What is incivility?
Incivility is “rude or disruptive behaviour that can result in psychological or physiological distress for the people involved.” Staff, patients, and relatives can all be affected in the hospital setting, especially in life-or-death situations.
Does incivility exist in hospitals?
I was unfamiliar with the word – incivility. Now I understand its definition. I can appreciate its presence in healthcare. Stressful situations and busy departments breed uncivil words, gestures, and actions; if not addressed, there can be devastating consequences.
Incivility and doctors
Many studies have looked at incivility in nursing, but fewer in medicine. The research that does exist shows that doctors experience incivility regularly.
Let’s look at Bradley et al. This mixed-method study surveyed 606 trainees and consultants from three large teaching hospitals. One-third of respondents reported being subject to rude behaviour several times a week. All grades were affected, though consultants were less so. 40% were moderately or severely affected by the interaction. Worryingly, 7% said this caused them to make a mistake.
Klingberg et al. focussed on emergency departments. The number of doctors experiencing incivility was much lower, possibly due to the smaller sample size (only 50 doctors in one ED). ED colleagues radiated a sense of psychological safety, whereas speciality teams engendered more irritation.
Both studies found external specialities, particularly cardiology and radiology, were more hostile than their own teams. Both also found that incivility occurred more frequently during critical situations. Both studies could have been biased by self-reporting, and 86% claimed they had never communicated rudely or only did so a few times a year. These studies only show one side of the story. It would be interesting to examine the alleged victim and perpetrator following interaction and then analyse how the incivility started.
A randomised controlled trial conducted by Riskin et al. looked at neonatal teams with a clever design using a simulated scenario either with or without incivility. When a team member was subjected to rude comments by an external expert, there was reduced information sharing and fewer requests for help. The babies the teams were looking after became more unwell due to poor procedural and diagnostic performance. It shocked me how big an effect this expert had on the teams, especially given the studied teams usually worked together and had an average of seven years of neonatal experience.
How often have you been a victim of incivility or, indeed, the perpetrator? A 13-year-old girl came to the ED with an unprecedented, prolonged seizure. A head CT scan was arranged. When she arrived in the department, the seizure had stopped. However, she remained agitated, making the transfer to the scanning bed difficult.
The radiographer stated, rather aggressively, that the child could not be scanned and refused to carry on. This interaction took place in front of the scared, confused child.
We explained she would soon settle but were told the department was too busy to wait. Eventually, she reluctantly agreed to give her one chance. The child settled, and the scan was completed with no further disruption.
What were the causes of incivility? This child was my responsibility and was unwell, requiring urgent treatment. Yet the radiographer was rude and obstructive. She had already alluded to the department’s time constraints and busyness. Anything that goes wrong in the scanner is her responsibility. A fighting teenager is a major safety concern. Conflict arises when both parties have differing responsibilities and agendas.
As the situation escalated, I held up my hands and did an eye roll to my colleagues—a clear sign of incivility. I felt smug that we got our scan, although this was incivility in mind only. That’s twice within a ten-minute window. Yet, I consider myself to be an amenable and approachable doctor.
This begs the question as to how honest participants were in those studies. Is it the case that people do not appreciate what makes a gesture or comment uncivil? Had my eye roll been seen, I know that would have added fuel to the fire in an already heated situation, a situation one does not want when a patient is critically unwell.
I remember ringing the cardiology registrar. I asked for some advice on electrically cardioverting a 970g preterm baby. Despite the usual medications, they remained in symptomatic SVT.
Her response was to shout down the phone, “It’s just APLS, Vic!”
That was the end of the conversation.
My confidence took a knock. I was shocked by the way I had been spoken to, scared about breaking the baby, and felt out of my depth.
We successfully cardioverted the baby as per APLS. However, I still hear that statement several months later and dread another conversation.
How should we manage incivility in the hospital setting?
Work environments benefit from educational programmes, teambuilding exercises and facilitated discussions. Interventions such as CREW and SMART have also proved successful.
CREW (Civility, Respect and Engagement in the Workplace)
CREW was developed with the Department of Veterans Affairs to reduce workplace incivility. A facilitator supports a specific team within an organisation. They discuss incivility and what staff see as good and bad behaviours in others. They then spend six months providing training with supporting materials.
A systematic review by Hodgins et al. found CREW to be one of the few successful interventions, improving the working environment by focusing on an organisational level.
Changing the attitude and beliefs of the organisation has a longer-term impact on individuals. Nurses introduced to CREW reported feeling empowered, reduced supervisor incivility and improved trust in management. This can greatly improve the working environment plus staff retention.
SMART (System of confidential reporting, Managing report information, Addressing incivility, Rewarding civility, Tracking and evaluating progress)
SMART encourages reporting incivility, addressing both the victim and perpetrator to figure out how to resolve the situation. It also acknowledges good behaviours boosting staff morale. We have ward noticeboards for this.
By formally reporting incidents, you may pick up a pattern with repeat offenders –– either a department or an individual. A culture may need addressing.
Unfortunately, incident reporting can be time-consuming. As useful as this process could be, other tasks will inevitably trump it. Would someone complete a form whenever a bad word or eye roll was aimed toward them?
Despite these frameworks, tackling incivility is hard. Words are often said, and gestures are made in the heat of the moment when managing critically ill patients. We should consider bringing SMART and CREW into healthcare to combat incivility. However, when stress levels are high, putting such training into action is easier said than done.
A radiologist was once very rude to me because I had forgotten to cancel a CT scan he had kindly agreed to do out-of-hours. I emailed him, apologising for the inconvenience explaining that I was resuscitating a child and lost track of time.
Unexpectedly, he replied with an apology. In future, he would “try to be more careful in expressing his frustrations in the absence of complete information.”
Maybe the answer is developing the ability to recognise when you have been uncivil. Maybe it should be accepted that during critical situations, incivilities occur.
An immediate (hot) debrief provides a crucial opportunity to address any issues. Being able to apologise to one’s colleagues is commendable. Having insight into one’s faults is a step toward changing one’s own behaviours and, hopefully, that of others.
Food for thought…
Have you been subject to incivility? How did it make you feel?
Have you been uncivilised to a work colleague? How did they respond?
How are you going to address incivility in your department?
Armstrong N. E. (2017) A Quality Improvement Project Measuring the Effect of an Evidence-Based Civility Training Program on Nursing Workplace Incivility in a Rural Hospital Using Quantitative Methods 17(1) https://doi.org/10.14574/ojrnhc.v17i1.438
Bar-David S. (2018) What’s in an eye roll? It is time we explore the role of workplace incivility in healthcare. Israel Journal of Health Policy Research https://doi.org/10.1186/s13584-018-0209-0
Bradley V, Liddle S, Shaw R, Savage E, Rabbitts R, Trim C, Lasoye T. A. and Whitelaw B. C. (2015) Sticks and stones: investigating rude, dismissive and aggressive communication between doctors Clinical Medicine 15(6) 541-545
Clark C. M. (2019) Fostering a Culture of Civility and Respect in Nursing. Journal of Nursing Regulation. 10(1):44-52
Hodgins M, MacCurtain S. and Mannix-McNamara (2014) Workplace bullying and incivility: a systematic review of interventions International Journal of Workplace Health Management 7(1):54-72 https://doi.org/10.1108/IJWHM-08-2013-0030
Klingberg K, Gadelhak K, Jegerlehner S. N, Brown A. D, Exadaktylos A. K. and Srivastava D. S. (2018) Bad manners in the Emergency Department: Incivility among doctors PLOS ONE https://doi.org/10.1371/journal.pone.0194933
Lasater K, Mood L, Buchwach D. and Dieckmann N. F. (2014) Reducing Incivility in the Workplace: Results of a Three-Part Educational Intervention The Journal of Continuing Education in Nursing. https://doi.org/10.3928/00220124-20141224-01
Osatuke K, Leiter M, Belton L, Dyrenforth S. and Ramsel D. (2013) Civility, Respect and Engagement at the Workplace (CREW): A National Organization Development Program at the Department of Veterans Affairs. Journal of Management Policies and Practices https://jmppnet.com/journals/jmpp/Vol_1_No_2_December_2013/4.pdf
Riskin A, Erez A, Foulk T. A. Kugelman A, Gover A, Shoris I, Riskin K. S. and Bamberger P. A. (2015) The Impact of Rudeness on Medical Team Performance: A Randomised Control Trial Pediatrics 136(3) 487-495 https://doi.org/10.1542/peds.2015-1385
Spence Laschinger H. K, Leiter M. P, Day A, Gilin-Oore D. and Mackinnon S. P. (2012) Building Empowering Work Environments That Foster Civility And Organizational Trust: Testing an Intervention. Nursing Research 61(5):316-325 https://doi.org/10.1097/NNR.0b013e318265a58d