Scroll through the theory and some of the evidence we believe makes the message of civility and the impact of incivility so important.
Everything we do for our patients requires teamwork.
It may come as no surprise by now, that good teams perform better and this leads to better outcomes.
We often think about what makes a good team; clear roles, good communication, a shared vision or goal come to mind easily.
But how often do we consider the team culture in that? Feeling valued and respected as part of the team - do these matter?
The New Zealand rugby team believes so, so they have a "no asshole rule" that reduces rudeness and individuals "being a d*ck", because when it is all about them, it's not about the team.
This is embedded in their team culture and has contributed to them becoming the most successful national rugby team in the world.
Why good teams matter in healthcare
The King's Fund Survey identified numerous benefits from when staff perceived themselves to be in a good team:
- Reduced Hospital Standardised Mortality Rates
- Reduced patient complaints
- Improved staff satisfaction
- Improved staff performances
- Better reported health of staff
So when we are in a team which values and respects us, the benefits impact us and our patients.
In other words; good teams save lives.
This is where we start to think about incivility and the impact it has.
What is incivility?
Incivility can be anything ranging from rude or unsociable speech or behaviour.
Importantly, it is as interpreted by the recipient.
There are many examples:
Shouting at someone, swearing, aggression (not necessarily towards someone), belittling someone, sending emails while in meetings, talking over others, being difficult over the phone, rolling eyes or tutting at someone. The list goes on!
What happens when someone is rude?
When someone is rude to us, it reduces our bandwidth; our ability to effectively juggle multiple tasks and conscious thoughts.
For example, on a good day, we can actively juggle 6-8 things, like remembering to pick up the shopping on the way home, remembering the important birthday next week.
But this also includes tasks for our patients, like chasing the blood results, ordering investigations, being able to consider differential diagnoses.
Therefore, rudeness reduces our ability to do our jobs, until all we can focus on is them. They are actively making us worse.
The Impact of Incivility
This impact has a direct impact on the recipient, and this has been measured in the office place by Christine Porath. She found:
- 61% reduction in cognitive ability
There were also many other impacts:
- 80% lose time worrying about the rudeness
- 78% reduced their commitment to work
- 63% lose time avoiding the offender
- 48% reduced their time at work
- 38% reduce the quality of their work
- 25% took it out on others, including customers
- 12% leave
The impact spreads to others
The impact of rudeness spreads through a team like a ripple in a pond, impacting those who observe the rudeness too:
- 20% decrease in performance
- 50% reduction in willingness to help others
So it is affecting the function of others and their willing to work as a team.
It also impacts customers:
- 75% less enthusiasm for the organisation
- 66% feel anxious dealing with staff
This might prevent a patient asking staff for help, or reporting a symptom.
Medical teams perform worse in the presence of rudeness
Riskin and Erez  demonstrated the negative impact of rudeness on clinical outcomes.
They conducted a Randomised Control Trial using resus scenarios comparing one with rudeness within the team to without.
When rudeness was present, there was an increase in diagnostic and procedural errors, and they were able to attribute more than 50% of this to the rudeness.
Katz et al  showed how rudeness in a simulated surgical scenario reduced the performance of the anaesthetist by almost 33%.
Further to this, the anaesthetists were not good at recognising that they were performing worse - the impacts were going unnoticed.
When we condone rudeness in our teams, we accept poorer outcomes for our patients.
Much in the same way medical advice changed around smoking, our practice must change around incivility and rudeness.
In the 1950s smoking would be actively encouraged to help treat TB as a way to open out the lungs.
As research and knowledge advanced, this changed.
Research and knowledge about the impact of incivility is in it's infancy, but there is already evidence to suggest the massive impact it is having on team performance and clinical outcomes.
Opportunities are created
Recognising the impact of incivility is the first step.
The next step is acknowledging it and taking steps to change.
Whether that is within a clinical team, within a department, or within a wider organisation.
The best time to change was in the past. The next best is right now!
1. The King's Fund Employee Engagement and NHS Performance Survey. https://www.kingsfund.org.uk/sites/default/files/employee-engagement-nhs-performance-west-dawson-leadership-review2012-paper.pdf
2. The price of incivility. Christine Porath. https://www.ncbi.nlm.nih.gov/pubmed/23390745
3. The impact of rudeness on clinical team performance. Riskin and Erez et al. Paediatrics. 2015.
4. Exposure to incivility hinders clinical performance in a simulated operative crisis. Katz et al. BMJ Quality and Safety. 2019.