Play Nice: The Impact of Rude Behavior On Quality of Care

Recent studies have proven that rude behavior among providers can have a strongly negative impact on the quality of care delivered

You and the resident are in a room, examining a patient with hip pain. Once the x-ray is complete, the patient is diagnosed with a hip fracture and you ask the resident to consult your orthopedic colleagues. But the consultant refuses to evaluate the patient until Judet films are ordered and hangs up as the resident is asking if the extra views are really necessary. You then ask the resident to discuss the case with radiology and within minutes you can hear the radiologist scolding the resident over the phone for failing to order a CT of the hip. The resident is frazzled and, to her dismay, fails twice when attempting a femoral nerve block. Later on, you and the resident are discussing what happened. The resident felt the encounters impacted her performance. The question is, should it? And if so, how does the idea of “rudeness” in the workplace potentially impact patient care?

As it turns out, this isn’t just the personal problem of one of my residents. In fact, the Joint Commission itself has asserted that rudeness impacts patient safety [1]. In 2008, they issued an alert describing rude language and behavior among medical personnel as a threat to quality of care and patient safety. A lot of the evidence is based on anecdotes and research in non-medical settings. But there is a growing body of evidence supporting the Joint Commission’s position.

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How common is rudeness among medical professionals? In 2007, the results of a survey of almost 400 OR staff was published. Sixty-six percent of subjects reported receiving “aggressive behavior” from nurses and 53% from surgeons during a six month period [2]. In another survey of 50 hospitals and more than 1500 doctors and nurses, 86% of the nurses responded that they had witnessed disruptive behavior by physicians and 47% of physicians responded that they had witnessed the same from nurses [3]. In yet another study, 96% of nurses in VA hospitals reported witnessing disruptive physician behavior [4]. Exposure to rudeness starts early in training. One study looked at over 1500 medical students across 16 medical schools and found that, by their senior year, 42% of students reported harassment and 82% felt they had been belittled [5].

So we need to face the facts: rudeness is common in our line of work. But does it cause harm? As a matter of fact, it does. One series of experiments conducted with university students showed that even witnessing rudeness reduces performance on both routine and creative tasks. This was true regardless of whether the incivility came from an authority figure or from a peer [6]. The same researchers showed that being the direct recipient of rudeness impairs cognitive skills [7]. A review of teamwork and communication among medical providers in emergency departments showed moderate evidence that these behaviors improved patient satisfaction, staff satisfaction and reduced clinical errors [8].

One of the best studies to examine the impact of rudeness on the function of medical teams was a recently published randomized, controlled trial done in Israel [9]. Participants were physician-nurse teams of providers in neonatal intensive care units (NICUs). The teams were invited to take part in a simulation in their NICU, followed by a workshop. A visiting expert via live Webcam served as the experimental condition. Towards some teams his comments were neutral but towards others he made scripted remarks designed to be rude, such as he was “not impressed with the quality of medicine in Israel”, the staff he observed “wouldn’t last a week” in his department and he hoped he would not get sick while in Israel. In the end the majority of individual performance items were negatively impacted by the rudeness, including both diagnostic and procedural performance. Rudeness reduced information-sharing and help-seeking within the teams. Rudeness alone explained about 12% of the variance in diagnostic and procedural performance and when a model looked at the interaction of all the collaborative processes, rudeness explained 52% of the variance in diagnostic performance and 43% of the performance in procedural performance.

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Of course, this is just one study, and yes, the NICU is not at all like emergency departments. However, these findings begin to measure something we’ve suspected for a long time: hostility affects performance, and that’s likely true wherever doctors practice. In our efforts to improve patient care, we focus on evidence-based medicine, and improved tools and workflow, but we often fail to factor in a key component: striving to change ourselves. Just minimizing rudeness can boost performance, improve quality of care and patient safety, and help facilitate better communication and teamwork amongst medical providers. While we cannot control how our patients treat us, we can control how we treat each other. So, everybody: play nice!

REFERENCES

1. Joint Commission. Behaviors that undermine a culture of safety. Sentinel Alert 40.2008. www.jointcommision.org/SentinelEvents/SentinelEventAlert/sea_40.htm.
2. Coe R, Gould D. Disagreement and aggression in the operating theatre. J Adv Nursing 2007;61:609-618.
3. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes:perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54-65.
4. Rosenstein AH. Nurse-physican relationships:impact on nurse satisfaction and retention. Am J Nurs. 2002;102(6):26-34.
5. Frank E, Carrera JS, Stratton T, et al. Experiences of belittlement and harassment and their correlates among medical students in the United States:longitudinal survey. BMJ. 2006;333(7570):682.
6. Porath CL, Erez A. Overlooked but not untouched:how rudeness reduces onlookers’ performance on routine and creative tasks. Organiz Behav and Human Decision Processes. 2009;109:29-44.
7. Porath CL, Erez A. Does rudeness matter? The effects of rude behavior on task performance and helpfulness. Acad Manage J. 2007;50:1181-1197.
8. Kilner E, Sheppard LA. The role of teamwork and communication in the emergency department: a systematic review. International Emerg Nurs. 2010;18:127-137.
9. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136(3):487-495.