Civility at work is of great importance for patient safety, staff wellbeing, productivity, and overcoming burnout.
Just back from holidays? Many of us have returned from a well-earned break with a spring in our step. You may be sticking to your new exercise regimen, healthy eating commitment, less time on devices or another well-intended New Year’s resolution.
Those of us who worked over the break may have enjoyed a somewhat quieter hospital or practice, having time to meet up with colleagues, clean our desks and even get home at the appointed hour. Like me, you might have a sense of optimism and a feeling of renewed energy as you face a new year.
How do we hold on to that feeling as the work and stress inevitably starts to pile up again?
My New Year’s resolution – be nice
With New Year’s resolutions in mind, I have a resolution of my own I would like to disclose, and I will share some good scientific backing for its importance in building resilience. Are you ready?
Be nice to others at work. Nice, pleasant, polite, courteous, kind and respectful. These qualities can be summed up as civility.
Not rocket science, but there is a clear and growing body of evidence that civility at work is of great importance for patient safety, staff wellbeing, productivity, and overcoming burnout. Workplace incivility can lead to spiraling negative consequences for both patients and health workers1.
What do we mean by workplace incivility?
Workplace incivility is defined as low-level, deviant behavior in the workplace2. Examples of workplace incivility might include ignoring a colleague, showing up late for meetings, 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. These “seemingly insignificant behaviours that are rude, disrespectful, discourteous, or insensitive” cause a lot of distress and yet the definition notes that “the intent to harm is ambiguous or unclear” 2.
In contrast to behaviour that most could easily identify as unprofessional, such as verbal abuse or physical aggression, the ambiguity of incivility means we don’t always know how or even if to respond3. Are we being oversensitive? Are we reading too much into it? Incivility can lead to a spiral, in which an initial thoughtless act may lead to retaliation by others in support of the target, with escalating uncivil acts4.
In our daily work, we are (mostly, I hope) kind, tolerant and empathic towards patients. Why is it we don’t always extend that same consideration towards our co-workers? Maybe we believe that as professionals, we should just get on with our work and not expect niceties. Or we may suffer from compassion fatigue; in other words, we have used up our stores of caring in our patient interactions and have nothing left in the compassion bank.
The nature of healthcare is often fast paced, and for those of us working in bigger organisations, there is usually a large number of work colleagues we may not know. This means it is tempting to excuse ourselves for lack of day-to-day pleasantries. But delivering excellent care isn’t just about when we are face-to-face with patients and their families; we all have a responsibility to bring our best selves to the team.
Campaigns such as “Hello my name is…” have become widespread in health settings. There is an appreciation that we need to put the humanity back into health care5. Greeting one another (by name if we can) is the first step in making that human connection, with patients, their loved ones, and with each other.
Civility is important for patient safety
A landmark study by Riskin and colleagues6 has provided scientific evidence that, not only is civility a ‘nice to have’ but it is critical for patient safety. The initial pilot study from 2015 was backed up by a bigger study in 2017, which showed that rudeness from either colleagues or patients’ families can impact clinician performance and patient safety7.
In these studies, neonatal intensive care unit teams participated in simulations with preterm babies who were critically ill. The results showed that exposure to an observer who made rude comments significantly impacted individuals’ cognitive (diagnostic) performance and procedural skills, and team functioning. It seems that when we are in an environment of even mild rudeness or incivility, we are less likely to ask for help, to share our knowledge and skills, and to work well together, and this can have profound effects on patient care.
In another study, a randomised controlled trial examined medical students’ willingness to speak up to a surgeon in a simulated surgical error. Whether the surgeon was encouraging and kind, or mildly rude and discouraging, made a significant difference to the medical students’ decision to speak up to prevent patient harm8. When I say significant, 82% of the “encouraged” group spoke up, compared with 30% of those where the surgeon followed the “discourage” script.
Civility helps team functioning and productivity
Sam Walton, the founder of American supermarket chain Walmart and one of the most successful entrepreneurs of all time, created the “Walton Ten-Foot Rule” (that’s 3 metres for the younger generations) and demanded it of all his employees, whom he referred to as associates. According to the Rule, when Walmart associates come within ten feet of customers, they are to smile, make eye contact, greet the customer, and offer assistance. He couldn’t beat his rivals on price alone so he beat them on customer service. Walmart is still the top-earning Fortune 500 Company, ranked number one in 2018, for the sixth year in a row9.
Porath and Pearson10 surveyed 800 respondents from 17 industries, and found employees who had been targets of incivility reported intentionally reducing their work effort (48%), intentionally decreasing the time spent at work (47%) and even, in 38% of cases, intentionally decreasing the quality of their work. That is a big impact on quality and workload.
Civility can help prevent and overcome burnout
There is one more piece of evidence I would like to share in support of being kind, polite and courteous at work. Civility is an antidote to burnout. Burnout is a syndrome characterised by exhaustion, cynicism, and reduced personal accomplishment11. We know that burnout is at epidemic proportions now in health care, with numerous studies showing rates of burnout from 30% to more than 50% in all countries where this occupational syndrome has been studied12‑16. Research has shown that not only is it possible to deliberately increase civility at work, but that doing so can lead to an enduring reduction in burnout among those who work in health17. That’s correct… simply increasing courteous and thoughtful interactions in the workplace can reduce clinician burnout18.
Speaking up and promoting civility at work
Healthcare organisations need to define acceptable workplace standards of behaviour. Managers can model respectful behaviour and can promote civility through recognition of professionalism, and by providing training in effective communication, such as how to speak up to a colleague about concerns while maintaining respect.
Understanding the link between incivility, stress and burnout means that maybe we need to check the wellbeing of a colleague displaying rudeness, or give a gentle nudge by way of non-judgmental feedback about how their behaviour is being interpreted.
My New Year’s exercise and diet resolutions may slip, but I have enough evidence to stick with my personal promise to ‘be nice’ and to do what I can promote a work environment of kindness and good manners.
- Pattani ER, Ginsburg ES, Mascarenhas Johnson EA, Moore EJ, Jassemi ES, Straus ES. Organizational Factors Contributing to Incivility at an Academic Medical Center and Systems-Based Solutions: A Qualitative Study. Academic Medicine. 2018;93(10):1569-75.
- Andersson L, Pearson CM. Tit for tat? The spiraling effect of incivility in the workplace1999. 452-71 p.
- Barriers to Achieving Shared Understanding and Decision Making: Discussion. Medscape Web MD (http://wwwmedscapecom/viewarticle/735613_4?src=emailthis). 2011;N/A(N/A):1.
- Foulk T, Woolum A, Erez A. Catching Rudeness Is Like Catching a Cold: The Contagion Effects of Low-Intensity Negative Behaviors2015.
- 2019 [cited 2019 17 January]. Available from: https://www.hellomynameis.org.uk/.
- Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136:487-95.
- Riskin A, Erez A, Foulk TA, Riskin-Geuz KS, Ziv A, Sela R, et al. Rudeness and Medical Team Performance. Pediatrics. 2017;139(2).
- Salazar MJB, Minkoff H, Bayya J, Gillett B, Onoriode H, Weedon J, et al. Influence of Surgeon Behavior on Trainee Willingness to Speak Up: A Randomized Controlled Trial. JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS. 2014;219(5):1001-7.
- 2019 [cited 2019 17 January]. Available from: http://fortune.com/fortune500/walmart/.
- Porath C, Pearson C. The price of incivility. Harvard business review. 2013;91(1-2):114.
- Maslach C, Schaufeli W, Leiter M. Job burnout. Ann Rev of Psych. 2001;52(397-422).
- Siu C, Yuen SK, Cheung A. Burnout among public doctors in Hong Kong: cross-sectional survey. Hong Kong medical journal = Xianggang yi xue za zhi. 2012;18(3):186-92.
- Tawfik DS, Profit J, Morgenthaler TI, Satele DV, Sinsky CA, Dyrbye LN, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings.
- Ashkar K, Romani M, Musharrafieh U, Chaaya M. Prevalence of burnout syndrome among medical residents: experience of a developing country. Postgraduate medical journal. 2010;86(1015):266-71.
- Creedy DK, Sidebotham M, Gamble J, Pallant J, Fenwick J. Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth. 2017;17(1):13.
- Dyrbye LN ST, Sinsky CA, Cipriano PF, Bhatt J, Ommaya A, West CP, Meyers D. Burnout Among Health Care Professionals, A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Perspectives. 2017.
- Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical Teacher. 2017:1-4.
- Leiter MP, Laschinger HKS, Day A, Oore DG. The impact of civility interventions on employee social behavior, distress, and attitudes. Journal of Applied Psychology. 2011;96(6):1258-74.
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