Why does culture matter?

The evidence is clear – rudeness affects performance at work, (Porath 2013). In her research, Christine Porath showed rudeness resulted in a 61% reduction in cognitive ability at work.

Rudeness at work is potentially catastrophic for everyone involved. In 2009, two Northwest Airlines pilots were flying a passenger aircraft from San Diego to Minneapolis. After becoming involved in an argument with one another, they lost situational awareness and overshot the destination by 150 miles before another member of the crew noticed and informed them (Flin, 2010).

One of our contributors Dr Chris Turner explores when rudeness in teams can be deadly in a TEDx talk.

Clinical performance and patient safety are affected by even mild rudeness. A randomised controlled trial in a simulated neonatal unit in Holland reported on the effects of mild rudeness (Riskin 2015). When rudeness was present, there was 12% variance in diagnostic and procedural errors in the teams experiencing rudeness. More than 50% of this was attributed to the rudeness. Variance increased between the intervention (rudeness) and control (usual behaviour) groups once information-seeking and help-seeking were accounted for in the analysis. A subsequent study ‘Rudeness and Medical Team Performance’, Riskin (2017), confirmed the effect on the team performance and found cognitive modification bias training could help to reduce the effect but not entirely remove the effects of the rudeness.

A study of performance of resident anaesthetists experiencing incivility in a simulated operating theatre showed rudeness reduced the anaesthetists’ performances by an average of 33%. Multiple areas were impacted including vigilance, diagnosis, communication and patient management. However, participants were not aware of these effects and self-reported as performing normally.

The film Just a Routine Operation shows the devastating result of lack of respect and teamwork. Theatre nurses, who were part of the team tried to intervene in a critical incident and were ignored. They were left feeling powerless to act. In this case a young woman died. Her husband, Martin Bromiley, an airline pilot, knew that in aviation, 75% of accidents are caused by human factors. The evidence was not obvious in healthcare, and in 2007 he founded the Clinical Human Factors Group, (CHFG) to improve patient safety and address human factors in healthcare.

Incidents are also observed by students:

“A medical student on their first day on the wards, observed two senior clinicians trying to complete what should have been a simple procedure. They ignored the patient and team and spent an hour repeatedly trying. At no point did they step back, ask for advice or reflect. No one involved, including the patient, felt able to speak up and everyone felt uncomfortable. This resulted in a worse outcome for the patient”.

This above incident suggests we are not learning the lessons outlined in Civility Saves Lives, or the Clinical Human Factors Group, (CHFG) campaign. These are just a few examples of the effects of rudeness and incivility and there is much more evidence for example in Civility Saves Lives. There is high quality training available including in Clinical Human Factors Group, (CHFG).

These are matters of patient safety. In the NHS there are 230 preventable deaths in hospital a week, 12,000 preventable deaths in hospital a year and 24,000 safety incidents reported to the NHS every year. Rudeness is not the only cause, but human factors are significant. Films on the Clinical Human Factors Group website addressing issues discussed in this course include:

• ‘What’s bullying got to do with patient safety?
• ‘Is bullying a safety issue?’
• ‘How do we convince the Board?’

Discussion

Can you think of a time when your work was impacted negatively by rudeness? You could have been involved or an observer.

• How did you feel?
• What was the impact on the team and patients who observed the incident? How did this situation arise?
• Can you think of a time when your work was improved by civility and kindness? How did you feel?
• What was the effect on the team, the patient, and those observing?

Please share some of your experiences if you feel able to.

• Reflect on how you might prevent problems in the future.
• What would you like to do and how might you manage it in your organisation?
• What is the culture of healthcare like in your country? Can you share any international similarities or differences?

References

Porath C, Pearson C. The price of incivility. Harvard Business Review. 2013 Jan-Feb;91(1-2):114-21, 146. https://www.ncbi.nlm.nih.gov/pubmed/23390745 (accessed 23/3/25).

Riskin A, Erez A, Foulk TA et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics 2015;136:487

Rudeness and Medical Team Performance. Riskin A, Erez A, Foulk TA, Riskin-Geuz KS, Ziv A, Sela R, Pessach-Gelblum L, Bamberger PA.Pediatrics. 2017 Feb;139(2):e20162305. doi: 10.1542/peds.2016-2305. Epub 2017 Jan 10.PMID: 28073958 Clinical Trial.

Katz D, Blasius K, Isaak R et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf 2019;28:750–7. 2