severe and highly dysfunctional PD is rare
in doctors because selected against
BUT mild-moderate dynamic dysfunction
may be common in certain group
situations
Also associated with depression and
substance misuse
NCAS Annual Conference 2011 - Disruptive Behaviour
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IPDE RESULTS – (COHORT 84)
IDPE REPORT RESULTS
50
45
40
35
30
No of Dx (4+ +ves)
25
%
20
15
10
5
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ID
O
AV
EP
EN
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AN
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R
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SI
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IA
L
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AN
IS
TO
H
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P
IZ
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H
IC
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ID
IZ
O
H
SC
SC
PA
R
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ID
0
Take home messages
„
„
„
„
Rule breaking clinicians of any sort are
unusuall
So they stand out and cause alarm,
distress and anger in those around them
Early intervention would help: not just
identification
Real issue about provision of services:
NHS needs to think about costcost-offset
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