“Civility costs nothing, and buys everything” – Mary Wortley Montagu, 1756.

Does it seem to be both a grand claim and at the same time too basic, to believe that something as simple as civility in our hospitals and health services could reduce medicolegal risk, and indeed save patients’ lives?

In the broader business world, incivility and the risks associated with a workplace culture of rudeness or disrespect have been recognised as problematic for over two decades and incivility is known to be increasing (1). This may be due to larger and more complex organisations, the pressure cooker environment of doing more with less, changes in societal expectations around courtesy and, at least in some part, the use of technology, changing much communication from personal to electronic.

Costs to your organisation

Across many industries, incivility has been linked to lower worker engagement (with associated reduction in effort, work outputs and commitment to the organisation), lost productivity, increased absenteeism and workforce turnover, and increased stress at work (1). Indeed, workplace stress alone costs organisations vast sums with the economic costs of work stress estimated to lie between 0.5% and 1.2% of UK Gross Domestic Product (2) and the largest contribution to work stress being relationships at work (3).

The British Workplace Behaviour Survey (2008) found that 40% of the nearly 4000 people surveyed had experienced incivility and disrespect at work, with 6% experiencing physical violence (4). These authors also found that, in comparison with other work places, employees in health and social care were more at risk of incivility and disrespect, and of experiencing violence and injury at work. Their detailed investigation found some surprising results:

“The people we interviewed told us that they expected these types of behaviour from patients and their families but they did not expect them from fellow co-workers, and especially not from senior medical staff.” (4)

A survey of nurses in the USA found concerning results, with 85% of nurses experiencing workplace incivility at an estimated cost of US$11,581 ($16,069AUD) per nurse per year in lost productivity (5). In the UK, a recent survey found that 44% of health workers reported illness because of work-related stress in the last 12 months, a steady increase from 37% in 2016 (6). Therefore, in health, as in other industries, there is compelling evidence for the impact of incivility on worker health and safety, and its cost. Importantly, there is an increasing body of literature linking incivility to patient harm, and to medicolegal and complaints risk.

Patient harm linked to incivility

A recent publication by Katz and colleagues explored the impact of rudeness on professional performance in a randomised controlled trial in a simulated operating room environment (7). They found that experienced anaesthetic trainees exposed to a rude (but not violent or aggressive) surgeon actor were significantly and negatively affected during a simulated crisis, in their vigilance, communication and teamwork. Four times as many anaesthetists exposed to rudeness performed below the expected standard – 36.4% compared with 8.8% of the control group – a truly concerning result.

Other important research studies by Riskin (8, 9) found that exposure to rudeness by either a colleague or the parent of a neonatal patient, in a simulated clinical emergency, significantly and negatively impacted both diagnostic and procedural performance of the teams. These studies are critical to our understanding of the importance of building a culture of respect in healthcare. Civility isn’t merely a ‘nice-to-have’ or a relevant non-technical attribute (a ‘soft skill’) of the health workforce – it is important for technical performance as well.

What is incivility at work?

What do we mean by incivility in the workplace? The definition widely accepted is by Andersson and Pearson (10), and is described as ‘…low-intensity deviant behaviour with ambiguous intent to harm the target in violation of workplace norms for mutual respect’.

It is important to appreciate that incivility is ‘in the eyes of the beholder’; what to one person may be seemingly inconsequential words and deeds, may be perceived by another as inconsiderate, rude or disrespectful. Incivility is not an objective phenomenon, but an interpretation about how another’s words or deeds make one feel. Examples might include ignoring a colleague, failing to say please and thank-you, texting during a meeting or conversation, not returning calls, or acts of thoughtlessness like walking away after using the last of the paper in the photocopier or leaving dirty dishes in the communal sink.

The ambiguity noted in the definition is important. When exposed to disrespect, I may wonder if the other person intended to be rude, and be uncertain how or if to respond. Being both low-level and ambiguous also means that health leaders may be unaware of these events, or uncertain whether to act and how to manage them. Eye rolling in a meeting may not appear to reach a threshold for any ‘management action’, and yet is exactly the sort of behaviour under discussion. Decades of research by Porath and her collaborators have shown that incivility impacts our cognitive and emotional state, our individual performance and teamwork, even if we only witness these events rather than being targets ourselves (11).

Moreover, uncivil behaviours are known to lead to ‘tit for tat’ retaliation and may lead to an incivility spiral, sometimes increasing to overt aggression (10). In the health setting, this could manifest as conflict between individuals or teams, bad-mouthing colleagues in front of patients, or unhelpful inter-professional rivalry. This increases the risks for complaints and medicolegal action, which we know are commonly triggered by concerns raised in conversation with another health professional (12). When members of the public witness unprofessional behaviour, it erodes trust, undermines confidence and can damage the reputation of an organisation (13). We also know that a patient’s experience of poor communication, including disrespect, is a very common trigger for a patient complaint (14).

Incivility in healthcare – learning more

There are strategies and practical tactics that health leaders can use to improve the civility in the healthcare workplace. Some of these are straightforward – promoting courteous respectful communication in the workplace and recognising and celebrating the value and contribution of all staff, regardless of position or duty – and could be added to organisational activities or improvement projects already underway. Some initiatives will require a substantial investment, such as organisational-wide culture change programmes to build accountability and professionalism. The costs of doing nothing cannot be justified when the evidence for organisational performance, staff health and safety, and patient safety implications are considered. Responding to incivility in healthcare begins with leaders understanding its importance and making a decision to create a culture of respect (15).

Article first published as ‘The price of disrespect‘, Healthcare Markets, LaingBuisson, July 2021. 


  1. Porath, C. and C. Pearson, The price of incivility. Harvard Business Review, 2013. 91(1-2): p. 114.
  2. Chandola, T., Stress at work. 2010, The British Academy Policy Centre: London.
  3. Porath, C., Mastering Civility: A Manifesto for the Workplace. 2016, New York: Little, Brown & Company.
  4. Fevre, R., et al., Insight into ill-treatment: patterns, causes and solutions. Contemporary Readings in Law and Social Justice, 2012. 4: p. 245-277.
  5. Lewis, P. and A. Malecha, The Impact of Workplace Incivility on the Work Environment, Manager Skill, and Productivity. The Journal of nursing administration, 2011. 41: p. 41-7.
  6. Survey Coordination Centre (Picker), NHS Staff Survey 2020 National Results Briefing. 2021, NHS England: United Kingdom.
  7. Katz, D., et al., Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety, 2019: p. bmjqs-2019-009598.
  8. Riskin, A., et al., The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics, 2015.
  9. Riskin, A., et al., Rudeness and Medical Team Performance. Pediatrics, 2017. 139(2).
  10. Andersson, L. and C.M. Pearson, Tit for tat? The spiraling effect of incivility in the workplace. Vol. 24. 1999. 452-471.
  11. Porath, C.L., T. Foulk, and A. Erez, How incivility hijacks performance: It robs cognitive resources, increases dysfunctional behavior, and infects team dynamics and functioning. Organizational Dynamics, 2015. 44(4): p. 258-265.
  12. Hickson, G.B., Factors that prompted families to file medical malpractice claims following perinatal injuries. . JAMA, 1992: p. 267(10):1359-63.
  13. Frimer, J.A. and L.J. Skitka, The Montagu Principle: Incivility decreases politicians’ public approval, even with their political base. Journal of Personality and Social Psychology, 2018. 115(5): p. 845-866.
  14. Wofford, M.M., et al., Patient complaints about physician behaviors: a qualitative study. Acad Med, 2004. 79(2): p. 134-8.
  15. Leape, L.L., et al., Perspective: A Culture of Respect, Part 2. Academic Medicine, 2012: p. 1.
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