NUR 7069 Module 2 Civility Paper: Rudeness, Team Performance and a Clinic Code of Conduct Example

Rudeness Has a Cost: A Civility Plan for an Interprofessional Cardiology Clinic in Hackensack

Student Name

M.S. in Nursing, Family and Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7069: Professional Identity Development for Nurse Practitioners

Mentor Name

Month Day, Year

Rudeness Has a Cost: A Civility Plan for an Interprofessional Cardiology Clinic in Hackensack

What Happened

Every person and event in this paper is invented. A hospital-owned cardiology clinic in Hackensack employs four physicians, three nurse practitioners, six registered nurses and a pharmacist. One visiting electrophysiologist sees patients there two days a week. Over six months, staff have described a pattern: he corrects nurses in front of patients, calls a nurse practitioner's medication plan "dangerous nonsense" in a hallway, ignores messages from the pharmacist and sighs loudly when asked to explain a device setting. Two nurses have asked not to be scheduled on his days. Last month a nurse noticed that a patient's anticoagulant dose looked high for her kidney function but did not call him, waited for another physician and passed on the question two hours later. The dose was corrected before harm, but the delay worried the clinic manager.

I am the clinic's lead nurse practitioner, and I was asked to propose a response. My first reaction was to treat this as one difficult person. The evidence persuaded me to treat it as a safety issue that the whole clinic has to address.

Does Rudeness Affect Care?

Riskin et al. (2015) ran a randomized trial with 24 neonatal intensive care teams during a simulation of a deteriorating premature infant. Before the simulation, teams heard comments from a supposed outside expert. For half the teams, the comments were mildly rude and had nothing to do with their skills; for the other half, they were neutral. Teams exposed to rudeness performed worse on both diagnostic and procedural measures. The effect operated largely through reduced information sharing and help seeking within the team. The rudeness was mild and came from someone the teams would never work with, which suggests that daily rudeness from a colleague could matter more.

That finding explains the anticoagulant delay. The nurse who hesitated was not careless; she had learned that asking this consultant a question carried a cost.

Naming the Behavior

Leape et al. (2012) argued that disrespect in medicine is a threat to patient safety and proposed six categories: disruptive behavior such as angry outbursts; humiliating, demeaning treatment of nurses, residents and students; passive-aggressive behavior; passive disrespect, such as chronic lateness or not answering calls; dismissive treatment of patients; and systemic disrespect built into how organizations work, such as long waits imposed on patients. They traced disrespect to individual factors and to an institutional culture that tolerated it, and they called on leaders to make respect an explicit expectation.

The same point was made to accredited organizations in a sentinel event alert from the Joint Commission (2008): intimidation and disruptive conduct feed medical errors, lower patient satisfaction and drive staff away. It asked organizations to adopt a code of conduct defining acceptable and unacceptable behavior and to create and carry out a process for managing those behaviors. The clinic's hospital has such a code, but staff in the clinic did not know how to use it, and nobody had used it about a physician.

Why It Persisted

The pattern lasted six months for reasons that had little to do with the consultant's personality. He brought referrals and procedure volume that the clinic's budget depended on. Nurses assumed the physicians had already spoken to him; the physicians assumed the nurses would report through the manager; the manager assumed a problem with a physician belonged to the medical director. Each person had a reason to wait, and the hospital's conduct policy had never been explained to clinic staff. Leape and colleagues described exactly this kind of institutional tolerance as a cause of persistent disrespect, and it meant that any plan had to change how the clinic responds, not only how one man behaves.

My Role as Lead NP

The nursing code of ethics and the clinic's own values ask nurse practitioners to protect patients and to model respectful practice. As lead NP, I have no authority over the consultant, but I have influence. I can model civility, speak to behavior when I see it, support staff who report and bring the pattern to the people who do have authority. Avoiding confrontation would protect my working relationship with him but would leave nurses carrying the risk.

The Civility Plan

First, I met privately with the consultant, described two specific incidents and their effect on the anticoagulant question and asked for his help in making it easier for staff to ask questions. He was surprised that the nurse had hesitated and agreed to change how he responds to calls. Second, the clinic adopted a short code of conduct written with staff, listing behaviors we expect from everyone, including me, such as answering messages within an hour on clinic days and correcting each other privately. Third, I presented the pattern and the evidence to the clinic's medical director, who agreed that further incidents would be reported through the hospital's professional conduct process. Fourth, we started a weekly huddle in which anyone can raise a safety concern, and I made a point of thanking people who did.

Measures

The clinic will repeat a short civility and safety survey every six months, track how long a nurse waits for a physician's reply on clinic days, record conduct reports and their outcomes and note staff requests to change schedules.

Limits

The simulation trial measured performance in a single session, not real outcomes. A code of conduct depends on leaders who enforce it, and my influence over a physician is limited. If the behavior continues, the matter moves out of my hands to the medical director.

Conclusion

A pattern of rudeness at a cardiology clinic delayed a safety question. Evidence that rudeness lowers team performance turned a personality conflict into a safety concern. A taxonomy made the behavior specific, and the Joint Commission's expectations gave the clinic a process. As lead NP, I began with a conversation and a code that applies to everyone.

References

Joint Commission. (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, (40). https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/

Leape, L. L., Shore, M. F., Dienstag, J. L., Mayer, R. J., Edgman-Levitan, S., Meyer, G. S., & Healy, G. B. (2012). Perspective: A culture of respect, part 1: The nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852. https://doi.org/10.1097/ACM.0b013e318258338d

Riskin, A., Erez, A., Foulk, T. A., Kugelman, A., Gover, A., Shoris, I., Riskin, K. S., & Bamberger, P. A. (2015). The impact of rudeness on medical team performance: A randomized trial. Pediatrics, 136(3), 487-495. https://doi.org/10.1542/peds.2015-1385