Maria’s husband, Tony, is about to go through a serious medical procedure. While Tony is being prepped, the couple overhears a nurse make a belittling comment to the co-worker who is tending to him. The affected co-worker is clearly upset and distracted. Her attempt to draw a blood sample misses. She apologizes and tries again unsuccessfully. This situation adds to the stress that Tony and Maria already feel. They become wary of the hospital staff. Recounting their experience to family and friends, they spread word of the upsetting event.
Hospital administration, managers, team leads and Human Resources professionals tend to underestimate the far-reaching impact of situations like this that take place between hospital personnel. Known as workplace incivility, these low-intensity, seemingly insignificant words or actions that show lack of regard for others’ feelings manifest in many forms: belittling comments such as what Maria and Tony witnessed, gossip, exclusion, dismissive gestures (eye rolling, lip sounds), skipping greetings, silent treatment, and rude use of mobile devices. In hospitals, many people complain about colleagues who communicate with one another in a foreign language that is not understood by their co-workers, who in turn are left feeling excluded and upset.
It is no secret that many hospitals struggle with persistent incivility issues. “Incivility is an ongoing challenge in the healthcare sector. Some hospitals are beginning to recognize that civility is critical to patient care and to maintaining excellence,” says Emma Pavlov, Executive Vice President, HR and OD at University Health Network and Program Director of the Masters Certificate in Healthcare Management at the Schulich Executive Education Centre.
When daily work involves life and death, attention to relationships is often trumped by attention to the task at hand. Ever-present stress triggers discourteous behaviour. A hierarchical structure compounded by the fact that physicians are not employees of the institution can result in a lack of consistent consequences. As jobs are performed with tight physical proximity and high role-interdependence, there is little time or space to check oneself before resorting to poor behaviour. Managers who manage large groups can’t stay on top of incivility. Rotating charge nurses who, after their turn in a leadership position return to work with peers, find it challenging to deal effectively with incivility, especially of the chronic kind. A multitude of stakeholders contributeS to the pressure, which leads to rudeness. And finally, multicultural healthcare environments where the stronger bonds that naturally connect people of the same background can result in cliques and fractures along cultural lines.
The Real-Life Effects of Incivility
Incivility is not as trivial as seems at first glance. In fact, it sends malignant tentacles into vital organizational organs and ends up bleeding into the quality of care itself. As humans, we all engage in some forms of incivility, but realizing its effects should give anyone who cares about healthcare reason to pause.
Exposure to incivility affects motivation. Research from across 17 industries shows that 48 per cent of respondents who were asked about their reaction to a workplace incident where they were treated in an uncivil manner reported that they purposely lowered their work effort. It also affects people’s ability to do their jobs: 80 per cent of respondents said that they lost time worrying, and 66 per cent reported that their performance declined following an incivility incident.
Collaboration and teamwork are also compromised. A training simulation of NICU teams found the experience of incivility reduced the amount of information sharing and help seeking between team members, which led to poor team diagnostic and procedural performance. Research based on more than 400 health professionals has found that having an uncivil colleague or supervisor exacerbates mental and physical health problems associated with overwork and not having enough control over one’s work. Using a sample of employees from five Canadian hospitals, research found the more incivility employees experience, the less satisfied and less committed they are to their job.
And then there’s the direct effect on patients and their families. Twenty-five per cent of people who participated in the 17-industry study above admitted to researchers that they took out their frustration on a customer or client after an incivility event.[i] That’s one out of four people—nothing to sneeze at.
Uncivil behaviour among hospital personnel will inevitably spill over into the interface with patients. Hospital employees who are distracted by colleagues’ incivility make mistakes, take longer breaks, forget information, and offer no creative solutions when that’s what is needed. Or, as happened to Maria and Tony, when team members are uncivil with each other, patients who witness the behaviour will feel worry, anxiety, and mistrust. Other times, staff members who are used to treating each other discourteously will inadvertently deal with a patient in the same manner or will refer to patients behind their backs in derogatory ways.
Paths to Solutions
Taming workplace incivility requires a thoughtful, multipronged approach. Indeed, many hospitals are already putting this matter on their agenda in commendable ways, thereby ensuring patients’ paths are not impacted negatively by the undesirable and unnecessary damage that incivility leaves in its wake. Adds Pavlov, “UHN has invested significant effort putting in place a host of measures to increase leaders’ and staff capacity and confidence to deal with situations early on. This is an ongoing effort for us and other hospitals, and one that is well worth the investment.”
Consistent good modeling by those in leadership is an imperative—leaders need to examine their own behaviour and tame their bad habits. A manager might convince herself that he absolutely must be reachable at all times but fails to see that staff experience his BlackBerry addiction as disrespectful. Modeling is not about being utterly
flawless but rather about authentically striving to do better, owning up to slips, being open to feedback, and doing things differently next time.
Having a shared understanding across the board as to what comprises incivility is crucial too. In many hospitals, all too often people say “she bullied me” or “he’s a bully” to describe a situation in which they experience even a minor instance of being treated with disrespect. However, the term “bullying” should be reserved to rare and serious situations; it refers to the repetitive mistreatment over time of a person by one or more others. However, in most cases the problem behaviour qualifies as incivility rather than bullying. Clearing the rampant confusion around the distinctions between incivility and other forms of bad behaviour can go a long way toward desirable change. This can be accomplished with clear policies, effective training, ongoing dialogue, and the provision of learning tools and strategies. At UHN, says Pavlov, “we have made significant efforts to change the conversation from one that is about bullying to one that is more accurately focused on incivility and disrespect.”
The next order of business is to empower staff and leaders at all levels to shift from being bystanders to becoming “upstanders.” Bystanders’ silence condones bad behaviour and contributes to the distress of the person who is subject to it. When Tammy witnesses Charisa speaking rudely to Rodney of the environmental staff and says nothing, an opportunity for correction and learning is missed. Charisa assumes her behaviour is acceptable and will repeat it in the future, Rodney’s work will be compromised by his upset and worry (possibly leading to missing contaminated surfaces), and Tammy will for hours feel bad for having betrayed her personal integrity.
Meanwhile, patients who interact with the three professionals are sure to note the lack of focus and poor demeanour. Everyone in this scenario would have benefited if Tammy had been an upstander—someone who takes positive action even if he or she is alone in doing so.
Tackling the underlying beliefs that shape the work environment is another key path. Much of the incivility in hospitals is nurtured and even fueled by potent core notions that go unnoticed and unquestioned. These notions are sometimes shared overtly; however, they often percolate under the surface, accepted as truth without anyone ever stopping to question them or examine their negative effects more closely.
Common examples of such beliefs that are prevalent in healthcare include: in our high-pressure environment, it’s okay to skip the niceties; people shouldn’t be so sensitive—if you want to enter the kitchen you have to tolerate the heat; no one can hold doctors accountable for abrasive conduct; we’re like a family here—we don’t have to watch every word we say to each other; it’s okay to let loose by speaking one’s mother tongue with a colleague even if others don’t understand it; the best way to release steam when you’re frustrated with someone is to vent about them to another colleague.
When the group you belong to (a team, a division or even the entire hospital) buys into such beliefs, its members accept conduct that they otherwise would not. It is as if everyone has blinders on, preventing them from seeing uncivil behavior for what it is.
Finally, addressing instances where incivility has become chronic is a must-do. On many teams, poor interpersonal conduct has become a built-in feature. Other times, the chronic bad behaviour of one or two people has a negative effect on an entire group. When leaders fail to address these situations effectively, it sends a strong
condoning message. This in turn has a ripple effect, discouraging those who want to do better and inadvertently giving rise to similar bad behaviour by others who perceive that there are no meaningful consequences.
As complex and challenging as it may be, hospitals need to take charge of incivility in a visible and decisive way to ensure that their commitment to excellence in patient care is upheld.