In 2015, a team of Israeli researchers studied the impact of
rude comments by another doctor on medical teams while they did a simulation
of caring for a very sick premature baby.
The words, from an expert the
participants were told was observing them, included that he was “not impressed
with the quality of medicine in Israel” and that medical staff in Israel
“wouldn’t last a week” in his NICU in the United States.
Twenty-four NICU teams participated and teams
were randomly assigned to hear the expert’s rude comments or to hear his neutral
comments. The teams that experienced the rude comments scored less well in
their diagnosis of the baby’s problems and in how they performed tasks like
resuscitation and asking for the right lab tests. They were rated by two
judges. “Rudeness exposure [by a medical superior] can adversely affect the
cognitive functions required for effective diagnostic and medical procedural
performance,” the researchers conclude, and may be a source of devastating medical
error.
In a new study published in Pediatrics this month, the same scientists look at what happens
when an actress, playing the role of the baby’s parent in a simulation, belittles the medical team. In this study, four Israeli medical teams performed
five emergency scenarios. Three of the teams were confronted by a mother who
accused them of misdiagnosing her child, threatened to move the child to
another hospital, and said: ‘I knew we should have gone to a better hospital
where they don’t practice Third World medicine!’ The control team was not
exposed to rudeness.
Two teams were given a preventative intervention—one was a
cognitive bias-changing game and the other a therapeutic writing exercise. The
20-minute computer game before the simulation showed angry and happy faces and
provided feedback that made them less sensitive to negative emotions. The
writing exercise involved having one team write about the rude event after it
happened. The teams that experienced the rude comments from the mother scored
less well on how they diagnosed the baby and intervened, as well as how their
team shared information and workload. The researchers showed that the pre-simulation computer game reduced
these negative effects on care, while the post-intervention writing exercise
was ineffective.
BLOOM interviewed lead investigator Dr. Arik Riskin, a
neonatologist at Bnai-Zion Medical Center in Haifa, Israel, by e-mail to learn more.
BLOOM: Why was the study about parent rudeness needed?
Arik Riskin: The study is important because it increases
awareness that there are many factors related to human behaviour, relations and
communication between [health workers] and between them and their patients or
families. We are not robots, we are human beings with
feelings, and we react to social situations and behaviours as do other humans. But,
in the case of [health workers], the impact can be devastating, because we are
dealing with patients, treatments and life-and-death decisions. The remedy starts from awareness and
recognition that there may be a problem with this issue. Awareness is important
for us as medical team members, but it’s also important to our patients and
their families and to healthcare management authorities dealing with ways to
decrease medical errors and improve care and patient safety.
BLOOM: How did you define rude behaviour?
Arik Riskin: Rudeness is defined as
insensitive or disrespectful behaviour enacted by a person that displays a lack
of regard for others. Rudeness should be regarded as a form of uncivil
behaviour. Workplace rudeness may include insulting comments, denigration of a
person’s work, spreading false rumours, social isolation and bad manners. Rudeness, particularly with respect to
speech, is necessarily confrontational at its core. What constitutes rude
speech depends on the culture, the setting and the speaker’s social position in
the culture. Rudeness is primarily concerned with violations of human dignity
or respect.
BLOOM: What are common causes of rude parent behaviour in
the NICU?
Arik Riskin: I would pay a fortune to find out the answer to
this question. However, I’ll share with you some of our insights from our
experience. Many times rude behaviour is a late response to an incident or some
stress (and the NICU experience is very stressful) that the parents experienced
before, sometimes even a few days or hours before.
The rudeness is not
necessarily turned toward the [health worker] that was involved in that previous
incident, and may be unrelated to the parent's infant or to the NICU or hospital. It
can be some argument between the parents or in their larger family.
However,
when it hits the physician or nurse out of the blue, they start thinking ‘What
have I done wrong?’ This starts the process of rumination—thinking over and
over ‘Why did I get this insult?,’ drains their cognitive resources and
eventually can affect their ability to treat patients.
BLOOM: What were the main findings on rude parent behaviour?
Arik Riskin: Rudeness has robust, deleterious effects on the
performance of medical teams. Moreover,
exposure to rudeness debilitated the [collaboration] recognized as essential
for patient care and safety.
BLOOM: How does rudeness impair a medical team’s ability to
provide good care?
Arik Riskin: Teams exposed to mild rudeness by the patient’s
mother had diminished team performance with respect to outcome parameters
relating to diagnosis and intervention, and process parameters including team
information and workload sharing. These findings not only replicate our earlier
findings demonstrating the [negative] effects of rudeness expressed by a senior
colleague on individual medical performance, but extend them by demonstrating
that similar effects are elicited by rudeness from other sources and are
manifested at the team level.
In this study, we also demonstrated that these
deleterious effects of rudeness are not restricted to individuals, but also to
teams. This is important because—based on the assumption that teams can often
overcome and compensate for individual performance limitations—medical work is
increasingly structured around teams. Our findings demonstrate that when
rudeness is present, the very collaborative processes that generally enable
teams to outperform individuals may break down.
To the extent that rudeness impedes team
helping and workload sharing, teams may not be able to deliver the heightened
level of patient care that practitioners have come to expect from them.
BLOOM: Why was the computer game some teams played effective
in reducing the negative effects of rudeness, while the writing exercise others
did wasn’t?
Erik Raskin: Prior to the simulation, teams in the
preventative cognitive-bias modification intervention engaged in a 20-minute computer
game in which they looked at a series of morphing faces, were asked to move a
cursor to indicate whether the emotion was more of anger or pleasure, and then
received immediate feedback on their choice.
During this game, the computer
determined the participant’s threshold to threat—that is, the angry faces—and
then gave them feedback designed to raise this threshold and ‘immunize’ them
from devoting substantial attention to minor threats.
Examination of the manipulation checks showed that those in
the computer intervention viewed the mother as ruder than
those who experienced the rude comments with no intervention.
As
designed, the computer intervention ‘immunized’ participants’ medical and
therapeutic performance and teamwork by shifting their attention away from the
implicit threat posed by the mother, likely preserving cognitive resources for
the tasks at hand. The computer intervention operated not so much by mitigating
the appraisal of rudeness, but by making team members more resilient to it.
The teams who did the writing exercise worked on the
simulation with rudeness first, and then went to a debriefing room where they
were asked to write a paragraph or two about how they thought the mother of the
infant felt when it seemed to her that the team was unsuccessful in treating
the baby.
By the end of the day, those in the narrative group did not view the
mother as ruder than controls. These results suggest that while writing about
the experience from the mother’s perspective facilitated participants’ positive
reappraisal of her rude behaviour, it failed to help them overcome the
cognitive disruption caused by it.
BLOOM: Is there a danger in making health workers less
emotionally responsive to families?
Erik Raskin: As mentioned in my answer above, the computer
game didn’t make health workers less emotionally responsive. On the contrary, it just ‘immunized’ them, thus changing their focus
and less disturbing them in their work.
BLOOM: Are there times when a parent questioning the care is appropriate?
Erik Raskin: Parents questioning the care is always
appropriate. They have the right to ask questions. In my opinion we can use it
as a means to help us do better, think again about the diagnosis, re-think
treatments given and other options of treatment. Generally, this is a good
interaction with parents, and many physicians and nurses, like me, see parents
as our partners in the goal of giving the best treatment to their children,
helping them survive and grow, and go home, as healthy and happy as possible.
There is a big difference between real questioning and
seeking explanations in the best interest of your baby, and rude comments,
insults and blaming of the physicians and nurses. [In the latter case], parents
throw all their stress and frustration (because the infant was born prematurely
and is very sick) on the medical team that is trying its best to save their
infant, give life and treat as best as they can.
There is also the issue of
timing. We allow parents in our NICU all day long, including in rounds, but
parents must understand that we also need to treat, to do resuscitation and
other procedures, and to look after other babies. So we are not all the time
available to answer every question. They should be patient and understand that
sometimes we simply don’t have time to talk to them immediately, and we’ll be
happy to do so later when we have time.
So, please don’t start shouting at us,
making rude remarks about how careless or less attentive we are. This makes us feel bad, makes us ruminate about ‘What have we
done wrong?’ and drains our cognitive resources in a way that eventually hurts
our performance or even causes us to do unintentional harm.
BLOOM: A media story about your study includes a quote from
a doctor who says that outside the NICU, parent rudeness is often a legitimate
reaction to poor care and system problems. Is it possible that this could also
happen in the NICU?
Arik Riskin: Sorry, but I disagree with this statement.
Rudeness is never a legitimate reaction—not in the NICU, not outside the NICU
and not anywhere else. This is not a nice way to express your concerns. It is a
totally unacceptable form of communication among people in general. It is an
act of incivility that is no less harmful than aggressiveness or bullying.
Parents should and can express their concerns about treatment, and if they
think it’s poor care, they should tell this to the medical team. If this
doesn’t help, they can talk to their superiors, and if this doesn’t help, they
can ask to go and get the treatment in another facility. The problem is that
many times it’s not poor care, but mainly frustration on behalf of the parents
because their infant is really sick and doing badly despite all the treatments
given to him or her.
But, I’m ready to hear this from parents, too, and I’m not
ashamed to consult another expert and seek another opinion, as long as it is
for the best care of my patients. Unfortunately, many times nowadays parents
are confused by a general atmosphere that is very criticizing [about]
everything. This is reinforced by the media ‘looking for headline news,’
attorneys looking for law suits, and family members (who think they are
supporting the parents by questioning everything, but cause the parents lots of
confusion and eventually mistrust in the care their baby gets.
Parents need to
have some trust and faith in the team taking care of their baby in order not to
lose hope, which is so important for them, and us too. Parents should ask
questions, should learn and read about their infant’s condition, and should
inquire about the diagnosis and possible other treatments. But at a certain
[point] they need to have some trust and confidence in us as medical team
members, coming days and nights to do our best for their babies.
BLOOM: Are there differences in how parent rudeness vs
medical staff rudeness impacts medical care?
Arik Riskin: Both are as bad, having devastating effects on
individual team members and on medical teams’ performance as a whole. We haven’t
compared both sources at the same time in the same settings, so I can’t
guarantee which is worst. But based on our studies and the studies of Professor
Erez and colleagues on rudeness in other settings, both have very bad
influences on the [person targeted] and on those who witness it.
BLOOM: What advice would you give parents?
Arik Riskin: Try to be as patient and polite as possible. We
understand that you are in real [distress], and are there for you. We even
understand when you are not so nice to us because you are sad and worried. But,
being sad or worried and even frustrated doesn’t necessarily need to make you
rude to us.
Being rude simply doesn’t help and might actually cause the
opposite by distracting us and disturbing us from doing our best.
I have worked
with many parents over the years and those that had a positive attitude to all
that was happening, despite all the stress and hard times they were going
through, coped much better than other parents. I believe that this attitude
gave them hope, which is so important in tough times. I think they may have
also been more open to the support we are willing and trying as best as we can
to give to all the parents of the sick infants and preemies we’re taking care
of.
BLOOM: What measures should hospitals put in place to try to
reduce rudeness by senior medical staff or among medical peers?
Arik Riskin: Awareness is also
important among team members, educating us to treat each other with dignity and
respect. The days when a senior physician or charge nurse could be rude to a
resident or trainee are over…not because it’s impolite and unfriendly, but
because it [endangers] our patients.
By highlighting the impact that adverse
social contexts may have on team-level [collaboration], our findings provide
the foundation for a wide range of interventions aimed at enhancing patient
safety. Our results suggest that instituting protocols and procedures aimed at
bolstering the defenses of medical teams to the cognitive distraction and drain
elicited by rudeness can help mitigate the devastating consequences of these
events, even when they can’t be prevented.
BLOOM: Do you
feel there’s a role for narrative writing and reflection, even though the
intervention used in your study didn’t show a benefit?
Arik Riskin:
Yes, I would definitely not quit this possible route of interventions,
especially not reflection, which is an excellent learning tool for medical
teams.
BLOOM: Have
you considered doing a study to look at the impact of rudeness by medical teams
on parents of premature babies? Some parents have traumatic experiences related
to being talked to in a callous or dismissive way, or in hearing their child
being talked about in a degrading or disrespectful way.
Arik Riskin: This
is an important subject, which I’m sorry to say still exists as a problem. I
haven’t done research on it, but I know that many others have studied this
important aspect of communication.
Teaching
physicians and other health workers to talk nicely, gently and politely with
parents is no less important than the medical treatment we provide. I recall my first lesson in
neonatology as a resident. The director of our NICU then, the late Dr. Berger,
taught me. We went to talk to a mother after a delivery. The mother was very
stressed and frustrated even though her baby was improving. Then Dr. Berger sat
with me and told me her insights about how mothers feel after delivery, and how
we need to talk to them and support them. She told me this was my first lesson
in pediatrics and in neonatology—How to talk to a mother—and it was more
important than any other lesson I’d learn.
I carry this important lesson with
me and pass it over to my students, residents and fellows. I still find talking
to parents the most challenging, but also the most rewarding, part of my work.
I look at them as our teammates in the long, long [journey] we have to go together to
make their infant survive and to be as healthy and happy as possible.
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