Rudeness can have serious consequences in health care. Although rudeness has been studied mainly in the context of sustained, abusive behaviour and incivility by a subgroup of medical practitioners, recent evidence indicates that even more subtle incidents of rudeness displayed by any member of the health care team, the patient, or the patient’s family affect team performance and patient safety and outcomes. This paper reviews the psychological and sociological consequences of rudeness in the health care setting, and offers suggestions on how physicians can step up as leaders to prevent or handle such situations.
KEY WORDS: disruptive behaviour, incivility, disrespect, team performance, patient outcomes
Definition
12-5
Rudeness decreases cognitive ability, team performance, and patient outcomes
Physicians can be at both the receiving and giving ends of rudeness. In the United Kingdom, one in three physicians experiences dismissive communication at least once weekly.2 For medical trainees, as many as three out of four are affected weekly, some even daily.2 Top
In a United States study published earlier this year, the effect of physician rudeness on patient outcomes was estimated by analyzing unsolicited observations from 32 000 patients, involving 800 surgeons at seven academic sites.6 Patients described disrespectful or rude interactions of physicians with patients or members of the team that caused distraction, made people feel embarrassed or intimidated, and deterred communication. Surgeons in the highest quartile in terms of number of observations of rudeness had a postoperative complication rate that was 14% higher than surgeons in the lowest quartile.6 The association may not be directly linked to these surgeons’ technical skills; e.g., abusive surgeons may attract lower-quality teams of people, who may be less skilled technically or in terms of collaboration and communication, leading to low morale.6, 7
Not only individuals, but also entire teams can be affected by rudeness. During handovers, such as those between a stressed transport team and an anxious accepting team or between an ICU team and an OR team, hostile comments can lead to cognitive disruption and reduced performance.8 In such stressful situations, simple comments such as, “Who told you to come to resus?” or “We were told the child was three, not two,” can be perceived as hostile,8 even if they were not intended to be. Top
Rudeness in the form of negative comments from the patient, family members, or outsiders can also diminish diagnostic and procedural performance. Recent neonatal studies not only showed cognitive inhibition of individual team members after negative comments from a visiting outsider,3 but also impaired diagnostic and intervention performance of the entire team after negative comments by an infant’s mother.9 In addition, team processes, such as information and task sharing, were decreased. Even a mildly rude statement such as, “I knew we should have gone to a better hospital where they don’t practise third-world medicine,” reduced the team’s scores.9 In the long-term, team members can experience fatigue and the team might develop low morale. Figure 1 summarizes the effect of rudeness on individual cognitive performance, team function, and patient outcomes.
Rudeness is also contagious, so much so that people may not even be aware of the original source of their own aggressive behaviour.10 As rudeness is repeated in an organization, there is a risk of it becoming a cultural or hierarchical norm.2,5
Not surprisingly, just witnessing (indirect) or recalling (perceived) rudeness can disrupt cognitive processes and creative tasks as much as being the direct recipient. In a series of studies among business students, the results of standard cognitive function tests deteriorated in each of three groups: direct victims of rudeness in the moment, those who witnessed rudeness toward someone else, and those who had to recall an instance of being treated rudely in the past.4
In short, no matter which partner in the patient–health care provider relationship displays disrespect and no matter whether the rudeness is direct, indirect, or perceived, individual cognitive performance and patient outcomes are affected negatively, and health care team members are less willing to share information or offer help. Top
Neurophysiology of negative interactions
The physiological experience of an interaction affects the resonance or dissonance of a relationship. Resonance is physiological attunement and interpersonal synchrony. Resonant relationships are characterized as positive emotions, a subjective sense of being in synchrony with one another, and with physiological effects of the parasympathetic nervous system. These effects expand one’s attention, enabling more creative thinking and learning.11 A dissonant relationship produces negative emotions, interpersonal discord, and sympathetic nervous system activation.11 Dissonant memories, like rudeness, move one’s thoughts more toward “self-pain” than toward thinking of others and narrow one’s attention.
MRI studies have shown that recalling resonant experiences activates brain areas associated with social networking and positive affect; recalling dissonant experiences activates regions associated with avoidance, narrowed attention, decreased compassion, and negative emotions.11 These neuro-imaging findings help explain cognitive inhibition, impaired diagnostic and intervention performance, and reduced willingness to offer information or help.9 They further explained poor performance on cognition tests in a study involving business students.4 The association also means that previous negative interactions with someone, if unresolved, are likely to reduce the potential results of any future working relationship. Top
What can we do about rudeness?
As a physician leader or a member of a health care team, how can we help those displaying rude behaviour, including ourselves (the instigators), and how can we immunize ourselves and our team (the receivers) against the effects
of rudeness?
Causes of rudeness
First, consider why the rude event may have occurred. If you know the instigator, is the rudeness a pattern or an unusual occurrence? If the former, then rudeness may be part of the instigator’s values and vision of the world — part of who he or she is. Luckily, rudeness as part of a disruptive behaviour pattern is the rarest cause. Unfortunately, it is also the most difficult for the physician leader to handle, often requiring help from other professionals to support the person displaying the disruptive behaviour pattern. As indicated above, this article does not deal with the complexity of persistently dysfunctional behaviour. Top
Sometimes, we see negative behaviour as part of someone’s character, when it may simply be a way of hiding insufficient or missing skills. This is called a fundamental attribution error.12 Rude comments may be a way of hiding lack of competence and shifting blame. For those with limited coping skills in stressful situations, rudeness may be an expression of ambiguity toward the unknown and the unpredictable, perhaps aggravated by fatigue or feelings related to unfulfilled physiological, safety, or social needs according to Maslow.13 If those needs remain unfulfilled, the person may experience complete disengagement and burnout. Sometimes, the missing skill is simply an inability to communicate appropriately or function optimally in stressful situations. Top
What to do if you are the instigator?
Mindless interactions can lead to disrespectful behaviour, particularly when we find ourselves in pressured, emotionally charged situations. Self-awareness and self-management are foundational leadership capabilities in those situations. In addition to unfulfilled physiological, safety, and social needs from Maslow’s pyramid, our physical and emotional state, personality, and communication style, attitudes and assumptions, knowledge gaps, and personal values can all influence our behaviour subconsciously, unless we remain fully aware and manage ourselves accordingly.14 Given the contagion of rudeness,10 our behaviour and interactions are also influenced by external norms and expectations from the organizational culture. Thus, in addition to remaining self-aware, we must also be aware of the culture around us; are disrespect and rudeness “the way things are done around here”?14 Top
The ABC strategy helps with awareness during stressful moments, where A stands for awareness, B for breathe, and C for communicate effectively.14 Be aware of early physiologic warning signs, such as teeth clenching, tightness in neck or shoulders, sweating, fast heart rate, churning in your gut. Also, notice how others are reacting. Take a few mindful breaths, four seconds to breathe in and four to breathe out, allow a brief pause to reflect on the situation, and create a moment to re-engage the executive part of your brain for critical appraisal of what comes next. Communicate effectively, using directive but respectful language to motivate appropriate responses in an efficient and timely manner.16 Slow the pace of your speech, adjust the volume, and be clear and concise in your choice of words. Watch your body language and facial expressions. Explain what is happening and, if possible, hold a debriefing session after the crisis to further add clarification. Be prepared for and remain open to comments from others.
Rude behaviour, real or perceived, is never acceptable. To apologize requires humility, one of the values of great leaders, according to Collins.15 A humble person has an open mind, recognizes her/his limitations, and is willing to consider other ways of thinking or behaving.1 “I am sorry, can we start over?” helps to defuse a situation and redirect the interaction. Top
How can we help others when we are exposed to rudeness?
Some elements of the five fundamentals of civility for physicians1,14,16-18 are useful in response to rudeness, not only from colleagues, but also from others. There is never room for retaliating, even when you are unable to respect the instigator of rudeness for whatever reason. Self-respect is important in all civil interactions: how will you feel about yourself if you respond with rudeness? How will others perceive you as physician or as leader in the future, and will the role model you provide affect the culture of your team and organization? This is an opportunity to show leadership by demonstrating assertive and courteous communication skills.
Be in the moment and ask yourself whether the HALT syndrome could be influencing your interpretation of the rudeness: is it real or perceived, could it be unintentional? Might the instigator be the one suffering from HALT? To find out and communicate in a non-threatening way, use iSTAT (an acronym modified from VitalSmarts19) to guide the inquiring conversation. Like the hand-held, point-of-care blood analyzer with the same name, iSTAT provides an immediate tool to guide difficult conversations and minimize the chance of escalation. Top
The i stands for invitation, “Can we talk about something for a moment?” S is for state the facts, “I notice that….” T stands for tell your story, “It makes me think that….. It makes me worry that….” A is for ask the other’s story, “Is that what is going on? Can you help me understand? What do you think is happening?” The second T is for tentatively, meaning that the tone of the conversation is inquiring and tentative, without judgemental words or phrases. Active and deep listening will help make using iSTAT successful. The tool also improves our emotional intelligence skills by raising self-awareness and self-management and by allowing us to practise empathy to understand another person’s issues better. Ask yourself why a reasonable human being would act like that.19
Ignoring rude behaviour may send a signal that you condone it or add to the contagion of the behaviour; addressing it might be an opportunity to provide support and help to the instigator. Deal with the culprit directly, preferably in private, while not ignoring the impact on the team. In an informal debrief, share with the team that rudeness is unacceptable and that the event will be addressed with the rude individual. Always keep in mind that the rudeness can be an expression of a wide variety of stresses, from a one-time event caused by a long nightshift to lack of resilience
and burnout. Top
How to prevent or immunize against direct, indirect, and perceived rudeness
The best preventive measure is to create a culture of respect and civility. This is where great leaders act as role models and help others develop the skills needed to create such an organizational culture. How do we behave with our colleagues, trainees, and patients? Are we as respectful as we could be? Are we always aware in the moment of some things that may be derogatory in certain circumstances? Do we contribute to the contagion? Have we developed skills that strengthen our emotional intelligence, such as active or deep listening, self-awareness and management, empathy, and communication under stressful conditions?20 Increasing psychological capital further contributes to respectful teams and organizations: offer praise for things well done, listen to staff, build resilience through informal debriefs after difficult events, and maintain a culture of learning and improvement.
Recently, several hospitals in Canada have begun to adopt and adapt psychological training, originally developed by the United States Navy SEALs to increase resilience in stressful situations.21 In a four-hour session, participants learn simple skills that allow them to stay calm in the face of fear, overriding the amygdala and controlling the hormonal response to stress and fear. These skills are variations on the four ways Navy SEALs acquire mental toughness: set very short and very specific goals, repeat mental visualization frequently, exercise positive self-talk, and control your mental state and arousal.22 Top
A recent study evaluated cognitive bias modification (CBM) by giving practitioners and teams skills that allowed them to reframe derogatory comments in terms of the context of the situation. CBM helped to maintain concentration on the problem at hand, rather than on the rudeness.9 The interventions involved brief, computerized cognitive training modules to promote a more positive and benign, rather than a threat-based interpretation of ambiguous information or stimuli.9 With CBM, people learned to interpret interpersonal emotional expression as less hostile, such that their cognitive resources were less affected by the disruption and were instead applied to the tasks at hand, including providing clinical care.
In summary
Health care supposedly takes place in a caring environment. We must remove rudeness from the health care world, as it has too many negative consequences for all stakeholders in the caring partnership. Each and all of us are responsible for the culture we create in our health care system. Each time we encounter an act of incivility, a rude comment, or disrespectful behaviour, real or perceived, it behooves us to act skillfully and empathetically, because failing to do so impairs our cognitive performance and patient outcomes. Top
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Author
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past-president of the Canadian Society of Physician Leaders.
Correspondence to: johny.vanaerde@gmail.com