Incivility in the ED

Authors: Nicki Credland, Dan Darbyshire / Editor: Liz Herrieven, Adam Dalby / Codes: / Published: 23/08/2022

To follow on from the RCEMLearning blogs on Bullying in the ED and Undermining in the ED, we will move on to an unwanted behaviour that is less subtle.

Defining incivility

The importance of civility grows as the frequency and complexity of interactions between people increases [1]. It is not surprising, then, that the opposite behaviour – incivility – can have a real impact in the emergency department.

Incivility can be defined as behaviours that violate norms of respect but whose intent to harm is ambiguous [2]. But what does that mean? I think we instinctively, or through experience, know what the first bit refers to. Things like answering the phone with what? or interrupting someone can demonstrate a lack of respect. But what about the intent to harm? These two examples most likely demonstrate a lack of awareness of the impact of the behaviour on someone else. They are more often self-centred rather than deliberately aggressive.

Incivility or rudeness is a form of interpersonal aggression and it can have an insidious effect [3]. It can be verbal or non-verbal, overt or covert and the cumulative effect is much greater than the sum of its parts. More subtle forms such as eye-rolling or being ignored during a handover can be even more insidious than overt bullying and aggression [4]. They seem minor at first and are therefore ignored or overlooked. However, they build up, erode staff morale, reduce confidence and create a perception of apathy amongst colleagues.

Incivility in the Emergency Department

Studies suggest that up to 90% of healthcare staff encounter incivility at work [4,5]. Incivility is unacceptable from any individual, however it is acknowledged that patients and their relatives are often under a great deal of physical and psychological stress, which could explain incivil behaviour. Studies show that incivility between colleagues, whilst also likely due to stress, is generally felt to be less acceptable by professionals[6].

A study by Credland & Whitfield [7] explored the incidence and impact of incivility in paramedicine. Paramedics reported that a lack of understanding of their role created a culture of disrespect amongst professional colleagues. This often led to paramedics feeling undermined in their clinical judgement and decision making. The site of this incivility was often (though not always) the emergency department.

EMTA Survey Data

Previous EMTA surveys have not specifically asked about incivility. However, the free-text responses to the questions about bullying and harassment provide plenty of examples of clear incivility [8].

Standard for the course. Always has been at this Trust, it is an unfriendly place to work.
EMTA Survey Respondent

If I had worked in this department as my first EM job I would never have applied to EM training.
EMTA Survey Respondent

Added to the surveys are numerous academic studies demonstrating the common-place nature of incivility in the emergency department. They also show that this is a problem in many countries. A study from Switzerland found that the incidence of incivility was high among ED physicians [9].

Another study based in the NHS found that nearly a third of physicians are exposed to incivility every week [10].

How incivility can change behaviour

Incivility has been shown to have adverse consequences on clinical decision making, as well as diagnostic and procedural performance. Rudeness from patients and relatives was shown to result in statistically significant poorer performance from medical teams [6]. Porath & Pearson suggest that 38% of employees reduce the quality of their work when faced with incivility [11]. Spence, Laschinger & Nosko found that incivility and quality of nursing care were directly related, reporting that nurses felt that incivility caused them to make more clinical errors [12], while paramedics suggested that incivility created feelings of vulnerability which undermined their confidence in their own practice potentially impacting on the quality of the care provided [7].

Impact on wellbeing

Workplace incivility has been shown to be a contributor to high staff turnover [13], long-term absence [14], loss of work motivation [15], and incidence of post-traumatic stress disorder [12]. Cash et al found that exposure to these negative behaviours led to job dissatisfaction and stress, absence from work, and increased the intention of staff to leave their job [16]. It is evident that the incivility has a significant negative effect on healthcare professionals mental well-being [7]. Incivility appears to have a cumulative effect: a single episode is easier to deal with, but subsequent episodes compound the first.

Credland & Whitfield suggest that coping strategies used by paramedics ranged from avoidance to adaptation [7]. Paramedics felt that good team working and peer support helped them to cope with the incivility they face. They also reported difficulties in controlling their own behaviours in response to incivil behaviour from others. One paramedic reported: Theres a feeling of absolute frustration, youre getting backed into a corner because you are having to control your own behaviour because all you really want to do is retaliate in that situation. Theres that constant sense of disappointment. It takes emotional energy to deal with it and you can feel quite fatigued by constantly wanting to do the right thing in terms of upholding your own set of personal professional standards and trying to lead by example.

Final thought

One definition from the literature states that workplace incivility involves acting with disregard for others in the workplace, in violation of workplace norms for respect [1]. This is helpful as it leads to the question – what are your workplace norms for respect? Modelling good behaviour may be a starting point in managing incivility, along with identifying incivility and refusing to tolerate it.

Resources

References

  1. Andersson LM, Pearson CM. Tit for Tat? The spiralling effect of incivility in the workplace. The Academy of Management Review 1999;24:45271. doi:10.2307/259136
  2. Keller S, Yule S, Zagarese V, et al. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open 2020;10:e035471. doi:10.1136/bmjopen-2019-035471
  3. Kabat-Farr D, Settles IH, Cortina LM. Selective incivility: an insidious form of discrimination in organizations. Equality, Diversity and Inclusion: An International Journal 2020;39:25360. doi:10.1108/EDI-09-2019-0239
  4. Vessey JA, Demarco RF, Gaffney DA, et al. Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environments. J Prof Nurs 2009;25:299306. doi:10.1016/j.profnurs.2009.01.022
  5. Smith LM, Andrusyszyn MA, Spence Laschinger HK. Effects of workplace incivility and empowerment on newly-graduated nurses organizational commitment. Journal of Nursing Management 2010;18. doi:10.1111/j.1365-2834.2010.01165.x
  6. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics 2015;136:48795. doi:10.1542/peds.2015-1385
  7. Credland NJ, Whitfield C. Incidence and impact of incivility in paramedicine: a qualitative study. Emerg Med J 2022;39:526. doi:10.1136/emermed-2020-209961
  8. Bailey J, Mashru A, Stewart P, et al. EMTA survey 2017. London, UK: Emergency Medicine Trainees Association 2018. [accessed 4 Feb 2019].
  9. Klingberg K, Gadelhak K, Jegerlehner SN, et al. Bad manners in the Emergency Department: Incivility among doctors. PLOS ONE 2018;13:e0194933. doi:10.1371/journal.pone.0194933
  10. Bradley V, Liddle S, Shaw R, et al. Sticks and stones: investigating rude, dismissive and aggressive communication between doctors. Clin Med (Lond) 2015;15:5415. doi:10.7861/clinmedicine.15-6-541
  11. Porath C, Pearson C. The price of incivility. Harv Bus Rev 2013;91:11421, 146.
  12. Spence Laschinger HK, Nosko A. Exposure to workplace bullying and post-traumatic stress disorder symptomology: the role of protective psychological resources. J Nurs Manag 2015;23:25262. doi:10.1111/jonm.12122
  13. Berry PA, Gillespie GL, Fisher BS, et al. Psychological distress and workplace bullying among registered nurses. Online J Issues Nurs 2016;21:8. doi:10.3912/OJIN.Vol21No03PPT41
  14. Ortega A, Christensen KB, Hogh A, et al. One-year prospective study on the effect of workplace bullying on long-term sickness absence. J Nurs Manag 2011;19:7529. doi:10.1111/j.1365-2834.2010.01179.x
  15. Ekici D, Beder A. The effects of workplace bullying on physicians and nurses. Australian Journal of Advanced Nursing 2014;31:2433.
  16. Cash RE, White-Mills K, Crowe RP, et al. Workplace incivility among nationally certified EMS professionals and associations with workforce-reducing factors and organizational culture. Prehosp Emerg Care 2019;23:34655. doi:10.1080/10903127.2018.1502383

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