Intended for healthcare professionals


Rudeness at work

BMJ 2010; 340 doi: (Published 19 May 2010) Cite this as: BMJ 2010;340:c2480
  1. Rhona Flin, professor of applied psychology
  1. 1King’s College, University of Aberdeen, Old Aberdeen AB242UB
  1. r.flin{at}

    A threat to patient safety and quality of care

    Does rudeness at work have any effect beyond the risk of emotional arousal for those involved? Could it influence a worker’s concentration and consequently affect the safety of high risk tasks? The effects of incivility on task performance are beginning to interest psychologists who study human behaviour in high risk work environments.

    Last year, it was reported that two Northwest Airlines pilots flying an Airbus A320 from San Diego to Minneapolis, with 147 passengers onboard, became so engrossed in a “heated discussion over airline policy” that they “lost situational awareness” and overshot the airport by 150 miles before a member of the cabin crew called the flightdeck and they realised their mistake.1 The flight landed safely after contact with air traffic control was resumed. The airline has treated this as a serious safety incident and suspended the two pilots, whose licences have been revoked. Whatever caused their lack of attention, the story illustrates the interplay between emotionally charged behaviour, namely arguing or rudeness, and cognitive skills, such as concentration.

    Rudeness in the workplace is not uncommon. In a poll of 800 employees in North American organisations, 10% reported witnessing workplace rudeness daily.2 Is this level of incivility applicable to healthcare work settings? For instance, in a high risk domain, such as the operating theatre, do disagreements or rudeness occur between team members?

    Recent studies suggest that disagreements and aggression between clinical staff are not uncommon. In a survey of 391 NHS operating theatre staff, 66% of respondents said they had “received aggressive behaviour” from nurses and 53% from surgeons during the previous six months.3 Disagreements between surgeons and theatre nurses were reported by 63% of respondents, and disagreements between theatre nurses and ward nurses were reported by 58%. The main source of this problem was the management of the operating list. Interviews with scrub nurses indicated that they sometimes had to tolerate surgeons’ bad temper and tantrums.4

    Does it matter if clinical staff have to cope with incivility from colleagues? Is there any cost beyond an unpleasant emotional response in the unwilling recipient? Psychological research shows that it may have additional effects that can affect patient safety.

    A series of studies has shown that being the victim of rudeness can impair cognitive skills. Students invited to take part in an experiment who were insulted by a professor on the way to the test session performed worse on a series of memory tasks than controls who had not been spoken to rudely.5 This reaction is probably caused by the emotional arousal caused by the rudeness, which resulted in a switchover of cognitive capacity to deal with the required emotional processing, or it may, more simply, be caused by distraction. Human attention is powerfully driven by emotion and is particularly attracted to aversive stimuli, which have a high salience or “pop out” effect.6

    The latest study in the series tested whether merely witnessing rudeness rather than being the victim would produce a similar result. A confederate student (briefed as to the purpose of the study and how to behave) was late for a group experiment and apologised, to which the experimenter responded, “What is it with you? You arrive late . . . you are irresponsible . . . look at you . . . how do you expect to hold down a job in the real world?” This was spoken at a normal volume and the level of rudeness was not extreme. The student was then told that he could not participate in the experiment. The other students who had just watched the exchange then completed several cognitive tests. They performed significantly worse on memory and creativity tasks than students in the control group who had not observed a rude interaction.7

    The study suggests that in confined work areas, such as operating theatres, even watching rudeness that occurs between colleagues might impair team members’ thinking skills. In surgical environments, all staff require high levels of attention and memory for task execution—for example, anaesthetists remembering to administer drugs or nurses counting instruments. If incivility does occur in operating theatres and affects workers’ ability to perform tasks, the risks for surgical patients—whose treatment depends on particularly high levels of mental concentration and flawless task execution—could increase.

    It should be underlined that these studies come from a psychological laboratory with students performing cognitive tasks, so the external validity of the results has not been confirmed. An emerging field of patient safety research uses observations of behaviour in the operating theatre,8 but studies tend to measure the presence and content, rather than the tone, of communications. Few of these studies have related the manner of communication, such as rudeness, to patient or staff outcomes. One notable exception found that times of tension in the operating theatre particularly affected novices, “who respond with behaviors that may intensify rather than resolve interpersonal conflict.”9

    Of course, rudeness occurs in almost all workplaces and may or may not be tolerated in the prevailing culture. People concerned with patient safety should note that civility between workers may have more benefits than just a harmonious atmosphere. This was recognised by the Joint Commission (which accredits healthcare organisations in the United States), which issued an alert in 2008 warning that rude language and hostile behaviour among healthcare professionals pose a serious threat to patient safety and the quality of care.10


    Cite this as: BMJ 2010;340:c2480


    • Competing interests: The author has completed the Unified Competing Interest form at (available on request from the corresponding author) and declares: (1) No financial support for the submitted work from anyone other than her employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouse, partner, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Not commissioned; externally peer reviewed.