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Academic Papers

We hope to create a library of important and relevant papers published in the field of civility in healthcare for your reference.

This list isn't exhaustive, so be sure to do your own searches!

August 31, 2015

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

Arieh Riskin, Amir Erez, Trevor A. Foulk, Amir Kugelman, Ayala Gover, Irit Shoris, Kinneret S. Riskin, Peter A. Bamberger ​ Pediatrics. September 2015, VOLUME 136 / ISSUE 3



Iatrogenesis often results from performance deficiencies among medical team members. Team-targeted rudeness may underlie such performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Our objective was to explore the impact of rudeness on the performance of medical teams.


Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by 3 independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing, and help-seeking.


The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [P = .005] and 2.8 vs 3.3 [P = .008], respectively). Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. A model specifying information-sharing and help-seeking as mediators linking rudeness to team performance explained an even greater portion of the variance in diagnostic and procedural performance (R2 = 52.3 and 42.7, respectively).


Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.

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May 30, 2019

Exposure to incivility hinders clinical performance in a simulated operative crisis

Daniel Katz, Kimberly Blasius, Robert Isaak, Jonathan Lipps, Michael Kushelev, Andrew Goldberg, Jarrett Fastman, Benjamin Marsh, Samuel DeMaria



Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.


This is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or ‘rude’ environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups.


76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112).


Although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

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March 24, 2011

The price of incivility.

Porath C, Pearson C. Harv Bus Rev. 2013 Jan-Feb;91(1-2):114-21, 146


We've all heard of (or experienced) the "boss from hell." But that's just one form that incivility in the workplace can take. Rudeness on the job is surprisingly common, and it's on the rise. Whether it involves overt bullying or subtle acts of thoughtlessness, incivility takes a toll. It erodes productivity, chips away at morale, leads employees to quit, and damages customer relationships. Dealing with its aftermath can soak up weeks of managerial attention and time. Over the past 14 years the authors have conducted interviews with and collected data from more than 14,000 people throughout the United States and Canada in order to track the prevalence, types, causes, costs, and cures of incivility at work. They suggest several steps leaders can take to counter rudeness. Managers should start with themselves-monitoring their own behavior, asking for feedback on it, and making sure that their actions are a model for others. When it comes to managing the organization, leaders should hire with civility in mind, teach it on the job, create group norms, reward good behavior, and penalize bad behavior. Lest consistent civility seem an extravagance, the authors caution that just one habitually offensive employee critically positioned in an organization can cost millions in Lost employees, lost customers, and lost productivity.

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10 November 2020

The prevalence and impact of unprofessional behaviour among hospital workers: a survey in seven Australian hospitals.

Johanna Westbrook, Neroli Sunderland, Ling Li, Alain Koyama, Ryan McMullan, Rachel Urwin, Kate Churruca, Melissa T Baysari, Catherine Jones, Erwin Loh, Elizabeth C McInnes.

Medical Journal of Australia. Volume 214, Issue 1 p. 31-37



To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees.

Design, setting, participants

Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 – Nov 2018) about their experience of unprofessional behaviours — 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) — and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking-up skills.

Main Outcome Measures

Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self-reported speaking-up skills.


Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9–94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5–40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6–15.5%) reported extreme unprofessional behaviour. Nurses and non-clinical staff members aged 25–34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self-reported speaking-up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46–0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67–0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38–0.51).


Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

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June 30, 2011

Barbers of Civility

Andrew S. Klein, MD, MBA; Pier M. Forni, PhD. Arch Surg. 2011;146(7):774-777. doi:10.1001/archsurg.2011.150


In 1540, with the support and encouragement of King Henry VIII, the Worshipful Company of Barbers and the Fellowship of Surgeons merged to form the Company of Barber-Surgeons.1 For centuries, relative strangers confronted by serious injuries and ill health have placed their trust in the lineage that arose from these barber-surgeons. In many significant ways, that trust and the responsibility that surgeons assume in accepting that trust have not changed for nearly 500 years. However, what has clearly evolved is the civility quotient applied to surgical practice, the level of courtesy modeled by senior surgeons as reflected in the means by which new surgeons are trained, and an appreciation of the consequences of rude behavior on ourselves, our coworkers, and our patients. Only recently has the qualitative belief that civility can tangibly affect the surgical workplace enjoyed confirmation by quantitative analysis. Consequently, medical organizations have begun to appreciate that disruptive behavior is a problem deserving of serious attention.

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March 18, 2010

Patient safety in surgery: non-technical aspects of safe surgical performance

George G Youngson and Rhona Flin. Patient Saf Surg. 2010; 4: 4.


The performance of operative surgery has an understandable focus placed on dexterity, technical precision, as well as the choice of procedure. There is less appreciation of the cognitive and social skills of the individual surgeon and the effect that these have on the surgical team and on patient outcome. This article highlights that impact and explores the contribution of non-technical skills to safe practice within the operating room.

"Lack of non-technical skills can have lethal consequences for patients. However, the NHS [National Health Service] lags unacceptably behind other safety-critical industries, such as aviation, in this respect. Human Factors training must be fully integrated into undergraduate and postgraduate education."

Parliamentary Report into Patient Safety, London, July 2009

Contemporary surgical practice is, at first sight, more sophisticated, efficient and effective than ever before, and yet the incidence of adverse events during surgical care is reported at approximately 15% of cases [1] in retrospective series, and in reality is probably greater. The actual number of adverse events during operative treatment is not routinely charted, since some will have no clinical impact and others are remedied. Hence there is a complexity to the analysis in outcomes from surgery which precludes precision in a way that is often possible in other risk related situations. The concept that complexity is the "enemy of safety" in relation to medical sciences is well based. The consequences of this failure are huge and the global burden of adverse incidents occurring in the operating theatre is staggering and stands comparison with the mortality sustained in armed conflict. Such an incidence in the number of casualties of "friendly fire" would simply not be tolerated by the military forces of any country or state and yet these are the consequences of our well-intentioned but imprecisely executed actions in the operating theatre[2].

There is widespread appreciation of the physical hazards to patient and staff posed by sharps, needles, electric currents, radiation, contaminated body fluids, poor patient positioning, and other risks contained in the operating theatre environment. Whereas there is an expectation that the individual technical skills of the surgeon, anaesthetist and scrub nurse will blend in an imperceptible fashion to produce a successful surgical intervention, there has been less recognition of the risk to patients from failures in communication, leadership and decision making. Consequently, the surgical literature over the past decades is replete with knowledge of the techniques to successfully complete the intended procedure, and the training required to help surgeons acquire these elusive technical skills. And yet these hard-won technical skills are not sufficient to guarantee patient safety. Adverse events are typically seeded from deficiencies in non-technical skills (i.e. cognitive and social skills that complement technical skills and contribute to safe and efficient task performance). These are rarely the focus of surgical research and consequently do not normally feature in professional standards or training syllabi.

This situation is now changing as clinicians and social scientists begin to collaborate on systematic analyses of observed behaviours of operating room staff [3]. Many of their studies adopt an approach favoured in European aviation, where pilots are trained and individually assessed on non-technical skills that are protective for flight safety. An evidence base from aviation psychology on topics such as risk tolerance, team coordination, high speed decision making and the effects of fatigue on crew error defines the skill set to be trained. Similarly, in other high risk work settings, e.g. nuclear power plants, assuring competence in non-technical skills is a key component of licensing and revalidation[4].

Recently some more visionary medical institutions have embraced this aspect of professionalism. The Royal Australasian College of Surgeons, for example, explicitly incorporates non-technical skills in their competence and performance framework [5]. The contribution of non-technical skills (NTS) to surgical performance needs better recognition and this aspect of clinical surgery needs stronger advocacy to provide it with its correct status and importance.

Our experience of training surgeons in NTS [6] is that they readily embrace the material on cognition and find concepts such as working memory or situation awareness of immediate interest and relevance for their practice. Appreciation of the role of interpersonal skills in patient safety can be harder to convey; surgeons, like airline pilots in the first generation of Crew Resource Management training [7], do not always see why 'charm school' behaviours are relevant for technical performance. What they do not always realise is that inappropriate social behaviours, such as rudeness can diminish other team members' cognitive skills [8] and thus threaten the safe execution of a surgical procedure.

Communication is acknowledged as a key component of team performance but in surgery, it is often assumed to be a desirable and inherent attribute rather than being regarded as an important and acquired clinical skill, which may need to be applied with care [9]. Teamwork, whilst similarly valued and often judged to be developed to a high level in the operating room, may simply stem from a disparate collection of healthcare workers attempting to work together, rather than a cohesive group who explicitly recognize the objectives, the component tasks, and function with a shared mental model. As Gawande has so elegantly argued, the surgical checklist addresses both team communication and the risks of missing key tasks through the briefing mechanism [10].

Whether NTS are more important in elective or to emergency surgery is unclear. NTS have been studied more in the elective situation, but emergency surgery, by contradistinction, deals with the sickest patients with often unexpected conditions, in an environment which has availability of treatment facilities on a "first come - first served basis" rather than a triaged system within many hospitals. Emergency care is increasingly being re-organised and given greater priority than the position it previously occupied as a secondary consideration behind elective surgery. The relative inconsistency of the emergency team and "short notice" aspect to the work, places it at the forefront of risk from surgical error. The elevated mortality rates of emergency surgery are therefore attributable to a range of risks extending from the nature of the illness, to the level of experience of the attending staff; but also the time and timing of interventions, with an incomplete information base contributing to variable outcomes [11]. As yet, this is still the area most deficient from supervision of surgeons in training, time for preparation and familiarity between team members, and the greater challenge is that the awareness and importance of human factors in emergency surgery, is at an early stage of acceptance within the profession.

The new focus placed on safety in surgical practice has implications for training, education, research, and delivery of clinical care and as such, constitutes a major reason for cooperation among the responsible institutions. Training bodies, colleges and universities in Scotland over the last few years have worked together on a programme of non-technical skills research in anaesthesia, surgery and nursing, based on psychological methods used to study human performance in other safety-critical industries (e.g. civil aviation, fire fighting, prison service, oil industry, nuclear industry). Part of this work has resulted in the production of a classification of the safe behaviours relevant to surgery in a language that is finding acceptance internationally amongst surgeons - Non-Technical Surgical Skills for Surgeons - NOTSS[12]. The research flowing from collaboration between psychologists and clinicians has made a major contribution to surgeons, educators, and curriculum developers appreciating the importance, content, and teaching of patient safety, It also reveals a pressing need to develop a better understanding of those social behaviours and cognitive skills that are needed by the individual members of an operating team to ensure safe and efficient surgical performance.

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March 01, 2018

Association of the nurse work environment with nurse incivility in hospitals.

Smith JG, Morin KH, Lake ET. J Nurs Manag. 2018 Mar;26(2):219-226. doi: 10.1111/jonm.12537. Epub 2017 Oct 9.



To determine whether nurse coworker incivility is associated with the nurse work environment, defined as organisational characteristics that promote nurse autonomy.


Workplace incivility can negatively affect nurses, hospitals and patients. Plentiful evidence documents that nurses working in better nurse work environments have improved job and health outcomes. There is minimal knowledge about how nurse coworker incivility relates to the United States nurse work environment.


Quantitative, cross-sectional. Data were collected through online surveys of registered nurses in a southwestern United States health system. The survey content included the National Quality Forum-endorsed Practice Environment Scale of the Nursing Work Index and the Workplace Incivility Scale. Data analyses were descriptive and correlational.


Mean levels of incivility were low in this sample of 233 staff nurses. Incivility occurred 'sporadically' (mean = 0.58; range 0.00-5.29). The nurse work environment was rated highly (mean = 3.10; range of 1.00-4.00). The nurse work environment was significantly inversely associated with coworker incivility. The nurse manager qualities were the principal factor of the nurse work environment associated with incivility.


Supportive nurse managers reduce coworker incivility.

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November 01, 2014

Incivility, retention and new graduate nurses: an integrated review of the literature

AMANDA M. D’AMBRA B S N , RN and DIANE R. ANDREWS P h D, RN. Journal of Nursing Management, 2014, 22, 735–742



To evaluate the influence of incivility on the new graduate nurse transition experience.

Incivility in the work environment is a major source of dissatisfaction and new graduate nurses are especially vulnerable. Incivility contributes to the high levels of turnover associated within the first 2 years of new graduate nurse employment.

An integrated review of the literature was conducted using MEDLINE-EBSCOhost, PsycInfo and CINAHL databases. Relevant articles were reviewed for appropriateness related to inclusion/exclusion criteria and for quality using established criteria. Sixteen studies were included in the final analysis.
Key issues

Themes that emerged included workplace incivility, nurse residency programmes, mentoring through preceptors and empowerment/work
environment. Findings indicated that incivility in the workplace was a significant predictor of low job satisfaction in new graduate nurses transitioning into

While graduate nurse transition programmes are associated with improved satisfaction and retention, they appear to address incivility by acculturating new graduate nurses to the experience of incivility. There is littleevidence that the culture of incivility has been addressed.
Implications for nursing management

Nurse managers have the responsibility to be aware of the prevalence of incivility, assess for its occurrence, and implement strategies which eliminate workplace incivility and tolerance for uncivil behaviours.

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March 03, 2015

Workplace incivility: a concept analysis.

Abolfazl Vagharseyyedin S. Contemp Nurse. 2015;50(1):115-25. doi: 10.1080/10376178.2015.1010262


This study aimed to describe the meaning of the concept 'workplace incivility' and promote consistency in its application in nursing research and practice. The methodology introduced by Walker and Avant was used to analyze this concept. A total number of 50 studies that had essentially addressed the concept of incivility in employees' work environment was selected. Ambiguous intent, violation of mutual respect, low intensity and lack of physical assault were identified as the defining attributes of workplace incivility. The necessary antecedent of workplace incivility consisted of the presence of two or more people, with one or more as the source of the incivility, and another or others as its target in the workplace. Moreover, certain individual and organisational factors were the potential antecedents of workplace incivility. Possible negative outcomes for victims, witnesses, organisations, society and perpetrators of such behaviours, such as increased cost for the organisation, reduced citizenship performance, psychological distress and anxiety were identified as outcomes of workplace incivility. Results of the current concept analysis can guide nurse managers to design interventions so that the occurrence of workplace incivility can be reduced. Further studies can focus on testing the psychometric properties of the existing workplace incivility scales, especially uncivil behaviours experienced by nurses across different societies or cultures.

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May 27, 2013

The Downward Spiral: Incivility in Nursing

Laura A. Stokowski, RN, MS DISCLOSURES


"Incivility often occurs when people are stressed, unhappy, and rushed. When these coincide, anything can happen. Incivility erodes self-esteem, damages relationships, increases stress, contaminates the work environment, and may escalate into violence."

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June 2020

Incivility and the clinical learner.

Laura JE Cheetham and Christopher TurnerDOI: Future Healthc J June 2020.


The impact of incivility in terms of individual and team performance in clinical environments is increasingly acknowledged and supported by a growing evidence base. However, clinical environments are not just areas where patient care is delivered, they are also rich, key learning arenas for healthcare professionals. To date, the potential impact of incivility in clinical environments on healthcare professional learning and development has not been comprehensively explored. This article provides an overview of the physiological mechanisms that inhibit learning and memory recall in individuals experiencing or observing incivility and social stress. It establishes a clear need for focus on the impact of incivility on clinical learners and educators and further evidence for the need for clinical environments in which civility is firmly rooted into the pervading culture.

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Oct-Dec 2018

The Level and Frequency of Faculty Incivility as Perceived by Nursing Students of Lorestan University of Medical Sciences.

Maryam Mohammadipour, Shirin Hasanvand, Fateme Goudarzi, Farzad Ebrahimzadeh, Yadollah Pournia. 

J Med Life​. Oct-Dec 2018;11(4):334-342.  doi: 10.25122/jml-2018-0055.



Little evidence exists concerning students' perception of faculty incivility. Given the growing trend of incivility and the stressful nature of these behaviors, the present study aimed to investigate the level and frequency of faculty incivility as perceived by nursing students.


A stratified random sample of 178 students from four nursing faculties of Lorestan University of Medical Sciences participated in the present cross-sectional study. The Incivility in Nursing Education-Revised Survey, consisting of 24 items, was used to investigate the prevalence and frequency of faculty incivility, and the mean and frequency of each item was calculated separately. The data were analyzed using descriptive and analytical statistics (chi-square, independent t-test and analysis of variance), and the significance level was set at 0.05.


Most of the participants were single, did not live in a dormitory, and ranged in age from 19 to 23. From their perspective, disrespect, physical threat, property damage, and physical violence were of paramount importance. 61.8% of them argued that they had "sometimes" and "always" experienced "unfair assessment" during the last year. Creating codes of behavior, enhancing awareness of civility, and developing and implementing policies for managing incivility were proposed as the most important strategies for improving civility.


Faculty members should be prepared for establishing friendly and respectful relationships, effective teaching, and applying a reality-based assessment. Identifying different and prevalent kinds of faculty incivility and making faculty members aware of them paves the way for faculty members to rethink their performance.

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