Wasting Resources, Risking Patient Care

The price of incivility in the workplace

Canada’s reflections on health care miss the system’s most squandered resources: people’s knowledge, energy, and enthusiasm.

The math is easy: salaries are the biggest cost in the system. Nothing else costs so much or carries such an ongoing commitment. Frittering away any of that resource has a big impact. The expertise of health care providers is a limited resource that works best when combined with the expertise of others.

A hospital does its work through sharing information. No one person can do everything that patients need. Patients are in the hospital for treatment that requires a lot of people’s skills, energy, and time.

A free flow of information among people providing care is pivotal to keeping everything working well. Regardless of the technology, a lot of communication happens through face-to-face conversations. Direct contact among people is what turns health care from a concept into action. When those contacts work, people filter out trivial and pass along vital info.

Information flows well when people express respect and consideration for one another. But sharing is a fragile thing, easily discouraged. In extreme situations, toxic work settings shut down communication. When people dislike, disrespect, or fear one another, the chances of sharing knowledge diminish, and the chance of making mistakes rises

Poor working cultures have a serious impact. Investigations into major errors—operating on the wrong patient is an example—tell a story of missed communications. It’s not simply that the essential information was unavailable. Someone knows that this patient is not scheduled for that procedure. Someone may even say so. But the words don’t turn into action. Perhaps the words are not heard. Perhaps they are heard but ignored.

It’s not only health care: studies of aircrews have identified occasions when someone clearly knew the pilot was on the wrong track but refrained from pointing out this potentially embarrassing error. They literally would rather die than risk rebuke.

Communication gaps happen all the time. In well working systems, gaps prompt action. When important information is ignored, the obvious response is to crank up the volume. Without corrective action, the error moves another step down the road.

In strained working cultures, professionals truly committed to patient care hesitate to contradict someone speaking with authority and confidence. They hesitate even more when they expect a cutting response to their objections. Challenging a coworker’s judgment is a serious thing. It takes a sophisticated professional culture to convey respect when challenging someone and to prompt a constructive response. Otherwise, the response is likely to reflect offense, anger, and resentment. People prefer to avoid such confrontations.

Sophisticated professional cultures may not be rare, but they are certainly not universal. On the extreme end of workplace cultures lie bullying and abuse. People will certainly hesitate to speak up when they anticipate physical or verbal intimidation. But more subtle responses also discourage people from speaking up. Sarcasm, rolling eyes, or a pained facial expression have a similar cooling effect. In recent surveys two thirds of health care providers report experiencing this sort of incivility at work.

Workplace civility defines a health care resource issue. Rude, inconsiderate words from a coworker are an unnecessary demand. They exact an emotional cost from their target. Responding to that demand—and these things are hard to ignore—wastes valuable time and emotional energy. Canada’s health care system will have a hard enough time meeting the legitimate demands upon it. It lacks the resources to respond to illegitimate demands.

This problem is solvable. It does not require significant advances in science. But it does require unwavering dedication from leaders. It also requires all the people working in this system to acknowledge the impact of their actions on the quality of civility in their worklife. For the most part, people actively participate in creating and sustaining their relationships. They can participate in creating more respectful and civil workplaces.

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