Continuous quality improvement undoubtedly contributes to the ongoing honing of best practices in medicine. This health care-specific parallel of total quality management programs in business helps us daily inch closer to the ultimate goal of eradicating patient harm. Health care professionals familiar with these variation-reducing processes are likely well-versed in the popular Ishikawa fishbone diagram. While the focus is intended to be spread across materials, processes, equipment, and environment, to some it seems that an inordinate amount of attention and blame is placed upon the people involved. While differing levels of “blame culture” may exist at varying institutions, rare is the health care provider who has not witnessed a quality improvement initiative devolve into a finger-pointing blame game.
Our jobs in health care demand a level of expertise that requires years of schooling, repetition, mastery, continuing education, and lifelong learning. When errors occur, are the people in health care roles simply failing to meet the demands of the job? Do we not have the requisite skills and knowledge? Are we weary from the ongoing tugs on our attention from electronic medical records, contract negotiations, professional politics, and insurance precertification? Or could there be another less-publicized factor limiting the performance of seemingly well-intentioned, well-trained health care professionals?
The data on civility (and its ugly counterpart incivility) has exploded in the last few years. Database searches will reveal an exponential growth curve as it pertains to incivility in the workplace. Researcher Christine Porath brought this data to light in a 2013 article entitled “The Price of Incivility” and her subsequent 2016 book Mastering Civility. Porath and coauthor Christine Pearson shared some alarming statistics. After 14 years of surveying US and Canadian workers, the researchers reported that 98% of respondents had experienced workplace incivility, with 50% reporting that it occurred at least once per week. In response, 48% of all respondents indicated that incivility led them to decrease their effort at work, and 38% reported being less creative as a result of workplace rudeness. Importantly, rudeness made workers 20% less effective personally, while also making them a full 50% less likely than peers to voluntarily help others. Sadly, 12% reported leaving their jobs altogether because of workplace incivility. In light of this data, it is no surprise that the price of incivility can be devastating to organizations, with one large and well-regarded business estimating that incivility cost the firm $12 million annually.
While we would like to believe that this is a “business” issue that doesn’t impact our health care system, the data would suggest otherwise. A 2008 survey of medical and nursing staff revealed that 77% of respondents witnessed disruptive behavior in physicians and 65% reported the same disruptive behavior in nurses. Alarmingly, 67% of respondents agreed that these behaviors led to adverse patient events ranging from medical error to patient mortality. The Joint Commission has consistently reported that teamwork failures are responsible for up to 80% of medical errors in the United States, with human factors, leadership, and communication cited as the top 3 causes of sentinel events. In a health care system already significantly more expensive than others around the globe, and where teamwork failures are a known contributor to medical error, the way that we treat each other in health care workplaces deserves our attention.
Further strengthening this sentiment are two studies where health care professionals were subjected to rude behavior in simulated medical settings. Neonatal intensive care teams participating in a training simulation on an acutely decompensating patient who were exposed to mild rudeness showed significantly lower diagnostic and procedural performance scores than peers exposed to neutral comments and behaviors. Further study revealed that rudeness seemed to impede information-sharing and help-seeking, both known mechanisms by which teams compensate for underperforming team members. Similarly, anesthesiology residents exposed to rude behavior in a massive hemorrhage simulation performed significantly worse than peers in a neutral environment. Not only were performance scores worse, but communication was worse in the team subjected to incivility. In both studies, researchers revealed in health care professionals what Porath and Pearson previously revealed in business: rude behavior not only limits the capacity and capability of individual team members, but it also further limits performance at the team level. This is a toxic combination that we can no longer tolerate in our hospitals, surgery centers, and clinics.
Recent data shows that this relationship between incivility and patient harm applies not only to medical simulations, but also to actual health care teams and patients. Hospitals whose health care teams were characterized by strongly divided homogeneous subgroups (based on profession, gender, or expertise, for example), deemed “faultlines” by the authors, were associated with decreased civility among team members. Lending support to the notion that our daily interactions are a risk factor for iatrogenesis, the decrease in civility associated with strong faultlines was associated with increased patient morbidity and mortality. Interestingly, the authors noted that units marked by strong faultlines but high on “collaborative conflict cultures” were associated with lower incivility. Individuals in these collaborative cultures were found to be more open to differing opinions while displaying mutual respect and listening actively. Such teams developed norms for open dialogue, emphasized mutual understanding, and stressed the importance of the collective group’s interests. The “social glue” of an overarching collaborative conflict culture seemed to prevent incivility by facilitating communication and uniting teams in pursuit of the higher mission of optimal patient care.
We must acknowledge incivility as a risk factor for iatrogenesis and clinician ill-being. The content and character of our behavior in the workplace matters, both to our team members and to our patients. We work in complex and co-dependent systems where the minimum unit of productivity is the team. In these settings, team members see things that others don’t, and we should create environments where all team members feel empowered to share those things. We don’t share when the environment is uncivil, depriving the team of valuable information that is the currency of good decision-making. We simply cannot afford teams that feel disrespected and suppress information. In our health care workspaces, civility saves lives.
Matthew Sherrer is an associate professor and director of care team collaboration at the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Department of Anesthesiology and Perioperative Medicine. With clinical interests in collective intelligence and value in health care, he is a founding member and physician liaison for the Anesthesia Care Team Optimization Committee at UAB—a team making unprecedented strides in building inclusive and respectful anesthesia care teams. He is also the program director for UAB’s Perioperative Leadership Fellowship, the only one of its kind in the Southeast. A graduate of the UAB Heersink School of Medicine, Dr. Sherrer is a board member of the Association of Anesthesia Clinical Directors (AACD) and is committed to developing future physician leaders and creating fulfilling work experiences for all members of the anesthesia care team.
He can be reached on X @MattSherrerMD and LinkedIn. He is also the co-host of the Fresh Flow podcast and has publications on PubMed.
Chris Turner is an emergency physician.
