Over
the past few months I have conversed with several experts on their views regarding
leadership attributes that either facilitate or impede teamwork as well as the
affective component in learning and teamwork (see links below). Needless
to say, after talking recently with Coach McCoy regarding the need to focus on
one’s behavior in response to stressful encounters, I have been more cognizant
of my interactions with fellow teammates over the past few months. With
this awareness I attempt to override my typical terseness in the midst of
difficult situations and view events with empathy (I don’t hear “you don’t have
to be sarcastic!” as much anymore). On the same note, Dr. Sotile and Dr. Schoomaker reminded us at
the Faegin Leadership conference that as we allow ourselves to become stressed
and don’t find a release outlet, our mental capacity is reduced and we become
angry (then everyone hates us). Modification of one’s innate behavior is by no
means an easy journey but a worthy one. While I am certain I have not been
hospitable in all circumstances over the past several months, I do feel less
stressed which in turn has clearly reduced my potential for an inhospitable
encounter (at least it appears that way to me). With that in mind, it was
perfect timing that Medscape recently highlighted a 2015 paper
titled “THE IMPACT OF RUDENESS ON MEDICAL TEAM PERFORMANCE”. It seems that the old adage, “You
catch more flies with honey than vinegar” may run true.
The study was performed amongst 72 NICU professionals recruited from four
Israeli Hospitals, who were organized into teams of one physician and 2 nurses
from the same unit. Each team was asked to participate in a 1-hour simulation
in their own hospital’s NICU. The teams were randomized into teams with
moderators who were either civil or mildly rude. Diagnostic skill and
procedural performance were compared between the two groups. The authors
reported that the majority of individual performance items as well as overall
diagnostic and procedural performances were negatively affected by exposure to
rudeness during their simulation. Overall, they discovered that model explained 52% of the variance in
diagnostic performance and 43% in variance in procedural performance. The
team pointed out that this study only assesses the effect of rudeness in very
short duration and was not target-specific, therefore the effect of more
intense or longer duration or specifically pointed incivility could be
associated with an even more significant deterioration of performance.
After
reading this report, I contacted the authors to see if they could provide more
information on their research. Dr. Amir Erez, PhD (AE) was kind enough to send
me another summary publication on their quest to understand the impact of an
uncivil incident and agreed to chat about this topic. Our conversation
regarding this subject is as follows:
--Just how serious are the consequences of incivility on the team?
AE. Rudeness can reduce performance
by a significant amount. As we noted in the study, an uncivil encounter can
cause an immediate reduction in people's performance. Our studies have shown
that even a single and brief incident of incivility can hinder performance.
Even worse, a single uncivil event can prime the witness / victim to severe
dysfunctional behavior / thoughts. This can become very contagious. Knowing
that just imagine the effects on highly complex patient care if a member or the
team losses the ability to concentrate or becomes dysfunctional. The results
can be deadly or at a minimum catastrophic (read their summary paper for
examples of how this can be extremely dangerous). We have another study that is
ongoing looking at rudeness during pediatric care that shows that incivility is
damaging by reducing production by 35% leading to serious mistakes. We have an anesthesia
study assessing if rudeness can affect a provider by causing them to focus on
the wrong diagnosis. They miss serious problems that led to death. They could
not switch their diagnosis. This even affected the witnesses.
--Is the effect brief (temporary) or long term?
AE. Rudeness can impact motivation and well-being but the effect goes way
beyond that. Those exposed to incivility have attention deficit, memory
malfunction, and a reduced ability to participate in teamwork, all of which
reduce performance. For example, our new study assesses the effect of rudeness in
the morning over the entire day. The effect is over the entire day. A second
study tests rudeness in the morning on the effect on executives. We found that
this also affects the exposed study participants all day. Another study
assessing the ability to negotiate, looking at contagiousness showed that the
effect on the group lasted over SEVEN days.
--Does this affect the recipient of the rudeness alone or does the team
suffer?
AE. One of the first studies we published on testing witnesses showed the
same issues. The effect can be widespread such that witnesses to an uncivil
incident (not even directed at them) suffer a reduction in their capacity to
solve complex problems and diminished creativity. As we discussed, the effects
can become infective in the organization. Teams will always be prone to
negative performance and unrest, but they typically band together. Not true
when they are victimized by uncivil behavior. Incivility breeds aggression and
then the teammates take out their frustration on each other. To make matters
worse they then fail to share information or workload. Surprisingly this is
regardless of whether or not the rudeness originated from a teammate or from
someone outside the team.
--Your 2015 study notes a diminished cognitive and procedural ability,
any clue what component of our processes is negatively affected?
AE. we have a study using Randy Engle’s measure of working memory and spatial memory
and found that working memory is greatly affected. The most impacted was goal
aspects and attention and problem solving.
Me: I talked with Randy Engle last
year about his research on working memory but can you expand?
AE.. Working memory is where we store
visual and verbal information used for decision making and goal management.
Witnesses to rudeness have an impact in all those areas. For instance, they do
worse with verbal tasks, become less creative, recall less, and miss visual
cues directly in front of them (see Simon and Chabri Harvard invisible
gorilla). The misinformation even in the center of their visual fields for 30
seconds is affected. This can be a real problem with surgeons. Simply having
this uncivil event on one’s mind can affect all components of working memory.
(For
those interested, I received a copy of EXECUTIVE
ATTENTION, WORKING MEMORY CAPACITY, AND A TWO-FACTOR THEORY OF COGNITIVE
CONTROL
from Randall Engle whereby they describe working memory
components – See down below for their description)
--Is incivility an individual problem or a sign of systemic issues? That
is how far reaching can it become. “This person is a disruptive physician” is
commonly what we hear.
AE. In of itself an uncivil culture can likely impact the entire
organization. It makes staff sad, mad, fearful and unmotivated. Whether this
starts with a single person or not it is typically very contagious and becomes
cultural. This affects everyone, doctors, nurses AND patients. Patients
themselves can create this distraction.
--Can you narrow down why humans are so negatively impacted? Why
can’t we just shake it off?
AE. Incivility becomes a major social threat. Under attack
by any threat our nature is to go into self-preservation mode. Then, that is
all we think about. We may not realize it but we become primed to respond to
this negative social issue. People ruminate about this and think on and on
“what should I have done? why did I not do that?” It becomes very disturbing to
us.
Of note, their 2015 paper goes
into detail about the amygdala response to threat described by Joseph Ledoux
and Antonio Damasio. This response to any catastrophic event was described by
Sweeney et al in LEADERSHIP IN DANGEROUS SITUATIONS. In that book, the
authors estimate that these events require one to wait at least a day prior to
returning to usual activities. The event clearly overshadows all other thought
processes.
--Can an organization do anything to curtail incivility? You mention the
following in your summary:
Recruitment: the
recruitment process can identify those who have had excessive issues with
incivility especially those who foster a hostile environment.
Set expectations
and norms for civility- civility should be held as an organizational mission
and value.
Recognition and
awards.
Coaching-
organizations must provide interpersonal skill development amongst its staff.
Intolerance of incivility.
i. Aside from that,
in many organizations rudeness seems to originate from the top. That is,
employees identify that the leadership of the organization does not take the
staff seriously and has been known to be rude to its employees. Does the organization
owe it to its staff to do a self-assessment first before it blames its
employees?
AE. We have a study
on 90 schools in Israel. When the Principals are rude to teachers then the
teachers are rude then the students misbehave. It’s the domino effect. People
tend to try to downplay rudeness.
ii. Doesn’t
the organization owe it to the staff to look internally in the facility to ask
the question “why does incivility still exist in healthcare when we are
supposed to be nurturers and providers?” That is- why are these people being
rude in the first place? Are they rude to everyone about everything or are
there events that trigger these episodes? Is anyone asking -what was that event
that triggered the inhospitable response? And- is it actually a serious event
that was overshadowed by a person’s outburst? It seems that most of what we
read regarding the disruptive physician centers around the person and the uncivil
event and not on the question as to why the event happened in the first place.
As a Chief, I had a recurring warning to staff to avoid their personally
becoming the focus of a negative event. That is, after something occurred
during their care of a patient, any outburst by them will overshadow the
negative event (or sequence of events) that caused them to become angry in the
first place. They always related to me that they felt someone was being
irresponsible, neglectful or just plain dangerous and no one seemed to care. My
response was for them to come find me and release their anger with me rather
than in public. Once they felt better we would outline the problem. As Chief,
if a recurring hindrance to effective care was causing them to lose their focus
and their temper, then that was my responsibility to find the team who would
work with me to make the situation better. It is clear that the person
with the personality drive that steers one towards complex patient care is
highly likely to take these events personally. The staff will have spent an
inordinate amount of time preparing the patient and themselves for that care
episode, so naturally when the results are suboptimal, they perceive this as a
personal failure (see Bosk, Forgive and Remember) and a reflection on their
personal performance. This research on rudeness reinforces that an uncivil
outburst can easily overshadow substandard care making any resolution difficult
if not impossible. It is now obvious to me that victims or witnesses of
incivility focus on the inhospitable encounter itself and are unable to move
beyond that instead of focusing on whatever situation triggered the event in
the first place. Everyone will lose the ability to reason and plan. With that
in mind after all this research what is your advice to the staff who feel the
need to express their exasperation in public when they feel that no one is
listening? As leaders, what do we do about that?
AE. “This is the question of -why do people behave this way? We do
interview people and ask them why they behave this way. The first reason is
that someone was rude to me. The second was that they reacted to an incompetent
person. THERE ARE REASONS, we just need to understand it. Something you may be
able to control by making them aware of the cognitive consequences, but we
cannot control the patients. These can be just as dramatic in the creation of
mistakes.”
--What can an individual do? Has this research lead to
potential intervention that looks to be successful?
AE. Take care of yourself by being aware of the problems
that incivility poses on the team and organization and taking time for stress
reduction. Reduce your potential for incivility when possible by steering clear
of those who have a propensity of being uncivil. Engage in mindfulness and
meditation- we do not have any evidence of this but it is highly probable that
it is effective. (see my recent post on an interview with Dr. Schoomaker on
meditation and mindfulness).
AE. People who are perspective taking seem to be more
resistant, but training people to take the perspective of the person who was
rude, did not work. Same methods used in PTSD may work. Inoculation may
work. Using cognitive behaviorally intervention for phobia treatment to raise
the threshold to hostility, seemed to work for Yair Bar Hain. It is clear
it works short term but no assessment if this works more than throughout the
day.
--Why are people rude?
AE. We do not know. We are having issues recreating
this to make people become rude. We have a study looking at this but have not
replicated it. We should know the benefits of this behavior- what are the gains
for acting this way? I am actually a positive moodness researcher. When I was
introduced to this, I did not believe this- I quickly learned people were
slower in their reactions after a negative encounter.
--How has this affected you personally? Do you act
different?
AE. I am more aware and more concerned. In social sciences
something that explains 5-10% of variation is huge but this effects 43%. For
example, resident sleep only effects 23% of production and this is twice a
bad”.
--Is there a regional cultural variation on the effect of
rudeness? Ie Northeast vs South vs Midwest Vs Pacific Coast vs Caribbean?
AE. I thought that there would be a variation on tolerance to rudeness.
We did this in California, Florida, Washington, UK, Israel, New York. We FOUND
NO difference except for perspective taking. We thought people in Israel would
be immune to this. We found the exact same response. I did not believe it would
affect everyone the same way but right now it is the same everywhere.
--This study is from 2015. Where have you gone from there? I.e. Have you
reversed the groups without their knowing it to see if the performance
significantly changed when the groups were exposed to the opposite style of
moderation?
AE. Don’t know if we can pull it off. The study participants were very
upset and we told them all that this was a study and not real. We are going to
do a study to survey people about rude experiences and relate them to medical
errors.
EXECUTIVE ATTENTION, WORKING MEMORY CAPACITY, AND A
TWO-FACTOR THEORY OF COGNITIVE CONTROL
– WITH PERMISSION OF Randall Engle & Michael J. Kane “As developed by Baddeley
(1986, 1996, 2000), the working memory model now arguably emphasizes structure
over function. It consists of both speech based and visual/spatial-based
temporary storage systems (the phonological loop and visuo-spatial sketchpad),
with associated rehearsal buffers, as well as an "episodic buffer"
thought to maintain episodic information using integrated, multi-modal codes.
Finally, a central executive component, analogous to Norman and Shallice's
(1986) supervisory attention system, regulates the flow of thought and is
responsible for implementing task goals.
By our view, then, working memory is a system of: (a)
short-term "stores," consisting of LTM traces in a variety of
representational formats active above a threshold; (b) rehearsal processes and
strategies for achieving and maintaining that activation; and (c) executive
attention. However, when
we refer to
individual differences in WMC, we really mean the capability of just one
element of the system: executive-attention. Thus, we assume that individual
differences in WMC are not really about memory storage per se, but about
executive control in maintaining goal-relevant information in a highly active,
accessible state under conditions of interference or competition. In other
words, we believe that WMC is critical for dealing with the effects of
interference and in avoiding the effects of distraction that would capture
attention away from maintenance of stimulus representations, novel productions,
or less habitual response tendencies. We
also believe that WMC is a domain general construct, important to complex
cognitive function across all stimulus and processing domains.
To better illustrate our view, let us
place WMC in a context of general cognition. We believe that much of what we
need to know to function, even in the modern world, can be derived from
retrieval of L TM-retrieval that is largely automatic and cue-driven in nature.
Under those circumstances, WMC is not very important. Even in some putatively
complex tasks such as reading, WMC is not required in all circumstances (Caplan
& Waters, 1999; Engle & Conway, 1998). However, as we see in the
following example, proactive interference can lead to problems from automatic
retrieval. When the present context leads to the automatic retrieval of
information, which in turn leads to an incorrect or inappropriate response in a
task currently being performed, a conflict occurs between the automatically
retrieved
response tendency and the response tendency necessary for the current task.
That conflict must often be resolved rather quickly, and so we need to have
some way to keep new, novel, and important task-relevant information easily accessible.
Take a simple example obvious to every American walking the
streets of London for the first time. While driving in a country such as
England can lead to potentially dangerous effects of proactive interference,
there are numerous cues such as the location of the steering wheel, the cars on
your side of the road, etc., prompting the maintenance of the proper task
goals. However, in walking the streets of England, the cues are much like those
present when walking the streets of any large American city and the temptation-shall
we say prepotent behavior-is to look to the left when crossing the street. This
can be disastrous. So much so that London places a warning, written on the
sidewalk itself, on many busy crosswalks used by tourists. This is a situation
in which the highly-learned production, "if crossing street then look
left," must be countered by a new production system leading to looking to
the right when crossing streets. This task seems particularly problematic when
operating under a load such as reading a map or maintaining a conversation. For
individuals that travel back and forth between England and America, they must
keep the relevant production in active memory to avoid disaster. ” Approved by Randall W Engle)
KENNETH A. LIPSHY, MD, FACS
Porath CL, Foulk T,
Erez A. How incivility hijacks performance: It robs cognitive resources,
increases dysfunctional behavior, and infects team dynamics and functioning. Organizational
Dynamics 2015;44:258—265.
A, Erez A, Foulk TA, Kugelman A, Gover A,
Shoris I, Riskine K, Bamberger PA. The Impact of Rudeness on Medical Team
Performance: A Randomized Trial. Pediatrics. 2015;136(3):487:495.
