Medicine requires teamwork. To achieve the best outcomes for a patient, a team needs to perform well. Good relationships between clinicians can help a team run like a well-oiled machine. There are many elements that contribute to good relationships, and being civil, or nice, is one of these. On the flip side of this, therefore, is incivility. Rudeness can manifest easily within a team. And like a faulty cog, incivility can cause a breakdown. The negative effects of incivility include reduced performance and it negatively impacts the clinical outcomes of our patients.
You get to your morning clinic and the senior doctor is already in a bad mood. They woke up late this morning because they forgot to set an alarm. They didn’t have time for breakfast and don’t have time for coffee now. The clinic is full and one of your colleagues has called in sick. You ask them a simple question about a patient and they shout at you. Does this sound familiar?
We have had several run-ins with senior colleagues like this. Doctors who are frequently rude find it easier to be rude again. Like flexing a muscle. One junior doctor we know was so scared of facing such rudeness, that he didn’t inform a senior about a new patient he admitted. He waited until handover, a few hours later, to mention the patient – a woman in A&E with severe lower abdominal pain. A woman who likely needed urgent surgery for suspected ovarian torsion. A woman who was now at risk of losing her ovary. A patient at risk of a worse outcome. Simply because a senior had been rude and unsupportive to the junior doctor.
Christine Porath is an Associate Professor of Business in the US. Christine has done a multitude of office-based research into the impacts of incivility. She found that people who experience incivility in the workplace waste time dwelling on the rudeness[1]. They can even become less committed to their work. And they can lose time avoiding the person who was previously rude to them. Almost half of the recipients spent less time at work, and over 10% will leave completely. If you consider this within healthcare, you can imagine the effect it would have on our ability to do our work. And therefore, the negative effects of incivility on our patients.
The effects of incivility don’t stop there. They have been shown to have a wider impact than you might initially think. Like a stone being dropped in a large pond. The ripples spread out amongst those around, not just affecting the subject of the rudeness. People who witness incivility show reduced performance and are 50% less likely to help others[1]. If a patient sees this happening, they will have less trust in the organisation and will feel anxious dealing with other staff members.
Gradually we are seeing more scientific papers highlighting the impact of rudeness on clinical performance. A randomised control study by Riskin et al.[2] observed neonatal resus teams working on a simulated emergency scenario, assessing their diagnostic and procedural performance. The groups were either exposed to rude comments or neutral comments during the emergency scenario. They found that the team that faced the rudeness performed worse. Rudeness alone explained nearly 12% of the variance. Put simply: when someone in a team is uncivil, that team is negatively affected and so is their patient.
So what can we do with this information? We were keen to find out. We had a meet up in a coffee shop with Dr Chris Turner, Emergency Medicine Consultant, after which we all felt a responsibility to share a message. A message that when spelled out sounded so simple. “Being rude negatively affects patients”.
We could all recall times when we had experienced incivility. Either as a recipient, an observer, or even from ourselves. Talking about those experiences, reliving them, and reflecting on them, emphasised the desire to promote the message. We found an increasing wealth of research to back it up. Yet we had never been part of any team or department where this was discussed or reviewed.
Billions of dollars are spent every year on medication. With very clear measurable outcomes and impacts on patient survival. Yet the numbers don’t compare to the demonstrable impact from removing incivility. Therefore we wanted to tell people about this.
Since we have started our work, our message has resonated with individuals and institutions alike. We feel there is a clear need for greater awareness and perhaps a more prominent inclusion in guidance and policy. It’s hard to argue the facts, but knowing what to do next is complicated. Challenging uncivil behaviour is a delicate and tricky task. Even identifying uncivil behaviour can be difficult, as it is subjective in the eyes of the recipient. One way we can start to address incivility is through self-reflection. Ask yourself, “could what I’m saying be interpreted as rude?”. If the answer is yes, then the first step is to apologise!
The next time you find yourself late for work, hungry, short-staffed and in a bad mood, take a second to think before you snap. Be mindful of our simple message: Civility Saves Lives.
For more information, see www.civilitysaveslives.com or check out our twitter on @civilitysaves.
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Renee Blanding
September 9, 2019 at 10:11 pmWe are starting the framework for a civility and professionalism learning community at Johns Hopkins Medicine in Baltimore, MD/USA. I would love to talk to you about your civility efforts. Thanks and I hope to hear from you soon.