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Incivility in Critical Care:  adding insult to the injuries

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You are working with your colleagues to assist an 8-year-old with multiple injuries following a high-impact traffic collision.

You’re thinking about the next steps and voicing the options; you hear an impatient voice saying, “Are up for this? Should I do it?” from one of the team.

What does incivility look like?

Whilst not a new concept, incivility is still a widely reported concern within healthcare. Explored in seminal research, incivility is described as “behaviours or mistreatment which violate the workplace norms of mutual respect“. 

Incivility isn’t just about obvious aggression but can take the form of passive aggression, public beratement, intimidation or habitual interruption.

Isn’t it just ‘part of the job?’

Unfortunately, incivility may be familiar in your workplace. 

A qualitative study of 2,815 pre-hospital clinicians reported that nearly half of the respondents had experienced incivility from professional teams at least once a week. A study of 659 nurses reports that a startling 85% had experienced workplace incivility in the prior 12 months. A review exploring the experience of 547 doctors reported that 85.3% had experienced workplace incivility.

Does incivility matter?

Incivility negatively impacts clinical decision-making by inducing clinical uncertainty. The quality of patient care can be determined by the working relationship, and incivility negatively affects these professional partnerships, regardless of the craft group.

An effective interprofessional partnership is pivotal to patient safety. Suppose we relate this back to the critically injured 8-year-old. In that case, the interdependence of all healthcare teams is based on a mutual understanding of scopes of practice, a culture of respect and the development of psychological safety. If individuals fear repercussions for speaking up, then this can lead to patient harm.

Speaking up creates an emotional load, and this may be connected to the decision to speak up next time. If team members are afraid of negative behaviours or feel at risk of humiliation, then they are less likely to raise concerns.   

Incivility doesn’t just affect the person on the receiving end of it. A study of teams over a 1-year period highlights that people witnessing incivility are also affected, which could lead to individuals feeling unsupported in their teams.  

But… doesn’t everyone have bad days?

Yes, and leading a team when managing a critically ill child may impact psychological capacity and clinical bandwidth. This can lead to increased psychological stress and uncivil behaviours. When this happens, it is more often how the incident is managed afterwards that determines the effect it has on the individual.

It could be something as simple as an apology, but it is less likely to be accepted if the act of rudeness is felt to be deeply offensive or if any one person is a regular target. 

There are, of course, other methods to dealing with workplace incivility, such as avoidance and even revenge; however, to maintain working relationships, forgiveness may be the coping mechanism to maintain relationships.

Who does incivility affect?

A systematic review demonstrates incivility across specialities.  Surgical subspecialties were often cited as comparably higher than other subspecialties, such as emergency medicine or paediatrics, for example. Still, the prevalence of incivility was demonstrable amongst various professional backgrounds, and there was a higher trend of incivility across interprofessional groups – where different professions work together.  In some cases, this starts at the beginning of the profession.  A meta-analysis of medical trainees reported that 60% had experienced incivility which further highlights that incivility is a universal problem starting at the beginning of medical careers and spanning across healthcare professions.

The example of incivility in the case above is low intensity and might be considered ambiguous. The ‘unhelpful’ suggestion may have been a poorly worded offer of help. The high frequency of reported incivilities calls to question the culture of healthcare practice and thought needs to be given to improving incivilities within healthcare teams, particularly as incivilities may be reciprocated with further incivility.

What has been done about it?

A Cochrane Review explored preventative measures to improve civility in teams. Interestingly, policy intervention, educational material or personal interface training showed minimal improvement in incivility with low-quality evidence around the effect of the interventions. Perhaps, reactive measurements are not what is required. Instead, it may be preventative measures might the way to reduce incivility.

Where do we go from here?

Incivility, whether during a critical case or during day-to-day practice, influences the overall culture of the workplace. The longer and more frequently individuals receive or witness incivility in their team spaces, the more likely that they will engage with this practice as it becomes part of the culture.

If we flip this on its head and suppose that culture could influence incivility, then perhaps there may be a way to reduce the frequency of civility across healthcare.

Developing and reinforcing a community of practice may be the way that teams can take ownership of their collective values. The term ‘community of practice’ coined by cognitive anthropologists include three main characteristics:

Although conceptualized around learning for practice, it may be carried forward to encompass practices in medicine, nursing, emergency care and wider healthcare teams.

A successful community of practice should help members recognise individual contributions, build a trusting playing field, and develop a sense of protection amongst the teams, which would arguably reduce incivility, reduce burnout, and promote growth instead. The over-arching philosophy of working and learning together in a supportive environment would help teams to prepare for critical case procedures, develop a shared understanding of the scope and allow strengths to develop within the team. When members identify with their community of practice, there is a sense of ownership over the welfare of members and objectives to align with the shared values; therefore, incivility within or towards the community of practice could be readily addressed.

The Bottom Line

Incivility exists and is wide-reaching.

It is everyone’s responsibility to create the teams we want to work and thrive in – organisational interventions won’t work on their own.

It is everyone’s responsibility to create the teams we want to work and thrive in – organisational interventions won’t work on their own.

References

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Bureau JS, Gagné M, Morin AJS, Mageau GA. Transformational Leadership and Incivility: A Multilevel and Longitudinal Test. Journal of Interpersonal Violence [Internet]. 2021:36:1–2, NP448–NP473 Available at. https://doi.org/10.1177/0886260517734219

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Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality & Safety [Internet] 2014; 23:106-115. Available at: http://dx.doi.org/10.1136/bmjqs-2013-001947

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Gillen PA, Sinclair M, Kernohan W, Begley CM, Luyben AG. Interventions for prevention of bullying in the workplace. Cochrane Database of Systematic Reviews [Internet] 2017, Issue 1. Art. No.: CD009778.

Iyer MS, Way DP, MacDowell DJ, Overholser BM, Spector MS, Nancy D, Reshma J. Bullying in Academic Medicine: Experiences of Women Physician Leaders. Academic Medicine [Internet] 2023: 98:2:255-263.

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Klingberg K, Gadelhak K, Jegerlehner SN, Brown AD, Exadaktylos AK, Srivastava DS. Bad manners in the Emergency Department: Incivility among doctors. PLoS ONE [Internet]. 2018 13(3): e0194933.

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Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res [Internet] 2014:14:61 (2014). Available at: https://doi.org/10.1186/1472-6963-14-61

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Author

  • Susie Rhind, is a Paramedic and Senior Lecturer in paramedic practice development, with a special interests in emergency paediatric care and maternal & newborn healthcare. Typically found wandering the countryside with her Golden Retriever and 2 children. She/Her.

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