Predictors and triggers of incivility within healthcare teams: a systematic review of the literature

Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review

Background

Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems.

Aim

To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines.

Data sources

Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022.

Results

Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models.

Conclusions

Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations.

Future work

Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues.

Limitations

This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care.

Study registration

This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

Factors affecting utilization of outpatient healthcare services among the elderly population in Butiama and Musoma districts, Tanzania: A community-based cross-sectional study

BACKGROUND

In Tanzania and Sub-Saharan Africa, the elderly population has grown significantly due to improved quality of life, subsequently leading to prolonged life expectancy. Despite global development initiatives, elders still face insufficient care. Through a community-based investigation, this study assessed outpatient department (OPD) healthcare utilization and its determinants among the elderly in Butiama and Musoma districts, Tanzania.

METHODOLOGY

This study involved 415 elderly individuals aged 60 or older in Tanzania's Butiama and Musoma districts. Structured questionnaires were used to gather data, and the results were analyzed using SPSS 22. Univariate analysis utilized descriptive statistics, bivariate analysis involved cross-tabulation data, and multivariate logistic regression identified factors influencing OPD service utilization.

RESULTS

Approximately 43.4% of participants used OPD services in the past year. Divorced or separated individuals were over two times more likely to utilize OPD services compared to single participants. This association was statistically significant (OR 1.958; 95% CI 1.001-3.829; p = 0.05). About 74.5% of surveyed elders held a positive perception of OPD utilization. Although not statistically significant (p>0.05), individuals with a positive perception had 1.167 times higher odds of using OPD services (95% CI 0.746-1.826).

CONCLUSION

This study highlights a low overall utilization rate of OPD healthcare services among the elderly. Elderly individuals aged 80 years or older, along with widowed or divorced individuals, encounter specific barriers when accessing healthcare services. Positive perceptions play a crucial role in influencing healthcare utilization. It is essential to proactively offer tailored support and conduct further research, specifically addressing the distinct needs of divorced and widowed individuals when seeking healthcare services.

Evidence of Horizontal Violence in Healthcare Settings: A Narrative Review

In the professional realm, the healthcare sector stands out as one of the most susceptible to violence. One notable manifestation of this is violence among colleagues, commonly referred to as horizontal violence, which has garnered significant attention in recent times. To delve deeper into this phenomenon across various categories of healthcare professionals, a comprehensive search was conducted on PubMed, Scopus, and CINAHL, resulting in the inclusion of 13 articles. The findings of this narrative review illuminate how horizontal violence can manifest in both physical and psychological forms and how it often becomes normalized among the healthcare professionals who endure it. Particularly vulnerable to such occurrences are recent graduates and those with limited professional experience. Furthermore, it has been observed that horizontal violence has detrimental effects on the well-being of those subjected to it, as well as on the quality of patient care delivered. Considering preventive measures, numerous studies emphasize the pivotal role of effective departmental leadership in fostering a harmonious work environment. Despite the largely underreported nature of this phenomenon, the conclusions drawn in this study advocate for a deeper exploration of the dynamics surrounding horizontal violence, with the goal of devising targeted strategies to mitigate its occurrence.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals

BACKGROUND

Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos.

METHODS

A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics.

RESULTS

In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message.

CONCLUSION

The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

Issues and Perspectives for the Study of Disruptive Clinician Behavior

This article discusses issues and perspectives related to the study of disruptive clinician behavior (DCB) to improve patient safety and healthcare professionals' work environments. Multiple terminologies and ambiguous definitions have resulted in conceptual confusion in studies on DCB. In addition, subjective classifications have led the attributes of DCB to overlap and fluctuate. Therefore, we share Rosenberg's definition of DCB as "any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical and sexual harassment." It is recommended that DCB be understood as a hierarchical structure identified through statistical analysis of field survey data. Furthermore, a recurring list of items is duplicated across existing studies on DCB triggers, contributing factors, and influences. These items can be organized into separate path models based on their mutual relationships. Given these assumed models, we believe that further studies on DCB can shift toward elucidating the mechanisms of occurrence and impact. Finally, based on the path models, we recommend improving healthcare professionals' psychological and social states through a policy shift from "zero-tolerance" to "to err is human" as a priority issue for DCB prevention and countermeasures.

Mixed-methods Assessment of Incivility During Surgical Mortality and Morbidity Conference

OBJECTIVE

This study assessed incivility during mortality and morbidity (M&M) conference.

BACKGROUND

A psychologically safe environment at M&M conference enables generative discussions to improve care. Incivility and exclusion demonstrated by "shame and blame" undermine generative discussion.

METHODS

We used a convergent mixed-methods design to collect qualitative data through nonparticipant observations of M&M conference and quantitative data through standardized survey instruments of M&M participants. The M&M conference was attended by attending surgeons (all academic ranks), fellows, residents, medical students on surgery rotation, advanced practice providers, and administrators from the department of surgery. A standardized observation guide was developed, piloted and adapted based on expert nonparticipant feedback. The Positive and Negative Affect Schedule Short-Form (PANAS) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey instruments were distributed to the Department of Surgery clinical faculty and categorical general surgery residents in an academic medical center.

RESULTS

We observed 11 M&M discussions of 30 cases, over 6 months with 4 different moderators. Case presentations (virtual format) included clinical scenario, decision-making, operative management, complications, and management of the complications. Discussion was free form, without a standard structure. The central theme was that limited discussion participation from attending surgeon of record, as well as absence of a systems-approach led to blame and then blame then set the stage for incivility. Among 147 eligible to participate in the survey, 54 (36.7%) responded. Assistant professors had a 2.60 higher Negative Affect score ( P =0.02), a 4.13 higher Exclusion Behavior score ( P =0.03), and a 7.6 higher UBCNE score ( P =0.04) compared with associate and full professors. Females had a 2.7 higher Negative Affect Score compared with males ( P =0.04).

CONCLUSION

Free-form M&M discussions led to incivility. Structuring discussion to focus upon improving care may create inclusion and more generative discussions to improve care.

From incivility to outcomes: tracing the effects of nursing incivility on nurse well-being, patient engagement, and health outcomes

BACKGROUND

Nursing incivility, defined as disrespectful behaviour toward nurses, is increasingly recognized as a pressing issue that affects nurses' well-being and quality of care. However, research on the pathways linking incivility to outcomes is limited, especially in Saudi hospitals.

METHODS

This cross-sectional study examined relationships between perceived nursing incivility, nurse stress, patient engagement, and health outcomes in four Saudi hospitals. Using validated scales, 289 nurses and 512 patients completed surveys on exposure to incivility, stress levels, activation, and medication adherence. The outcomes included readmissions at 30 days and satisfaction.

RESULTS

More than two-thirds of nurses reported experiencing moderate to severe workplace incivility. Correlation and regression analyzes revealed that nursing incivility was positively associated with nursing stress. An inverse relationship was found between stress and patient participation. Serial mediation analysis illuminated a detrimental cascade, incivility contributing to increased nurse stress, subsequently diminishing patient engagement, ultimately worsening care quality. Conclusions The findings present robust evidence that nursing incivility has adverse ripple effects, directly impacting nurse well-being while indirectly affecting patient outcomes through reduced care involvement. Practical implications advocate for systemic interventions focused on constructive nursing cultures and patient empowerment to improve both healthcare provider conditions and quality of care. This study provides compelling information to inform policies and strategies to mitigate workplace mistreatment and encourage participation among nurses and patients to improve health outcomes.

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals

A key component of professional accountability programmes is online reporting tools that allow hospital staff to report co-worker unprofessional behaviour. Few studies have analysed data from these systems to further understand the nature or impact of unprofessional behaviour amongst staff. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system. Ethos has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. This study included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. Submissions that indicated the behaviour increased the risk to patient safety were identified. Descriptive summary statistics were presented for reporters and subjects of submissions about unprofessional behaviour. Logistic regression was applied to examine the association between each unprofessional behaviour (of the six most frequently reported in the Ethos submissions) and patient safety risk reported in the submissions. The descriptions in the reports were reviewed and the patient safety risks were coded using a framework aligned with the World Health Organization's International Classification for Patient Safety. Of 1310 submissions about unprofessional behaviour, 395 (30.2%) indicated that there was a risk to patient safety. Nurses made the highest number of submissions that included a patient safety risk [3.47 submissions per 100 nursing staff, 95% confidence interval (CI): 3.09-3.9] compared to other professional groups. Medical professionals had the highest rate as subjects of submissions for unprofessional behaviour with a patient safety risk (5.19 submissions per 100 medical staff, 95% CI: 4.44-6.05). 'Opinions being ignored' (odds ratio: 1.68; 95% CI: 1.23-2.22; P < .001) and 'someone withholding information which affects work performance' were behaviours strongly associated with patient safety risk in the submissions (odds ratio: 2.50; 95% CI: 1.73-3.62; P < .001) compared to submissions without a patient safety risk. The two main types of risks to patient safety described were related to clinical process/procedure and clinical administration. Commonly reported events included staff not following policy or protocol; doctors refusing to review a patient; and interruptions and inadequate information during handover. Our findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organizations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.

The impact of leader member exchange quality and differentiation on counterproductive and citizenship behavior in health care teams

BACKGROUND

Organizational citizenship behavior (OCB) may increase service quality. In contrast, counterproductive work behavior (CWB) may undermine patient safety. Efforts to increase OCB and reduce CWB rely on a good understanding of their antecedents, yet there is a lack of research in health care to inform such endeavors.

PURPOSE

The aim of this study was to investigate the role of leadership, specifically leader-member exchange (LMX), in reducing CWB and increasing OCB in health care teams.

METHODOLOGY/APPROACH

Team survey data were collected from 75 teams in U.S. health services organizations. Polynomial regression and response surface analysis was used to investigate our hypotheses.

RESULTS

For OCB, the response surface along the line of incongruence (a3) was positive and significant, and for CWB, a3 was negative and significant.

CONCLUSION

The results of polynomial regression and response surface analysis indicate that OCB increases when LMX quality is high and that LMX differentiation is comparatively lower. In contrast, CWB increases when LMX differentiation is high, whereas LMX quality is lower.

PRACTICE IMPLICATIONS

These findings provide useful suggestions to promote valuable extra-role behaviors in health care teams. Health care team leaders should aim to develop strong exchange relationships with all members if they wish to increase citizenship behavior and decrease counterproductive behavior. Building positive exchange relationships with only a few team members is likely to undermine citizenship behavior and increase counterproductive behavior.

"Trust people you've never worked with" - A social network visualization of teamwork, cohesion, social support, and mental health in NHS Covid personnel

Background

The unprecedented rapid re-deployment of healthcare workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel's experiences, their ability to effectively work together, and the effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health.

Methods

Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 healthcare workers who were either permanent staff on Intensive Care/High Dependency Units used as COVID wards, had been rapidly deployed to such a ward, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modeling.

Results

Using thematic network analysis, four overarching thematic clusters were found, (1) teamwork, (2) organizational support and management, (3) cohesion and social support, and (4) psychological strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of preparedness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. Lastly the study identifies the more pronounced negative impact of COVID work on deployed personnel's workload, mental health, and career intentions, exacerbated by reduced levels of social support during, and after, their deployment.

Conclusion

The thematic network analysis was able to highlight that many of the traditional factors associated with the successful delivery of patient care were impeded by pandemic constraints, markedly influencing personnel's ability to work together and cope with pandemic work stressors. In this environment teamwork, delivery of care and staff well-being appear to depend on relational and organizational context, social group membership, and psycho-social skills related to managing team identity. While results hold lessons for personnel selection, training, co-location, and organizational support during and after a pandemic, further research is needed into the differential impact of pandemic deployment on HCWs mental health and teamwork.

Interventions for Preventing and Resolving Bullying in Nursing: A Scoping Review

Bullying in the workplace is a serious problem in nursing and has an impact on the well-being of teams, patients, and organisations. This study's aim is to map possible interventions designed to prevent or resolve bullying in nursing. A scoping review of primary research published in English and Italian between 2011 and 2021 was undertaken from four databases (Cochrane Collaboration, PubMed, CINAHL Complete, and PsycInfo). The data were analysed using Arksey and O'Malley's framework, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Checklist was followed to report the study. Fourteen papers met the review eligibility criteria. The analysis revealed four main themes: educational interventions, cognitive rehearsal, team building, and nursing leaders' experiences. Interventions enabled nurses to recognise bullying and address it with assertive communication. Further research is needed to demonstrate these interventions' effectiveness and if they lead to a significant decrease in the short-/long-term frequency of these issues. This review increases the available knowledge and guides nurse leaders in choosing effective interventions. Eradicating this phenomenon from healthcare settings involves active engagement of nurses, regardless of their role, in addition to support from the nurse leaders, the organisations, and professional and health policies.

Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network

BACKGROUND

Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research.

METHODS

In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations.

RESULTS

Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic.

CONCLUSIONS

Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Voice is not enough: A multilevel model of how frontline voice can reach implementation

ISSUE

When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

CRITICAL THEORETICAL ANALYSIS

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

INSIGHT/ADVANCE

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

PRACTICE IMPLICATIONS

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Inappropriate behaviours in a dental training environment: pilot of a UK-wide questionnaire

Incivility and inappropriate behaviour in the workplace are topics of growing interest due to their impact on patient care and safety. Several surveys and campaigns have emerged highlighting the existence of a problem. However, the true scale is difficult to ascertain. The aim of this study is to determine the existence of inappropriate behaviours within the UK dental training environment.An anonymous pilot questionnaire was distributed across multiple platforms reaching out to dental professionals within training environments, inviting responses between July 2022 and October 2022. A total of 215 responses were received. The vast majority (73.2%) felt that inappropriate behaviour is a problem within UK dental training. Senior colleagues were identified as perpetrators in 88% of responses. Most respondents (66%) reported feeling uncomfortable raising the issue, and when raised, 30% felt unsupported. Only 9% felt confident that action was taken after the issue was reported. Belittling was experienced and witnessed most commonly.The feedback received reveals the existence of inappropriate behaviours within dental training environments. Qualitative feedback indicates that if left unaddressed, the impact of such behaviour may persist long-term. Further research is required to address this issue, improve dental training conditions and job satisfaction.

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review

BACKGROUND

Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB.

METHODS

A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust.

CONCLUSION

Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Eyes on incivility in surgical teams: Teamwork, well-being, and an intervention

Incivility in surgery is prevalent and negatively impacts effectiveness and staff well-being. The purpose of this study was to a) examine relationships between incivility, team dynamics, and well-being outcomes, and b) explore a low-cost intervention of 'eye' signage in operating theater areas to reduce incivility in surgical teams. A mixed methods design was used in an orthopedic hospital. Surveys of incivility, teamwork, and well-being were administered three months apart in a small private hospital. An intervention of signage with eyes was placed in the theater area after administration of the first survey, using a pretest-posttest design. Participants also responded to an open-ended question about suggestions for improvements at the end of the survey which was then thematically analyzed. At the individual level (n = 74), incivility was statistically significantly related to team dynamics which in turn was significantly related to burnout, stress, and job attitudes. At the aggregate level, reported incivility was statistically significantly lower after the 'eye' sign intervention. Thematic analysis identified core issues of management behaviors, employee appreciation, communication, and work practices. Incivility in surgical teams has significant detrimental associations with burnout, stress, and job attitudes, which occurs through its impact on decreased team dynamics and communication. A simple intervention that evokes perceptions of being observed, such as signage of eyes in theater areas, has the potential to decrease incivility at least in the short term, demonstrating that incivility is amenable to being modified. Additional research on targeted interventions to address incivility are needed to improve teamwork and staff well-being.

Prevalence and Impact of Workplace Bullying among Pharmacy Practice Faculty in the United States

Objective: To identify the prevalence and impact of workplace bullying among pharmacy practice faculty in the United States. Methods: Members of the Pharmacy Practice section of the American Association of Colleges of Pharmacy were invited to complete an online survey about the frequency with which they experienced negative workplace behaviors in the communication, humiliation, manipulation, discrimination, and violence domains as well as workplace bullying in the previous 12 months. Independent t-tests and chi-squared tests were used to investigate associations between workplace bullying and pharmacy practice faculty demographic and employment characteristics. Results: Participants (n=256) reported a median of 6 negative behaviors in the workplace, most often in the communication and humiliation domains. A total of 50 (19.5%) reported experiencing workplace bullying. The most common impacts of workplace bullying included increasing their stress level (n=44/49, 89.8%), negative effects on their emotional health (n=42/49, 85.7%), and job dissatisfaction (n=40/49, 81.6%). Female participants more frequently reported workplace bullying (n=43/196, 21.9%) compared to male participants (n=4/56, 7.1%; p=0.012). Individuals who identified as white were less likely to report workplace bullying (n=40/233, 17.2%) compared to individuals of all other races (n=8/19, 42.1%; p=0.008). Conclusion: Most pharmacy practice faculty reported experiencing some degree of negative workplace behaviors during the past 12 months. Additional strategies are needed to create inclusive work environments with transparent, actionable policies when workplace bullying occurs.

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review

BACKGROUND

Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom.

METHODS

This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics.

CONCLUSIONS

Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Professional virtue of civility and the responsibilities of medical educators and academic leaders

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740-1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility.

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis

BACKGROUND

The critical role that middle managers play in enacting organisational culture change designed to address unprofessional co-worker behaviours has gone largely unexplored. We aimed to explore middle managers' perspectives on i) whether they speak up when they or their team members experience unprofessional behaviours (UBs); ii) how concerns are handled; iii) the outcomes; and iv) the role of a professional accountability culture change program (known as Ethos) in driving change.

METHODS

Qualitative, constructivist approach. Five metropolitan hospitals in Australia which had implemented Ethos. Purposive sampling was used to invite middle-level managers from medicine, nursing, and non-clinical support services. Semi-structured interviews conducted remotely. Inductive, reflexive thematic and descriptive thematic analyses undertaken using NVivo.

RESULTS

Thirty interviews (approximately 60 min; August 2020 to May 2021): Nursing (n = 12), Support Services (n = 10), and Medical (n = 8) staff, working in public (n = 18) and private (n = 12) hospitals. One-third (n = 10) had a formal role in Ethos. All middle managers (hearers) had experienced the raising of UBs by their team (speakers). Themes representing reasons for ongoing UBs were: staying silent but active; history and hierarchy; and double-edged swords. The Ethos program was valued as a confidential, informal, non-punitive system but required improvements in profile and effectiveness. Participants described four response stages: i) determining if reports were genuine; ii) taking action depending on the speaker's preference, behaviour factors (type, frequency, impact), if the person was known/unknown; iii) exploring for additional information; and iv) addressing either indirectly (e.g., change rosters) or directly (e.g., become a speaker).

CONCLUSIONS

Addressing UBs requires an organisational-level approach beyond supporting staff to speak up, to include those hearing and addressing UBs. We propose a new hearer's model that details middle managers' processes after a concern is raised, identifying where action can be taken to minimise avoidant behaviours to improve hospital culture, staff and patient safety.

Attributions and perpetrators of incivility in academic surgery

Purpose

Although incivility has been described in other specialties, little is known about the attributes and perpetrators of it in academic surgery. The goal of this study was to identify attributes and commonly associated perpetrators of incivility experienced by trainees and faculty at academic surgery programs in the U.S.

Methods

A web-based survey including the Workplace Incivility Scale (WIS) and questions regarding attributions and perpetrators of incivility was sent to trainees and faculty at academic institutions across the U.S. In addition to descriptive statistics, multivariable regression models were built to determine the impact of perpetrator type and number on overall incivility scores.

Results

We received 367 of 2,661 (13.8%) responses. Top three reasons for incivility were surgery hierarchy (50.1%), respondent's gender (33.8%) and intergenerational differences (28.1%). Faculty (58.6%), patients (36.8%), and nursing staff (31.9%) were the most reported parties responsible for incivility. Female surgeons reported experiencing incivility more frequently from all three top responsible parties (i.e., faculty, patients, and nurses) when compared to other gender identities. Additionally, those who reported faculty (β = 0.61, 95%CI 0.39-0.82) or nurses (β = 0.23, 95%CI 0.009-0.45) as perpetrators of incivility reported an increase in overall incivility scores.

Conclusions

Incivility in surgery is frequently attributed to surgery hierarchy, gender, and intergenerational differences. Surgical trainees and faculty reported that faculty, patients, and nurses were the most commonly identified as responsible for uncivil events in the surgical workforce. Exposure to a greater variety of perpetrators of incivility increases overall levels of incivility, emphasizing the importance of eliminating incivility from all sources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44186-023-00129-1.

The impact of interprofessional incivility on medical performance, service and patient care: a systematic review

The stressful nature of the medical profession is a known trigger for aggression or abuse among healthcare staff. Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. While incivility in nursing has been widely investigated, its prevalence among physicians and its impact on patient care are poorly understood. This review summarises current understanding of the effects of interprofessional incivility on medical performance, service and patient care. A structured search and screening of literature returned 13 studies of diverse origin, methodology, quality, size and population type. The consensus is that interprofessional incivility is common among physicians and nurses and has both psychological and clinical outcomes, resulting in stress, compromised patient safety and poor quality of care. Junior staff are affected more often than consultants, with higher rates in radiology, general surgery, neurosurgery and cardiology. Incivility also undermines medical team performance, particularly in perioperative settings. In patient care, incivility is associated with complications, medical errors, mortality, and compromised patient safety and quality of care. Patients whose surgeons have a record of incivility can be at higher risk of complications. The impact of incivility on medical performance, service and patient care appears systemic and must be addressed accordingly. This analysis was limited by the methodological weaknesses of the included studies, which highlights the need for more high-quality empirical research. This would benefit the NHS and other stakeholders when designing targeted interventions. In particular, establishing quantitative methods for identifying and measuring incivility will be crucial for improving our understanding of the phenomenon.

Incivility, Work Withdrawal, and Organizational Commitment Among US Surgeons

OBJECTIVE

To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment.

BACKGROUND

Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large.

METHODS

Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment.

RESULTS

There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153-0.203).

CONCLUSIONS

Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large.

Assisting physicians who exhibit disruptive behavior: Understanding the costs, contributors, and corrections

OBJECTIVE

The aim of this article is to discuss the etiology, prevalence, impact, and management of disruptive behavior in physicians. These various aspects will be examined at both the individual and system level, to provide appropriate perspective and detail effective approaches to address these behaviors.

METHOD

Clinical experience and review of the authors' and other researchers' findings provide consensus on numerous key aspects of physician disruptive behavior.

RESULTS

Physicians demonstrating disruptive behavior are often distressed. The behavior should be understood as arising from biopsychosocial contributors, knowledge gaps, insight, and systems factors. These contributors are inclusive and may interact with each other.

CONCLUSIONS

A comprehensive approach is required which can include assessment/reassessment tools, individualized programming (therapy, coaching, instruction), deliberate practice, medical follow-up, and system intervention. Complications include the diversity of disruptive behaviors, the many contributory factors therein, disagreement about methodology/measurement, and the role of the system.

Pilot Study Using Cognitive Rehearsal, Simulation, and Biomarker Data to Address Workplace Incivility

BACKGROUND

Workplace incivility poses a threat to patient safety. This intervention pilot study used simulation and biomarker data with newly graduated nurses to explore the impact of incivility on patient care and tested whether cognitive rehearsal could mitigate the effects of workplace incivility.

METHOD

A clinical scenario and script were used by actors to deliver either an uncivil or a hurried but not uncivil handoff report to participants before they conducted a focused patient assessment and administered medications to a standardized patient.

RESULTS

Participants identified gaps in understanding of both handoff reports that resulted in compromised patient care. Quantitative trends showed lower resilience scores and higher stress appraisal scores for participants who received the uncivil handoff report.

CONCLUSION

Although participants expressed confidence using cognitive rehearsal as an intervention before the simulation, responses indicated that a 60-minute session was insufficient to adequately prepare them to effectively address an uncivil nurse encounter. [J Contin Educ Nurs. 2023;54(2):79-88.].

What factors help and hinder efforts to address incivility in Australasian emergency departments? A modified Delphi study of FACEM perspectives

OBJECTIVE

Workplace incivility is a global challenge for healthcare and a major leadership challenge facing emergency physicians. However, little is known about emergency physicians' understanding of the factors that help and hinder attempts to address incivility, or what emergency physicians believe are the priority factors to address. The present study makes a novel contribution to research in this area by examining the perceived enablers of, and barriers to, efforts to address incivility in Australian and Aotearoa New Zealand EDs.

METHODS

An online modified Delphi study was conducted with 22 FACEMs. To structure the process, participants were sorted into four panels. Using a three-phase Delphi process, participants were guided through the process of brainstorming, narrowing down and ranking the factors that help and hinder attempts to address incivility in EDs.

RESULTS

There was general agreement that FACEMs' cross-department relationships and networks were key helping factors, and that poor workplace culture and time pressure were major hindering factors. However, despite agreement about these three factors, a wide range of intrapersonal, interpersonal, intergroup, and organisational factors were identified as pertinent to attempts to address incivility in EDs.

CONCLUSION

The causes of incivility in Australian and Aotearoa New Zealand EDs are complex and highlight incivility in EDs as a key adaptive leadership challenge of emergency physicians. Fundamentally, the results underscore the need to foster a workplace culture of respect, inclusion and civility in Australasian hospitals.

Cross-Cultural Adaptation of the Instrument "Nurse-Physician Relationship Survey: Impact of Disruptive Behavior in Patient Care" to the Spanish Context

Disruptive behavior in the healthcare context has an impact on patient care, healthcare personnel, and the health organization, and it also influences the therapeutic relationship, communication process, and adverse events. However, there is a lack of instruments that could be used for its analysis in the hospital care environment in the Spanish context. The objective of the study was to culturally adapt and perform a content validation of the tool “Nurse−Physician Relationship Survey: Impact of Disruptive Behavior on Patient Care”, to the Spanish content (Spain). An instrumental study was conducted, which included an analysis of conceptual and semantic equivalence. A panel of experts analyzed the translations, by analyzing the Content Validity Index (CVI) of the group of items in the scale through the Relevance Index (RI) and the Pertinence Index (PI). Only a single item obtained an RI value of 0.72, although with PI value of 0.81, with consensus reached for not deleting this item. The CVI of all the items was >0.80 for the mean value of the RI, as well as the PI. The instrument was adapted to the Spanish context and is adequate for evaluating the disruptive behaviors on nurse−physician relationships and its impact on patient care. However, the importance of continuing the analysis of the rest of the psychometric properties in future studies is underlined.

Radiography Managers’ Perspectives on the Strategies to Mitigate Disruptive Behaviours: A Qualitative Exploratory Study

Disruptive behaviours (DBs) are not normally in the scope of legal sanctions, notwithstanding their undesirable effects. Hence, many healthcare organizations still have difficulty in dealing with them in an effective manner. Several studies suggest that few organizations have tailor-made policies or procedures for evaluating, proving and mitigating these behaviours. However, evidence shows that mitigating DBs is critical to empowering healthcare workers to focus on providing superior, affordable and safe patient care. The aim of this study was to explore radiography managers’ perspectives on the strategies to mitigate DBs involving radiographers. An exploratory qualitative study employing one-on-one semi-structured in-depth interviews was carried out between March and April 2021. Eleven radiography managers at central hospitals in Harare Metropolitan Province were selected by criterion-purposive sampling. The interview data were analyzed using Tesch’s method of qualitative analysis. The data were first manually coded and then entered into Nvivo (QSR International Version 11) for further analysis. Three themes emerged from the interview data including awareness of DBs, willingness to address DBs, and conflict resolution. Context-specific strategies to mitigate DBs should be identified and implemented to guarantee a healthy work environment for radiographers so that they focus on providing excellent and safe patient care.

Organizational climate and interpersonal interactions among registered nurses in a neonatal intensive care unit: A qualitative study

AIM

The aim of this work is to describe the organizational climate and interpersonal interactions experienced by registered nurses in a level III neonatal intensive care unit.

BACKGROUND

Neonatal nurses have a demanding task in caring for a varied, highly vulnerable patient population and supporting patients' families. Nurses' psychosocial work environment affects quality of care as well as nurses' job satisfaction and organizational commitment.

METHOD

Semistructured interviews with 13 nurses, covering numerous aspects of their psychosocial work environment, were analyzed using thematic analysis.

RESULTS

High staff turnover and a preponderance of inexperienced nurses were described as stressful and detrimental to group cohesion. Work at the unit was considered overly demanding for newly qualified nurses, while senior nurses expressed frustration at the work of training new nurses who might not stay. While some were very satisfied with the group climate, others complained of a negative climate and incivilities from some experienced nurses toward new recruits.

CONCLUSIONS

High turnover and variable competence among staff present challenges for maintaining a positive organizational climate.

IMPLICATIONS FOR NURSING MANAGEMENT

Management should communicate a clear sense of the nature of neonatal intensive care when recruiting, foster group cohesion (e.g., by creating stable work teams) and reward commitment to working at the unit.

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic

A survey administered to staff at five hospitals investigated changes in unprofessional behaviour, teamwork and co‐operation during the COVID‐19 pandemic. From 1583 responses, 76.1% (95% confidence interval (CI): 74.0–78.2%) reported no change or a decrease in unprofessional behaviours. Across all professional groups, 43.6% (n = 579, 95% CI: 41.0–46.3%) reported improvements in teamwork and co‐operation. Findings suggest that intensifying work demands, such as those resulting from the pandemic, are not a major trigger for unprofessional behaviour, and root causes lie elsewhere.

Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: A systematic review of reviews

The rapid increase of acute and intensive care capacities in hospitals needed during the response to COVID-19 created an urgent demand for skilled healthcare staff across the globe. To upscale capacity, many hospitals chose to increase their teams in these departments with rapidly re-deployed inter-professional healthcare personnel, many of whom had no prior experience of working in a high-risk environment and were neither prepared nor trained for work on such wards. This systematic review of reviews examines the current evidence base for successful teamwork in rapidly deployed interprofessional teams in intensive and acute care settings, by assessing systematic reviews of empirical studies to inform future deployments and support of rapidly formed clinical teams. This study identified 18 systematic reviews for further analysis. Utilising an integrative narrative synthesis process supported by thematic coding and graphical network analysis, 13 themes were found to dominate the literature on teams and teamwork in inter-professional and inter-disciplinary teams. This approach was chosen to make the selection process more transparent and enable the thematic clusters in the reviewed papers to be presented visually and codifying four factors that structure the literature on inter-professional teams (i.e., team-internal procedures and dynamics, communicative processes, organisational and team extrinsic influences on teams, and lastly patient and staff outcomes). Practically, the findings suggest that managers and team leaders in fluid and ad-hoc inter-professional healthcare teams in an intensive care environment need to pay attention to reducing pre-existing occupational identities and power-dynamics by emphasizing skill mix, establishing combined workspaces and break areas, clarifying roles and responsibilities, facilitating formal information exchange and developing informal opportunities for communication. The results may guide the further analysis of factors that affect the performance of inter-professional teams in emergency and crisis deployment.

Gender Differences in the Relationship Between Workplace Civility and Burnout Among VA Primary Care Providers

BACKGROUND

Civility, or politeness, is an important part of the healthcare workplace, and its absence can lead to healthcare provider and staff burnout. Lack of civility is well-documented among mostly female nurses, but is not well-described among the gender-mixed primary care provider (PCP) workforce. Understanding civility and its relationship to burnout among male and female PCPs could help lead to tailored interventions to improve civility and reduce burnout in primary care.

OBJECTIVE

To analyze gender differences in civility, burnout, and the relationship between civility and burnout among male and female PCPs.

DESIGN

Multi-level logistic regression analysis of a cross-sectional national survey.

PARTICIPANTS

A total of 3216 PCP respondents (1946 women and 1270 men) in 135 medical centers from a 2019 national Veterans Health Administration (VA) survey.

MAIN MEASURES

Outcomes: burnout; predictors: workplace civility and gender; controls: race, ethnicity, VA tenure, and supervisory status.

KEY RESULTS

Workplace civility was rated higher (p<0.001) among male (mean = 4.07, standard deviation [SD] = 0.36, range 1-5) compared to female (mean = 3.88, SD = 0.33) PCPs. Almost half of the sample reported burnout (47.6%), but this difference was not significant (p = 0.73) between the genders. Higher workplace civility was significantly related to lower burnout among female PCPs (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31 to 0.69), but not among male PCPs (OR = 0.71, 95% CI = 0.42 to 1.22). Interactions between civility and other demographic variables (race, ethnicity, VA tenure, or supervisory status) were not significantly related to burnout.

CONCLUSION

Female PCPs report lower workplace civility than male PCPs. An inverse relationship between civility and burnout is present for women but not men. More research is needed on this phenomenon. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among PCPs.

Prevalence of incivility between ophthalmology and emergency medicine residents during interdepartmental consultations

OBJECTIVES

Since incivility is linked to adverse effects in patient care and health care worker well-being, evaluation of the prevalence of incivility during the formative years of residency training is warranted. The aim of this study was to determine the perceived presence and degree of incivility between emergency medicine (EM) and ophthalmology residents during emergency department (ED) consultations.

METHODS

We conducted a single-site, survey-based study, targeted to ophthalmology and EM residents. The survey we distributed included questions adapted from validated and widely used surveys measuring incivility in the workplace (Workplace Incivility Scale) and incivility within the ED.

RESULTS

Ophthalmology (13/15, 86.7%) and EM (42/48, 87.5%) residents participated, with an overall response rate of 55 of 63 (87.3%). Most residents (47/55, 85.5%) reported some degree of incivility during consultations, with a greater proportion of females reporting incivility (100%) than males (77.4%, p = 0.033). A total of 52.7% of respondents reported occurrence of incivility on a quarterly basis; 21.8% reported monthly, 10.9% weekly, and none daily. Incivilities were reported most commonly during nonurgent consults (85.5%). The two most common incivilities reported by trainees were when the other party paid little attention to their statements or opinions (80% of residents) or doubted their professional judgment (74.5% of residents). More female trainees reported jokes being told at their expense compared to males (15.8% vs. 0%, p = 0.049). Residents most often attributed incivility to stress (78.2%), loss of empathy/burnout (63.6%), or attempts to shift responsibility to another party (60.0%). Among EM residents surveyed, incivility was identified as occurring most often during consultations with surgical specialties.

CONCLUSIONS

Incivility during interdepartmental consultations between EM and ophthalmology is commonly reported by physicians-in-training. It occurs more often during consultations deemed as nonurgent and is more commonly reported by females. Given its associations with adverse outcomes, interventions to decrease incivility early in training may be warranted.

Witnessed Incivility and Perceptions of Patients and Visitors in Hospitals

Research has examined instances of incivility witnessed by physicians, nurses, or employees in hospitals. Although patients and visitors are members in hospitals, witnessed incivility from their perspective has rarely been empirically investigated. The aims of the current study are 2-fold: (1) to investigate the forms of incivility patients/visitors witness in hospitals and (2) to examine whether these patients/visitors believe these incivilities impact the target’s sense of perceived control. An integration of interpretative phenomenological analysis and thematic analysis was used to code qualitative data (N = 77). Eight themes of witnessed incivility and 3 themes for impact on perceived control were identified. The results illuminate patterns of incivility targeted at marginalized groups, historically underrepresented in hospital-focused incivility research (eg, homeless individuals, incarcerated individuals, the elderly individuals). The majority of witnesses believed the incident of incivility would negatively impact the target’s perception of control, possibly affecting their experience and health. The current study demonstrates that empirically investigating witnessed incivility from the patient/visitor perspective provides critical information about the unique patterns of mistreatment occurring within hospital contexts.

Incidence and impact of incivility in paramedicine: a qualitative study

BACKGROUND

Incivility or rudeness is a form of interpersonal aggression. Studies suggest that up to 90% of healthcare staff encounter incivility at work with it being considered 'part of the job'.

METHODS

Qualitative, in-depth, semistructured interviews (n=14) undertaken between June and December 2019. Purposive sampling was used to identify front-line paramedics working for one NHS Ambulance Trust. Interviews lasted between 16 and 45 min, were audiorecorded, verbatim transcribed and analysed using thematic analysis.

RESULTS

Four themes were identified: paramedics reported a lack of respect displayed both verbally and non-verbally from other professional groups. The general public and interdisciplinary colleagues alike have unrealistic expectations of the role of a paramedic. In order to deal with incivility paramedics often reported taking the path of least resistance which impacts on ways of working and shapes subsequent clinical decision-making, potentially threatening best practice. Finally paramedics report using coping strategies to support well-being at work. They report that a single episode of incivility is easier to deal with but subsequent episodes compound the first.

CONCLUSIONS

This study highlights the effect incivility can have on operational paramedics. Incivility from the general public and other health professionals alike can have a cumulative effect impacting on well-being and clinical decision-making.

Incivility in the Occupational Therapy Workplace: A Survey of Practitioners

IMPORTANCE

Incivility in health care settings has detrimental effects on practitioners' well-being, patient outcomes, and health care costs.

OBJECTIVE

To explore the prevalence and types of perceived incivility experienced by occupational therapy practitioners in their workplaces and the relationships between perceived incivility and practitioner demographics.

DESIGN

Cross-sectional, online survey.

SETTING

Surveys were posted to occupational therapy social media sites.

PARTICIPANTS

Occupational therapy practitioners throughout the United States. Outcomes and Measures: The Negative Acts Questionnaire-Revised (NAQ-R) was used to measure incivility and bullying. Participants answered demographic questions, and one-way analyses of variance and t tests were used to examine differences between demographic characteristics and mean scores on the NAQ-R.

RESULTS

A total of 1,320 practitioners completed the survey. Although the incidence of incivility was low compared with prior research in other health professions, 11% of respondents reported being victims of bullying in the workplace. Practitioners with less experience and who worked in long-term care and skilled nursing settings were more likely to experience incivility, and occupational therapy practitioners experienced significantly less incivility than occupational therapy assistants.

CONCLUSIONS AND RELEVANCE

Practitioners, colleagues, managers, and organizations must collaborate to foster an environment of civility and respect to mitigate the effects of incivility on patient outcomes, practitioners' well-being, and health care costs. What This Article Adds: This survey provides baseline information regarding incivility experienced by occupational therapy practitioners, an important first step in developing evidence-based interventions to promote safe and healthy workplaces.