Treat rude behavior as a threat to patient safety : JAAPA

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Treat rude behavior as a threat to patient safety

Reed, Harrison MMSc, PA-C

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JAAPA 33(2):p 8-9, February 2020. | DOI: 10.1097/01.JAA.0000615536.89999.1c
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Your colleague arrives to work at the hospital every day carrying a small vial of poison. He wanders the wards, stopping in every room to inject a few drops into each of your patients. He shrugs and goes about his day.

These poisonings unsettle you, but it's not exactly in your job description to do anything about them. Sometimes you make a face—or whisper a comment to a nearby friend—after your colleague with the poison walks away. Once, a student saw the poison and stood stunned, so you made a joke about it and changed the subject.

You thought about reporting the incidents to hospital administration, but the last time someone did so, their boss filled out a stack of paperwork and nothing else happened. Later, you heard the person with the poison got a promotion.

Of course, this level of apathy or inaction toward direct patient harm may sound preposterous. But we often shrug off an equally dangerous phenomenon: the rude and unprofessional behavior of our colleagues. And research suggests the results for our patients may be disastrous.

Destructive interpersonal behavior manifests in the healthcare setting along a broad spectrum from demonstrative tantrums to subtle sabotage. Regardless of the form it takes, toxic behavior is widespread. Surveys suggest nearly everyone in healthcare has been exposed to rude behavior, and many physicians and nurses say they experience it on a frequent basis.1

This toxic behavior has sweeping consequences: employees say it hurts their mental health and productivity and leads to absenteeism and resignations.1-3 That, of course, costs healthcare organizations a lot of money. But the greatest cost of rude behavior may be our patients' lives.

Healthcare workers report that one of the effects of rude behavior is reduced collaboration and communication, which can lead to patient-care errors.4 The Joint Commission issued a sentinel event alert in 2008 related to unprofessional interpersonal behavior, stating that even subtle offenses can undermine a culture of safety.5 That same year, a massive retrospective study involving 168 hospitals in Pennsylvania found that a better hospital environment (including managerial support and collegial nurse/physician relations) correlated with lower patient mortality.6

Surveys and retrospective studies may whisper hints of a link between interpersonal behavior and patient outcomes, but stronger empiric evidence has emerged to show how rude behavior causes direct patient harm.

Two randomized controlled trials examined the effect of rude behavior on high-stakes clinical situations. A 2015 study examined the performance of teams in a simulated neonatal resuscitation; a 2019 study measured the performance of anesthesiology residents during a simulated OR crisis.7,8 In both studies, teams were rated on their performance of technical and nontechnical skills, from diagnosis and procedures to communication and error recognition. But the researchers added a twist: while a control group performed the simulations under normal circumstances, the treatment group of each study worked alongside an observer who delivered occasional rude comments.

In both experiments, it was clear that even passive exposure to negative behavior hampered teams' performances. In the neonatal resuscitations, teams exposed to the rude comments had significantly worse performance in nearly every measurable category. In the OR resuscitations, more than 90% of the control group performed at an acceptable standard of care compared with only about 64% of the physicians exposed to rude behavior.

Poor performance in the real-life versions of these high-stakes clinical situations would certainly cost patients' lives. But despite this massive effect, infractions related to interpersonal behavior are not handled with the same concern as other preventable harms. In fact, many employees—especially those in positions of privilege and power—seem immune to the repercussions of their offenses.1

If patient safety is truly a priority, institutions must treat unprofessional behavior and incivility as a potentially lethal hazard. That means taking concrete actions to enforce professionalism policies that often only exist on paper. It means ensuring uniform consequences for infractions regardless of where a perpetrator sits in the power hierarchy. It means having open, candid discussions about the organizational culture and seeking input from those on the front lines of patient care. And it means encouraging an atmosphere of comradery built on a foundation of active, constructive communication.

Throughout medicine's history, we have harnessed powerful technologies and immense resources to improve human lives. To make the next leap forward in medicine and improve patient care, we may only need to access our humanity.


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4. Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. J Emerg Med. 2012;43(1):139–148.
5. The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety—2008. Accessed January 7, 2020.
6. Aiken LH, Clarke SP, Sloane DM, et al. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223–229.
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8. Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;28(9):750–757.
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