As departmental leader, one of the staff comes to you concerned about an unsettling episode. One of your team reportedly went on a “rampage” when the clinic was overbooked, raising their voice and belittling staff. This particular employee is known to have a ‘strong personality’. Should you let this go, take on the problem yourself, or censure the individual?

A foundational need of a successful institution is appropriate behaviour. Only if individuals feel safe and respected can you achieve their maximum effectiveness and productivity, both individually and in teams. When behaviour interferes with the quality of care it can be considered ‘disruptive’. Managing disruptive behaviour is fraught with difficulty. How do you address disruptive behaviour? What process should you follow? How do you remediate behaviour and maintain respectful working relationships? How do you avoid lawyers and lawsuits?

As the leader, be clear in your personal values, how you wish people to act and interact. You must model the behavioural standards you wish to create. However, that’s only the beginning. As noted in my prior post (Vision/Mission), establishing appropriate behaviour starts with institutional values. The values endorsed by the group set expectations. Throughout multiple posts I have suggested collegiality and respect are vital to success as a leader. You must make those values real through positive reinforcement. But you also need explicit policies and procedures with enforcement to ensure the values are consistent with the institutional culture. Institutional standards for behaviour include codes of conduct and/or respect in the workplace policies. Codes of conduct provide a framework for setting standards of behaviour.

Leaders need an explicit procedure to investigate and, if need be, manage disruptive behaviour. Confronted with allegations, how do you start? The entire process begins with a written complaint(s). Only with a written complaint can formal processes be invoked. You can’t act formally on anonymous complaints or hallway concerns. Hallway concerns might prompt you to speak with the individual, but a process can’t be formal until the complaint is written. The first step in responding to a formal complaint is to make sure that all staff are safe. Specifically, throughout all stages of the investigation, it is essential that the complainant be protected from retribution. However, never forget that it is also essential that the respondent be afforded due process and confidentiality: don’t jump to conclusions. Finally, if the complaint is based on sexual or criminal behaviour/harassment, then policies, other than disruptive behaviour, are usually invoked.

Having received a written complaint, the urge of many leaders is to jump in and “solve” the problem. If the issue is minor, or simply one of miscommunication, then a low-level informal intervention by the leaders is usually satisfactory and appropriate. However, if the complaint is more serious, then a formal process will need to be followed. The difficulty of the direct supervisor/leader attempting to mediate a serious complaint is that if the mediation is unsuccessful, then the leader cannot adjudicate disputes between complainant and respondent. This often happens when either or both the complainant and/or respondent are unhappy with the mediation. Rather than attempting to resolve issues, the role of the leader should be to guide the process and respond to any findings of the investigation.

A formal complaint requires a formal investigation. The investigation should be performed by a senior clinician that is not the direct supervisor of the individual. Given that the process may be challenged at a later stage, the senior clinician should generally be paired with a Human Resource partner. As noted above, confidentiality needs to be maintained at all stages. Through individual interviews, both the complainant and the respondent should have fulsome opportunities to present their sides of the dispute. Witnesses may also need to be interviewed. Through the investigative process, it may become clear that the precipitating event(s) that led to the individual’s disruptive behaviour is/are legitimate. These events require attention. However, the focus of the investigation should be on whether the response to the event was appropriate or inappropriate. In the case of disruptive behaviour, the response would be judged inappropriate.

The outcome of the investigation may be substantiated, unsubstantiated, or unclear. If the complaint is substantiated through the investigation, then the prime focus should initially be remediation of the individual’s behaviour. In addition to acknowledging and addressing the precipitating events, mitigating factors for the event need to be explored such as personal, financial or health issues. Having judged the behaviour to be disruptive and the complaint substantiated, there are several potential responses to a complaint; an apology by the respondent to the complainant, supervised meeting(s) between complainant and respondent to address the concerns, and/or counselling for the respondent. In addition, substantiated complaints need to be documented in writing from the leader to the respondent, with explicit expectations for satisfactory behaviour and consequences for any subsequent events. If the process has been fair, most individuals will respond by changing their behaviour. However, despite best attempts, some individuals will continue to act disruptively. The response to any future events if they occur should be graduated with more significant consequences. Short of suspension, one consequence should be enforced counselling for the individual.

Repeated substantiated and documented disruptive behaviour, despite reasonable attempts to remediate, ultimately will lead to suspension or revocation of privileges and appointment. For leaders, it is important to recognize that for most disruptive individuals, the individual disruptive events are often not egregious. The individual usually acts out in multiple ways over prolonged periods of time, thus creating a pattern of behaviour. This becomes particularly important in an event that “breaks the camel’s back”. While the pattern of behaviour may be well known, the final event, albeit disruptive, is usually not a major event. Repeated events need to be documented each time in writing. Documenting each event provides the pattern of cumulative disruptive behaviour.

In summary, appropriate management of disruptive behaviour is critical for a successful and productive group. While the aim is remediation, any policy and procedure must ensure that any consequences are well supported by explicit documentation.