The Daily Dose • Tuesday, May 21

Incivility and Destructive Behavior in the Workplace

By Adaora M. Chima, MBBS, MPH, from the IARS, AUA and SOCCA 2019 Annual Meetings*

Since the advent of the #metoo movement, incidents of inappropriate behavior in the workplace have inundated the media, and our personal conversations with peers and coworkers. It has unveiled a pattern of destructive behavior in the workplace that represents the more visible egregious behavior at one end of the spectrum, to the not subtle low intensity, destructive behaviors that could be simmering underneath the surface. The session, Incivility in Academic Medicine: Incidence, Instigators and Impact, on Monday, May 20, with panelists Qi Cui Ott, MD, Beth Israel Deaconess Medical Center; Maya Hastie, MD, Columbia University Medical Center; Harriet Hopf, MD, University of Utah Health Care; and Jonathan Hastie, MD Columbia University Medical Center, sought to deconstruct these behaviors and proffer approaches to managing them on the personal and institutional level.

Dr. Ott defined incivility as low intensity deviant behavior with ambiguous intent to harm a target, which violates workplace norms and mutual respect. Its ambiguity lies in the presence/absence of a conscious intention to harm the target. This may not be apparent to the instigator, target, or either. The characteristics that identify a conduct as uncivil include its violation of organizational norms of respect, its ambiguous intent, and its low intensity. More egregious behavior would be further along the spectrum as micro-aggression, bullying, sexual misconduct or violence.

No one is immune to incivility, and targets (on the receiving end) and instigators can be at any level of medical hierarchy. Although the action itself is of low intensity, the impact is often not. An American study showed that approximately 60% of medical trainees had experienced forms of harassment or incivility during training. In King’s College, London, 31% of health professionals surveyed reported being subjected to rude or aggressive communication multiple times a week. Among Canadian nurses in a similar survey, 70% reported personally experiencing incivility and 98% witnessed it. Incivility can also be selective, manifesting as biased behavior and discrimination in inconspicuous ways.

Examples of demonstrations of incivility in the workplace are: inappropriate language, ignoring coworkers or refusing to respond when spoken to, ignoring or dismissing his/her opinions, refusing to perform assigned tasks.

Are there determinants of this kind of behavior? Yes. Dr. Maya Hastie explained that the propensity to demonstrate incivility is determined by social power differentials, personality traits, conflict management skills and emotional intelligence. On review of the 5 big personality traits, individuals who are prone to these behaviors are argumentative, and consistently score low on agreeableness. A high score in neuroticism is associated with uncivil behavior.

Patients are at the highest risk of incivility, followed by trainees, then staff and then faculty. It can be part of the culture in a unit or institution with an ultimate impact on patient safety.

Frequently repeated micro-aggressions have greater pathogenic potential than episodic dramatic events that have coping strategies readily available.

The cost of workplace incivility can be quite significant. Individuals who have been targeted report intentionally decreasing their work effort and time spent at work, all contributing to lost work time in an effort to avoid the instigator. This can lead to inefficiency, frustration among other colleagues who have to make up for the target, possibly triggering incivility in others and creating a vicious cycle.

According to Dr. Hopf, surveys assessing the impact of incivility revealed that a single uncivil event in the workplace was responsible for >67% of reduced work effort. Eighty percent of individuals lost productive time worrying about the event and 12% left a job because of it.  Lost productivity due to incivility can cost as much as $11,581/nurse per year in lost work time.

The consequences can be cumulative, causing job dissatisfaction, reduced engagement, decline in physical health and ultimately, burnout.

An institutional culture that tolerates incivility results in reduced innovation, impaired team function, and up to a 50% decrease in willingness to share information. Such environments become toxic, resulting in attrition and additional costs to replace staff. It is important not to normalize bad behavior. Incivility can lead to deviation, amplification and increasingly counterproductive behaviors, spiraling and spreading across units and change culture. Incivility disrupts a culture of safety, increases errors, decreases respect for colleagues, and discourages students from entering the field. It is a barrier to optimal patient care and goes against the foundation of anesthesiology, which is the ultimate patient safety discipline.

Enjoined, everyone can eliminate incivility from the workplace.

Dr. Jonathan Hastie addressed strategies to address and eliminate incivility in the workplace. He started his presentation with a vignette that illustrated incivility in a clinical scenario. An interactive exercise with the audience revealed a diversity of responses to the instigator.

He described goals for managing incivility as psychological and physical safety, interpersonal relationships through affiliation and cooperation and organizational identity through alignment with the institution and demonstration of institutional values. Management of incivility occurs on a personal level, interpersonal level and at the institutional level.

On a personal level, it’s important to know your identity and values as these individual responses will depend on our natural tendencies for a certain style of conflict management. Different styles can be used in different situations or can shift from one to the other as the situation evolves.

The response to incivility should be tailored to the offense, the instigator and to the situation, taking your intention’s goal in mind. You might choose to ignore, deflect or confront or enlist advocates or bystanders. A decision to confront should depend on whether the behavior is intentional, repeated or in a safe situation to respond.

He and other panelists stated that there should be zero tolerance of incivility and cited business models that had turned their organizations around.

Incivility can easily tip over to aggression so it’s important to build a culture that eliminates it at the source. Institutions should have a zero tolerance policy for incivility. There are often departure points from every uncivil interaction and these should be explored during the encounter to avoid a spiral. Conflict management skills and emotional intelligence are important in the management of uncivil interactions, which can be developed over time. On an organizational level, leadership is key and critical to creating a civil environment and providing resources to train staff on conflict management. In essence, institutions need to establish norms of conduct (e.g., define incivility), educate on issues such as implicit bias and empower employees by making potential targets aware that they will be supported.

*Coverage from the panel, Incivility in Academic Medicine: Incidence, Instigators and Impact, during the IARS 2019 Annual Meeting