Published On November 11, 2022
It seemed like a minor incident. Peckish between cases, a top physician at a major health system grabbed an apple from a table in the hospital’s breakroom. But to the nurse who expected to eat the fruit, this was one insult too many. “Dr. Smith” often did things to rub people the wrong way. He was routinely condescending and once barked at a nurse, in front of a patient, to stop asking stupid questions. So this time, the owner of the pilfered apple filed a formal complaint.
Smith thought what he’d done was trivial. Yet the nurse’s choice to escalate the encounter—a matter for the hospital’s review and possible censure—is emblematic of a turning point in attitudes toward the much larger problem of small indignities, a souring of good behavior among doctors, nurses and other health care workers. The problem of incivility is pervasive and can compromise performance and safety. “We’re here to take care of people, and we forget to take care of each other,” says Linda Groah, a nurse and chief executive officer of the Association of periOperative Registered Nurses (AORN), one of several national nursing organizations working to raise awareness of the problem.
In many walks of life, rudeness is on the rise. Anger and toxicity are hallmarks of social media platforms. Research shows that rude behavior spreads like a virus, not only through people who experience it but also through those who witness it, and recent polls suggest most Americans believe incivility has risen to crisis levels. It’s a particular problem in the workplace, where three out of four employees report they experience rudeness on the job at least once a week.
But health care may be a hot zone for bad behavior, with verbal abuse and physical threats from colleagues and patients, ratcheted up during the COVID-19 pandemic, now at record highs. Small-scale irritants—eye-rolling, demeaning comments, gossip and a lack of cooperation—contribute to a general climate of disrespect and can lead to angry outbursts, verbal abuse and bullying. Soon, behavior may escalate to a level where it has legal consequences, with formal complaints for harassment, discrimination and even physical violence. Last May, a female surgeon filed a lawsuit accusing NewYork-Presbyterian/Columbia University Irving Medical Center of tolerating a “toxic culture of gender discrimination.”
Incivility within medical teams can have dire results for other workers as well as patients. It may take the focus away from essential tasks, leading to medical errors and substandard care. It also drives employees to leave their jobs during these days of rampant workforce turnover. “Now people across medicine have changing expectations about civility and improving how we should be treated,” says Jo Shapiro, associate professor of otolaryngology–head and neck surgery at Harvard Medical School. But reforming ingrained patterns of behavior, one colleague at a time, won’t happen quickly.
The word civility is derived from civilis, Latin for “the state of being a citizen.” Daniel Buccino, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore, describes it as an essential part of the social contract, a “benevolent awareness, a sense of respect for oneself and others.”
Buccino heads the Johns Hopkins Civility Initiative, founded in 1997 by the late P.M. Forni, a professor of early Italian literature and author of Choosing Civility: The Twenty-Five Rules of Considerate Conduct. For more than two decades, the initiative has been researching the place of civility in society and has sought to encourage its practice. Yet although the idea of civility continues to resonate, Buccino says, in practice it has been on the decline for many years. “There’s so much more emphasis on individualistic pursuits and success than on what we might achieve collectively,” he says. Add the stress of the pandemic and the anonymity of the internet, and the erosion of kindness and consideration seems inevitable. “The prevalence of incivility and disrespect in the workplace has spiked,” says Christine Porath, associate professor at Georgetown University’s McDonough School of Business, who has studied uncivil behavior in nearly two dozen industries, including health care.
In Porath’s research, health care ranks as one of the least civil industries, with its unique stresses triggering unkind and disruptive behavior. Moreover, medicine has long been built around a rigid, male-dominated hierarchy that tolerates brusque behavior from the physicians on top—at the expense of those who aren’t male and aren’t doctors. “The culture of uncivil behavior in health care didn’t happen by mistake,” says Stephen Paskoff, chief executive officer of Employment Learning Innovations, an Atlanta consulting firm that helps organizations create civil environments.
“This is a health care culture in which mentors traditionally abuse trainees on every level,” says Kit Bredimus, chief nursing officer at Midland Memorial Hospital, a teaching hospital in West Texas. “The old methodology was ‘tear you down to build you up.’” But many younger students and trainees now refuse to accept that approach. Younger surgical nurses, says AORN’s Linda Groah, show little tolerance toward the behavior their older peers have endured, and many are choosing the exit door. “They can’t believe the things mentors have told them they may have to put up with,” she says. “Their response is, ‘No, I don’t.’”
Many physicians, lulled by an abusive status quo, don’t even realize they’re part of the problem. “A surgeon told me recently that until he received some very frank feedback, he had no idea most people thought he was a jerk,” says Porath. “He was treating residents the way he’d been trained.” There’s also a persistent star system in medicine, in which the bad behavior of rainmakers is tolerated. “Physicians who are big revenue generators are given a pass when it comes to offensive behavior,” says an internist at a Pennsylvania hospital.
In national surveys conducted in 2003, 2013 and last year, the Institute for Safe Medical Practices asked health workers about disrespectful behavior and workplace intimidation. Respondents through the years have cited incidents of being demeaned by fellow workers. But in the more recent surveys, workers have noted a rising proportion of insults targeting race, religion and gender, and they’ve reported more and more disrespect happening online, through emails and in virtual meetings. Reports of physical assaults have also doubled since 2013.
Incivility within medical teams can have dire results for other workers as well as patients.
A 2022 Medscape survey of 1,500 physicians found that more than 80% said they had witnessed bullying and harassment by other doctors. Offenders were mostly male and in their 40s, and respondents identified oversized egos as a frequent source of trouble. But this awareness of the problem went only so far, with 85% of those surveyed saying their own conduct hadn’t contributed to the problem.
Emerging statistics about burgeoning workplace incivility almost certainly understate the problem because so much bad behavior goes unreported. “We encourage people to report incidents of rudeness and bullying, but even today there exists a power gradient that often prevents reporting,” says Diane Colgan, a physician at Johns Hopkins Medicine-Suburban Hospital in Bethesda. Physicians also tend to resist reporting their colleagues, she says, “no matter how egregious their behavior may be.”
Long-standing efforts to address workplace violence and other high-level behavioral problems are now being adapted to encompass rudeness. For example, The Joint Commission, an accrediting organization, last year updated 15-year-old requirements for hospitals to now include a broader definition of workplace violence that encompasses any disruptive or potentially harmful behavior, including verbal aggression and attempts to humiliate, sabotage or intimidate fellow workers.
Rudeness, often thought to be at the bottom of the scale of bad behavior, is increasingly being studied for the harm it can cause. A 2015 study published in Pediatrics showed how rudeness may sabotage cognitive processing and weaken team collaboration. It’s a pervasive issue in perioperative care, and in one survey, 98% of clinicians said they had witnessed disruptive behavior in the past year, which in a 2019 study in BMJ Quality & Safety was found to interfere with clinical performance. In a trial that included dozens of surgical teams at multiple institutions, anesthesiology residents exposed to rudeness showed decreased vigilance, communication and teamwork, and scored lower on every measure compared to simulations in which a surgeon was polite.
Other research suggests rudeness can amplify “anchoring bias,” the tendency to base decisions solely on the first piece of information received in a situation. Prior analyses have shown that anchoring is by far the most common cognitive error in medical diagnoses, and a study last year in the Journal of Applied Psychology showed that anesthesiology residents interrupted by rudeness from another physician were more likely to stick to an initial, anchored diagnosis, ignoring evidence that it was wrong.
Several doctor and nursing groups are now trying to raise the bar on civil behavior. Last March, the American College of Cardiology (ACC) issued a policy document on building respect, civility and inclusion in the cardiovascular workplace, and in October 2021 AORN and two other nursing organizations—the American Association of Nurse Anesthesiology and American Society of PeriAnesthesia Nurses—released a position statement on the need for workplace civility. Both documents urged health care organizations to adopt comprehensive policies. The ACC wants to see better awareness of the importance and prevalence of incivility, as well as clear repercussions for physicians and others who fall short. And although the problems of sexual harassment, discrimination and bullying are priorities for the group, the need to address more subtle forms of disrespectful behavior also became apparent during the project’s nearly two-year development, says Pamela Douglas, a cardiologist and professor of medicine at Duke University School of Medicine who helped write the document.
One institutional response to growing incivility is to make it easier to report. More than 180 U.S. health care systems (and dozens outside the country) have adopted the Co-Worker Observation Reporting System. Developed by Vanderbilt University’s Center for Patient and Professional Advocacy (CPPA), the program compiles complaints electronically, processes the data and sends back reports to participating institutions. It has accrued data on some 100,000 physicians and advanced practice professionals, says Gerald Hickson, a physician and a founder of the CPPA. Complaints have been made against doctors of all ages, and 93% of reports involve acts of disrespect rather than bullying, sexual harassment or physical threats.
In a model developed by CPPA, consequences increase as the number of reported incidents rises. The actions of Dr. Smith, who stole the apple, are described in a paper published in The Joint Commission Journal on Quality and Patient Safety. Following CPPA guidelines, Smith was notified of the nurse’s complaint and invited to discuss the incident over a cup of coffee with a trained physician mentor. Normally, the coffee meet-up is sufficient, Hickson says. But a fraction of offenders tend to account for a large number of complaints, and their misconduct may require escalating interventions. Smith was also required to have a performance evaluation, including a physical and mental health assessment, and his service chief met with him monthly to monitor his performance and see whether he needed additional support, such as coaching, or even disciplinary action.
“This wasn’t just about a pilfered apple, but rather one of many signals of a human in trouble,” Hickson says. Sometimes bad behavior is triggered by a heavy workload or other situational factors, but it can often be traced to personal issues, such as addiction, family problems or an inability to handle stress. “The goal of our work is to maximize the probability that the people having trouble can receive support, treatment or whatever else may be needed to help them remain as a productive part of a medical team.”
But sometimes behavior remains toxic, and hospital leaders need to rethink their tolerance even for star performers. As hospitals implement escalating interventions, habitual offenders will sometimes be fired or leave. But even then, about a fifth of the time, a fired physician will show up at another CPPA partner hospital and again appear in the reporting system. “We see people go from site to site and create problems in the new environment,” Hickson says.
Some health systems are now rolling out campaigns that emphasize civil behavior as an organizational priority. But tackling incivility requires a sustained commitment, says Stephen Paskoff of Employment Learning Innovations. “The problem isn’t a lack of policies and rules—everyone has those,” he says. The challenge is implementation.
At Texas’s Midland Memorial Health, that has meant taking the long view in a campaign now in its eighth year. The facility has implemented a checklist of strategies to improve working relationships. These include a new mission statement and an employee pledge to refrain from complaining, bullying, gossiping and engaging in other toxic emotional behaviors.
The pledge is displayed on posters throughout the hospital, along with a “Civil Proclamation” declaring that incivility and a list of other disruptive behaviors won’t be tolerated. All 2,200 employees have been required to complete one or two days of training.
Although the pandemic brought an uptick in disruptive incidents, the civility initiative seems to be helping, says chief nursing officer Kit Bredimus. “Part of our push has been to get employees to bring up these issues, document them and know that we are actually addressing them,” he says. The results of employee surveys have been largely positive, he says, and Midland Memorial is the only hospital in its West Texas area that hasn’t had to resort to sign-up bonuses to draw in potential nurses in a highly competitive market.
In 2016, at UMass Memorial Health, the largest health system in central Massachusetts, the results of an employee engagement survey made clear that many of the staff didn’t feel respected. A grassroots group of clinicians and staff then pushed for changes that eventually spread to the system’s two other community hospitals and to multiple clinics. More than 5,000 employees participated in a survey about respect, which in turn served as raw data for a civility campaign. It was based around what organizers dubbed the six standards of respect, which include listening, being kind, being responsive and being a team player.
Sometimes behavior remains toxic and hospital leaders need to rethink their tolerance even for star performers.
The health system’s leaders used the six standards as a starting point for a systemwide overhaul. It included rewriting the employee code of conduct and launching training workshops for the system’s 17,000 employees. Now, a manager feedback program gives employees a tool to suggest how managers can improve how they demonstrate respect, and UMass Memorial is updating its workplace violence reporting system. “We still have a way to go, but we’re doing a much better job of addressing disruptive behaviors,” says Tod Wiesman, UMass Memorial interim chief human resources officer. So far, the campaign has led to higher scores on patient satisfaction and employee engagement survey items about respect.
In 2019, MGH launched a program called Know the Line to prevent abusive workplace conduct, and the program has since been adopted across the Mass General Brigham system, providing a common language and approach for all organizations. Know the Line attempts to standardize training, content and reporting for culture and behavior, says Christine Pierga, vice president, employee relations and labor strategy. “We wanted something comprehensive to address the climate of the organization in a way that was educational and supportive, and not primarily disciplinary,” Pierga says. “We want people to have a way to interact with each other in a less confrontational way. We want to create an opportunity for a pause or a reflection when someone’s behavior doesn’t conform to expectations, a moment that can lead the conversation in a better direction.”
People can learn civility on the job, says Georgetown’s Christine Porath, and the benefits are clear. Her research shows that employees considered to be civil were more likely to be consulted for information and twice as likely to be seen as leaders, and nearly three out of four survey respondents said they would work harder for someone who treated them with respect. Organizations that have reformed their policies have begun to move the needle. “The number one thing that people seem to want is the sense of feeling valued,” she says. “They want respect.”
Mastering Civility: A Manifesto for the Workplace, by Christine Porath, Balance, 2016. Porath’s rigorous research shows what incivility is costing leaders and organizations and offers practical suggestions for building a more productive work culture.
“2022 American College of Cardiology Health Policy Statement on Building Respect, Civility and Inclusion in the Cardiovascular Workplace,” by Pamela S. Douglas et al., Journal of the American College of Cardiology, May 2022. A comprehensive report on the range and consequences of uncivil behaviors in the cardiovascular workplace, as well as strategies for improvement.
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