This blog is based upon a lecture I gave recently at my hospital, where I attempted to raise awareness of the impact of rudeness in healthcare. For more information I’d suggest a great place to start would be the Civility Saves Lives webpage where I got a lot of this information.
Rudeness is a problem that we all face on a daily basis. I write this not as an expert on being civil and never being rude but as a far to common perpetrator of rudeness and as someone more in need of giving apologies than seeking them.
To begin with, perhaps you can have a think for yourself about rudeness? Do you think it is common? If you have time, have a watch of this classic piece of British cinema and see if you think there is anything rude happening in it.
For me I spotted poor treatment of less esteemed staff, dismissal of certain treatments, a condescending attitude towards the patient, shouting, name calling and belittling students and at no point, despite being waited on hand and foot, did he ever say please or thank you! Sir Lancelot is not a role model we should be following and yet sadly he is exactly the role model many of us older doctors grew up with.
So, if we accept that rudeness happens in our workplace, let’s consider how it makes us feel? When you have experienced rudeness did it make you feel like a better person? Did it make you feel like working harder? Were you invigorated by the experience? Did you feel supported and nurtured? No, I thought not. Rudeness is never a positive experience which begs the question: Why do we tolerate it so much?
Now, there are probably two parts to this question, tolerating rudeness in others and tolerating it in ourselves. Let’s look at others first… it tends to be a more comfortable experience. Personally, I sometimes find a quick witted, punchy put down both amusing and something to be admired. Managing to circumvent the usual concerns of shouting or swearing at someone, a well placed, withering comment can be just as, if not more, effective at demonstrating our displeasure with someone. Perhaps this is why so many admired TV doctors (or at least the ones written about) are played this way. We live vicariously through their ability to do what we wouldn’t usually dare to but secretly wish we could. Rudeness can be cool. Another factor may be in the building of our tribes. Nothing quite says you are NOT part of our tribe than being treated negatively by one of our tribal leaders. In an attempt to define and build our tribes up, we sometimes resort to putting others down. So, we can then add in the fear of receiving a similar response from an individual if we dare to challenge their behaviour and risk being thrown out of our tribe. Given there is also often a power gradient involved in these situations, trying to stop someone from being rude can be a task beyond most people’s mental, moral and professional reserves. Look at our physician friend House, he absolutely epitomises all of these issues.
And what about rudeness in ourselves? How do we feel about that? How do we justify our own bad behaviour? Perhaps you take the approach of My Fair Lady’s Professor Henry Higgins who made a virtue of treating everyone the same… mostly badly! Or maybe you indulge in a little regional stereotyping and are a plain speaking Yorkshireman? ‘I tell it like it is’, ‘What you see is what you get’ and ‘I don’t suffer fools gladly’ are all just ways of saying ‘I don’t really care who I upset, I’m just going to do what I want.’
However, I think there is another, overwhelming reason we tolerate rudeness in our daily work and it is this I really want to tackle. Somewhere, somehow we have got it in to our heads that regardless of the behaviour, what matters is that the job gets done: after all, you can’t make an omelette without breaking some eggs. We are here to treat patients and as long as that happens, that’s the most important thing. So a secretary is upset that I had to shout to get the correct out patient appointment… that’s too bad, the patient comes first. Yes, the medical junior scurried away after a withering put down but they weren’t accepting the referral and were slowing down the care this patient needed. Whether they be physician or surgeon, porter or secretary, physiotherapist or pharmacist, look at people who are renowned for being rude and often it is tolerated because they are seen as being otherwise particularly talented, useful or productive… they get the job done!
But what if it didn’t? What if what we thought was okay actually wasn’t? What if, when we thought we were breaking eggs to make an omelette, we were just breaking eggs? What if these geniuses aren’t actually getting the job done? What if they are actually making things worse?
Imagine you are being treated badly by a colleague. What do you think is happening to you at this point: Physiologically, Cognitively, Socially?
Physiologically your heart rate is rising as is your blood pressure. Stress hormones are flooding your system causing these changes whilst also reducing your immunity. Psychologically the impact is even greater. You are wondering why this has happened to you? Do you deserve this? What did you do wrong… if anything? Am I incompetent or a failure? How do I respond to this threat? Your brain is searching for answers to all these questions and a dozen more besides. Socially you now have to reassess your relationship with this person. How do I continue to work with them? Will I speak to them about other tasks or bring other information to their attention in the future? What will I do should they ever need assistance?
When someone has experienced rudeness, the impact upon them is huge. Just try remembering a rude event that has happened to you and feel the physical and mental changes start to happen. With all this going on, does it alter our ability to do other tasks?Psychologists have looked at this and have come up with some stark figures for the impact of rudeness on our ability to function at work.
Victims of rudeness are less than half as cognitively able after the event and there is a 40% drop in the quality of their work… does that sound like the sort of person you want caring for patients? They are also 50% less likely to reduce their time spent at work and perhaps more worryingly, 1:4 of them will go on to take out their upset on someone else. Rudeness is not only a major inhibitor of our ability to work, it is also contagious.
Which brings us to second victims. What is the impact of rudeness on those who see it happening?
Witnesses of rudeness have a 50% drop in their helpfulness and a 20% drop in their cognitive ability/performance… from just seeing it happen! Service users who witness rudeness in staff have a 75% drop in enthusiasm for the organisation. Is this a surprise? What if you had come to the hospital or clinic, worried about your health, what it might mean for you and concerned maybe you were being silly or had done something to cause your condition. Would you witness staff rudeness and think ‘Yeah, these are the people who will take care of me and hold my hand through what troubles are to come, who will explain things to me and reassure me when I’m feeling uncertain’? No, I thought not.
But wait, did you pick up on that phrase ‘service users’ earlier? Yes, it isn’t a phrase usually used in healthcare settings (not unless you are particularly trendy) and I’ll admit that the evidence above comes from outside our workplace, from offices and factories. So is there any evidence from healthcare settings then? Well, it’s funny you should ask.
In a pair of studies carried out in SCBU staff from Israel, we have clear evidence that rudeness impacts upon both individuals and teams in healthcare settings. In these studies teams of doctors and nurses were tasked to care of seriously ill neonates in simulations. In one of the studies the staff experienced rudeness from an external ‘expert’ and in the other from a relative*. In both trials, compared to controls who received no rudeness, there were statistically significant drops in performance after the rudeness intervention.
Information sharing, diagnostic performance, help seeking, work sharing, helpfulness and procedural performance were some of the behaviours that were seen to deteriorate. The overall impact that rudeness had on performance was calculated at twice that of suffering with sleep deprivation. Not only that, the effects didn’t just last for the duration of that initial simulation, it lasted for the rest of the day across a further four simulations!
We must come to terms with the fact that rudeness is a serious problem and throw out any idea that it is somehow worth putting up with to get the job done. The reality is, not only does it not get the job done, it actually makes the job harder.
But before we all rush out and start challenging every rude action with our swords of righteousness and shields of patient safety, we do need to pause and consider another aspect of rudeness. Most staff are not naturally rude and have no desire to come to work, upset people and make life worse for their colleagues and patients. Rudeness can be a symptom of a colleague under stress, struggling to deal with the competing pressures they are having to deal with. Perhaps it is just one bad day… we need to be quick to forgive as well as gently pointing out the problem, but if this is becoming a regular problem this person needs help. It is absolutely right that we do not tolerate rude behaviour but it is also right that whilst we are hating the behaviour we attempt to care and understand the perpetrator. Indulging their behaviour helps nobody as this type of behaviour is often a red flag for an individual, for a department or even for an organisation that there is a deeper sickness at play and we need to be prepared to dig that little bit beyond just stopping behaviours and trying to understand them. This infographic from the Civility Saves Lives group shows this in a simple equation.
And so, I will leave you with these three messages to take away from this blog.
- Rudeness is unacceptable – it hurts staff and patients
- Challenge it gently but firmly – there are often reasons for this behaviour
- Be forgiving and understanding – we’ll all need them one day
*If you’d like to read or listen to a critic of the second SCBU based study on rudeness, you can click on the link and go to The Skeptics Guide to Emergency Medicine where Ken Milne and I looked at this paper in detail.