February 27, 2017
The neonatal intensive care unit is a place full of tiny, vulnerable and critically ill infants; fearful and anxious parents; and busy doctors and nurses working to save lives. But if a parent of a sick baby says something rude to the medical staff, the quality of care might suffer, a new Israeli study suggests.
“We weren’t looking at angry parents, we were looking at rude parents,” said Dr. Peter Bamberger, a study co-author and the associate dean for research at Coller School of Management at Tel Aviv University. The study used the kind of simulated crisis scenarios that are commonly performed to help medical staff practice, using actor “parents” and a realistic plastic baby “patient.” And the rude “mother” in the study said, loud enough for the staff to hear: “I knew we should have gone to a better hospital where they don’t practice Third World medicine.”
“It wasn’t anything horrible,” Dr. Bamberger said. “They weren’t going ballistic, they weren’t violent. They just said things that weren’t so pleasant for doctors to hear.”
But even such mild unpleasantness was enough to affect doctors’ and nurses’ medical skills. Individual performance and teamwork deteriorated to the point where diagnostic skills, procedural skills and team communication were impaired and medical errors were more likely, compared to control scenarios in which the mother would just say something general about being worried. The team’s ability to perform in critical medical situations with sick babies was affected for the rest of the day, the findings suggest.
“At the level of the team, it really hampers all the function,” said Dr. Arieh Riskin, the director of the neonatal intensive care unit at Bnai Zion Medical Center in Haifa and the lead author of the study, which was published in the journal Pediatrics. “All the collaborative mechanisms and things that make a team a team, rather than four individuals working separately, were damaged by the exposure to rudeness.”
Dr. Riskin said rudeness has long been part of medical culture, whether between senior doctors and trainees, or between surgeons and nurses in the operating room.
“The whole medical profession has a lot of hierarchy and people saying things they shouldn’t to each other,” Dr. Riskin said. “We started being interested in, what does it do to us as human beings having to take care of patients.”
An earlier simulation study that he and his colleagues conducted and published in 2015 looked at the effect of a rude comment made by a senior doctor on the functioning of NICU teams. The teams knew they were being assessed by an American expert; in some of the simulations, Dr. Riskin said, that observer made a derogatory remark about medicine in Israel: “Just something like, ‘Teams like the ones I have seen here in Israel wouldn’t last a week in my department.’”
After such a comment, the teams performed significantly worse in the simulated patient emergencies. Their diagnostic skills deteriorated, and so did their technical procedural abilities, from ventilating and resuscitating the artificial babies properly to ordering and giving the right medications. Both doctors and nurses tended to perform worse individually. They also worked less effectively as teams, as far as communicating and helping one another take care of the sick “patient.”
Dr. Bamberger, a co-author on that earlier study as well, said that many of the physicians weren’t even conscious that someone had been rude. “It was very mild incivility that people experience all the time in every workplace; things slip out that maybe shouldn’t slip out.” But in response to even mild rudeness, he said, people need to expend cognitive resources deciding whether they are in a threatening situation, and whether the threat is going to get worse; those concerns can draw cognitive resources away from the task at hand, and teamwork suffers.
The findings are consistent with earlier studies of rude behavior in other workplace environments, which have shown that even mild rudeness can have a potentially big impact. In both of the NICU studies, the effects on performance were significant; rudeness explained more error than the levels of error that have been shown to result from sleep deprivation.
Both studies were done in Israel, but the impact of rudeness does not seem to be culturally bound, a concern that was raised in the initial study design. “Israelis are not deemed to be the most polite people in the world; they say what’s on their mind,” Dr. Bamberger said. “The evidence suggests that even in a somewhat rude society, it still has an effect.”
In the latest study, the teams again knew that they were being observed while they dealt with simulated medical emergencies: a very premature birth, a baby in respiratory distress, a newborn severely deprived of oxygen. They were also told they would need to respond to family members while taking care of the critically ill babies, standard everyday imperatives in newborn intensive care.
The new study also looked at two different strategies to see whether they might help the teams deal with the rudeness.
In one, the medical personnel were asked to do a writing exercise immediately afterward, imagining the story from the mother’s point of view. But that narrative exercise seemed to have no effect on subsequent performance.
The other intervention did seem to provide some benefits. In that exercise, staff members were asked to play a computer game before the simulation, developed for people with post-traumatic stress disorder. In the game, participants were exposed to faces showing different emotions, rating them as either “angry” or “happy.” Then, after their threshold for perceiving threats — the angry faces — was established, they got feedback designed to raise that threshold, to help deflect their focus on minor threats.
Everyone working in the NICU understands that parents are under tremendous stress and cannot necessarily be expected to demonstrate good manners at all times. But it’s critical for the members of the medical team to be aware of the risk and to acknowledge the problem, Dr. Riskin said, in order to help protect one another and deliver optimal care.
“We are human beings; we are affected by rudeness.”