Rudeness at work
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2480 (Published 19 May 2010) Cite this as: BMJ 2010;340:c2480
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Do nurses really not mind being referred to as 'scrub nurses'?
Sounds rude and archaic to me.
Competing interests:
None declared
Competing interests: No competing interests
Rhona Flin describes disagreements and aggression in the operating theatre as though these are the same thing.1 I am not suggesting scrub nurses should have to tolerate surgeons’ bad temper and tantrums. But the example she gives of two airline pilots becoming so engrossed in a heated discussion over airline policy, when, as far as I can see, there is no evidence that the two pilots were being rude to each other, highlights the difference between disagreement and rudeness.
Abuse, rudeness and incivility should have no place at work. However, this does not mean that disagreements can be eradicated. In fact, the proposal for harmony apparently suggested by Flin would suit the command and control style of management that has caused problems in the NHS,2 and avoid any challenges to it. As the Francis report has recently reinforced,3 staff need to feel confident that they can raise genuine concerns and that these will be taken seriously. Fear of being called rude, or worse, in such circumstances also poses a threat to patient safety and quality of care, as does rudeness itself.
1. Flin R. Rudeness at work BMJ 2010;340:c2480 (31 July 2010) [Full text]
2. Ham C. Improving the performance of the English NHS. BMJ 2010;340:c1776 [Full text]
3. Francis R. (Chair) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009 [Full text]
Competing interests:
None declared
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I think the previous writer misunderstands what I was trying to say.
You can be very nice and yet cause a lot of difficulty in patient care and
may escape opprobrium because of your perceived niceness--eg
Shipman. Therefore niceness by itself does not improve final outcome but
nobody in his right mind would defend rudeness. More ethnic minorities and
others are subjected to procedures based on subjective signs and that are
attributed to "Cultural differences etc" and if the writer has escaped it
he is very lucky!. So the reality of the world may not be as rosy as my
learned friend supposes. Our worry is that such subjective qualities are
being given much more emphasis than objective qualities in assessments
Competing interests:
None declared
Competing interests: No competing interests
As a junior doctor, I come across a lot of my colleagues being rude
to one another in the work place. This definitely reduces the productivity of
a person. This also affects personal life. On the other hand, if one
person is rude to another with the view of looking for improvement, that's
fair enough if that message is passed on effectively.
I think people should respect others' hard work and try to make the
working environment pleasant. By being a good team player, one can
effectively reduce the harsh behaviour.
Competing interests:
None declared
Competing interests: No competing interests
I couldn't disagree more with this correspondent. Rudeness is
prevelant in all cultures,only it's definition and perceptions vary from
one nation or racial group to another.
As someone who has had the benefit of studying both Oriental and
Western yardsticks about civility and refinement, I am convinced that it
is our expectations and cultural practices which determine our judgment
about rudeness.
The world is not how it is, but how we perceive it.
Competing interests:
None declared
Competing interests: No competing interests
There appears to be a general tendency in medicine especially by the
non clinicians to laud subjective qualities like niceness over objective
qualities like competence. It is of course self evident that nobody would
say rudeness is a good quality. The problem comes when we start defining
rudeness. Some would have wished that some of Shipman’s colleagues or the
colleagues who lived with “epilepsy misdiagnosis” for years were a “Bit
ruder”
There is also the question of what is considered as appropriate
behaviour. Some think it is colonial British others think it is using more
Thank yous and pleases. Ethnic minorities have often been told to learn
proper Board room behaviour whatever it is
I for one would not give more power to the responsible officers and
others to use even more subjective criterion to assess their colleagues
and tarnish their reputation unless there is a consensus on such
definitions.
Competing interests:
Believe subjective criteron is used to marginalize ethnic minorities and others
Competing interests: No competing interests
Rudeness in clinical environments is part of a spectrum of
unprofessional behaviours which threaten patient safety. Flin has
highlighted how individuals who experience rudeness might be at risk of
making mistakes; there is already strong evidence that victims of
unprofessional behaviour are reluctant to speak up to prevent errors when
they have concerns about patient safety. This, along with detrimental
effects on safety culture and team-working, prompted the 2008 Joint
Commission alert, which also criticised our history of “tolerance and
indifference” to this (1).
Unprofessional behaviour can affect all staff groups but it is the
behaviour of doctors which causes most concern. The 5% of doctors who
infringe tend to do so recurrently and frequently go unchallenged (2).
Their behaviour can include shouting, swearing, throwing instruments,
refusal to comply with safety procedures, derogatory comments and abusive
e mail. Behavioural intervention programmes have proven effective in many
cases although disciplinary action is required in some (3).
This subject has received less attention in the UK than in the US,
but the work of the National Clinical Assessment Service (4) and an on-
line survey which we have conducted of NHS clinical leaders (unpublished
data) suggest that the problems are similar. Most of the 163 leaders in
our survey had to deal with episodes of unprofessional behaviour at least
6 times per year, many did this without using formal policies and
procedures and 20% described it as one of the most difficult and least
appealing parts of their jobs.
This is a serious patient safety issue and, as such, “tolerance and
indifference” are no longer acceptable. In the US, the Institute for
Healthcare Improvement has received strong support from the American
College of Physician Executives and the American College of Surgeons in
its efforts to highlight this (5). In the UK we now need to receive
similar robust support from our patient safety leaders, regulators and
professional bodies.
References
1. Joint Commission. Behaviors that undermine a culture of safety.
Sentinel Event Alert, July 9, 2008.
(athttp://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm)
2. Weber DO. Poll results: doctors' disruptive behavior disturbs
physician leaders. Physician Exec. 2004 Sep-Oct;30(5):6-14.
3. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary
approach to promoting professionalism: identifying, measuring, and
addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040-8.
4. National Clinical Assessment Service. Professionalism; dilemmas
and lapses. London. 2009
(http://www.ncas.npsa.nhs.uk/resources/publications/key-publications)
5.http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm?TabId=14
Competing interests:
None declared
Competing interests: No competing interests
Thank you Professor Flinn, for a very well-researched and interesting
article.
My experience is more often loss of concentration after a patient, not a
colleague, has been rude or threatening.
A break is not always possible, and I worry about the impact on my next
patient, whilst I try to regain my equanimity and composure.
How long does the effect endure? Would a cup of coffee, given the 5 or 10
minutes involved and the effect of caffeine, be a help or a hindrance?
What about throwing something across the room, doing breathing exercises,
or talking to a sympathetic workmate?
I generally do some or all of the above, wait until my pulse is normal,
try to concentrate on the problem in hand, and hope my decision-making is
not impaired.
Unhappily these options are not always available to pilots or surgeons.
Food for thought.
Competing interests:
None declared
Competing interests: No competing interests
Singh DK, Tuli L, Swain S.
E mail: deepakbhu@gmail.com, tuli_lekha@rediffmail.com.
The article [1] by Prof. Flin gives an elaborate description of the
deleterious effect of rude behaviour among co-workers and sheds light into
various aspects of work performance related to the same. However, there is
one more issue of prime importance which demands attention.
In the medical practice, bedside clinics form the backbone of medical
education and help inculcate the clinical acumen in a medical student and
residents. In the process, one comes across varied behavioural encounters,
with the patients, colleagues, juniors and senior doctors. However, apart
from increasing knowledge and providing a platform for the simultaneous
interaction of the physicians of different cadre and the patients, it
gives an opportunity to the patients for observing and experiencing the
interaction between fellow physicians.
At times, mostly unintentionally someone exhibits an inappropriate
behaviour towards a fellow doctor or a junior. This could be in the form
of temper, disrespect, indifference, incivility, exhibiting superiority or
derogatory remarks. It mostly has no consequences in dispensing health
care services or the therapy, but it may effect the future interaction
with the patients which manifests in different forms. Firstly, the patient
may give less respect to the junior doctors who remain in the immediate
vicinity and are directly responsible for the patient routine care.
Sometimes, they even refuse to follow the instructions imparted by them.
Secondly, it creates a doubt in patients mind about the competency of
these doctors, devoted to their routine care. This may effect dispensing
of proper health care at times. Thirdly, it shadows the abilities of an
individual if he is targeted more often, amounting to diffidence and
inadequate learning or dispensing of health care. These individuals act
meek due to fear of repercussions and avoid taking active part in decision
making, in turn affecting his and the group’s performance which manifest
as adverse health outcomes in the patients [2]. Fourthly, repeated bedside
encounters make these individuals prone to patient’s in-cooperation and
misbehaviour also.
Several solutions can be devised to avoid the surfacing of such
problems. Bedside clinics’ discussion could be shifted to a separate room
after the patient has been examined by every personnel. This would keep
the patients from witnessing the discussion not directly related to his
health. In a country like India where masses are uneducated in many
regions, the doctors communicate in English in the bedside clinics. This
adds an extra advantage because a large majority of citizens don’t know
English and rely on their native language. So, conversing in English may
form an easy way out with non English speaking patients. This language
barrier prevents any overhearing of the discussions or communication
between the doctors. However, this advantage is not available everywhere
and its not very difficult to read the emotions portrayed on one's face.
So, active participation of everyone to avoid such situtions is mandatory.
Finally, we all are aware that a harmonious atmosphere has no
alternative and one’s behaviour and communication rests in one’s own
hands.
References:
1. Flin R. Rudeness at work. BMJ 2010; 340:c2480
2. Joint Commission. Behaviors that undermine a culture of safety.
Sentinel Alert 40. 2008.
www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.
Competing interests:
None declared
Competing interests: No competing interests
Can you feel the heat?
There have been a number of responses to Professor Klin's article
about rudeness at work and the deleterious consequences to patient safety
and quality of care. We would like to highlight a case demonstrating that
all employees of the NHS can impact on patient's welfare through their
inappropriate behaviour.
While two porters were transporting a patient an argument broke out.
The heat brewed until they were shouting at the tops of their voices. A
passer-by stopped upon facing the commotion and thankfully made them aware
that this behaviour was unacceptable. One of the porters realised the
error in his ways and immediately apologised showing some insight into the
situation; the other did not.
During the short time that we have worked within the NHS, we have
witnessed many such conversations of inappropriate content and context.
Whilst rudeness, which occurs all too frequently in the work place may
well affect concentration and therefore patient care, we feel it is also
important to recognise that NHS workers become habituated to their
surrounding environment. Thus, every NHS employee must be mindful that
patient care is paramount, think about the context before speaking and
search for alternative means to resolve differences.
Competing interests: No competing interests