If a treatment came along that reduced surgical complications by up to 30%, lowered error rates, and decreased mortality, while also reducing burnout, depression and staff turnover, we would rush to adopt it. If it was simple, cheap and without side-effects, its popularity might rival the latest GLP-1 agonist.
The “treatment” actually exists but isn’t a drug or device.
What is it?
The treatment is better behaviour – a reduction in harassment, incivility and disrespect (HID) among healthcare professionals.
Good behaviour is a patient-safety intervention
Effects this big from a mere change in behaviour may be a little hard to believe, but the evidence appears solid. The way clinicians speak to and treat each other has a significant, measurable impact on both patient outcomes and staff wellbeing.
When surgeons display unprofessional behaviour, patients end up worse off. For example, in a 13,000-person study, patients treated by surgeons with documented disrespectful behaviour had 12–32% higher odds of post-operative complications, even after adjusting for the type of case involved.
HID is like a system contaminant
Research reinforces and explains these findings. In simulated surgical crises, a single rude comment from a senior clinician impairs team performance, reduces diagnostic and procedural scores, and increases errors. Once HID is introduced, it can spread quickly through a team, undermining communication and decision-making.
An “eggshell environment” lasting up to two hours is created, during which cognitive load increases, working memory is reduced, communication is supressed and situational awareness – the shared mental picture of what’s going on – is degraded.
In environments where teams must constantly reassess, communicate, and make rapid decisions, two hours of impaired collaboration is a significant safety threat. Critical questions may go unasked, problem escalation can be delayed and information sharing is likely to decrease.
Anaesthesiology – high risk for HID
In the US, anaesthesiology is documented to be one of the highest-risk specialties for HID and for gender harassment. Many, myself included, might assume surgeons are the main source of operating-room hostility but it turns out much of this behaviour is “anaesthesia-on-anaesthesia”.
Because anaesthesiologists work in multiple sites and interact with many clinicians each day, the impact of their poor behaviour is increased. The specialty therefore has both a significant internal problem and an opportunity for positive culture change.
HID shows up throughout the hospital in error rates, infections, and mortality
HID is not just an anaesthesia or surgery problem, it occurs across the entire healthcare system. Individually, effects might be small. Cumulatively, significant harm can result.
A 2024 meta-analysis in different hospital settings found that workplace incivility was associated with near misses, adverse events, hospital-acquired infections and mortality.
A multi-site study of 38 hospital units reported that a 10% increase in staff incivility predicted a 9% rise in infection rates and a 10% increase in mortality.
A field study showed that after an episode of rudeness, hand-hygiene compliance fell for up to 24 hours, and information-sharing within teams measurably decreased.
Impact on staff
Turning to direct effects of HID on the workforce, evidence is also strong. HID harms staff psychologically, emotionally and professionally, depletes morale, drives burnout, and pushes people out of the health professions.
- Burnout and depersonalisation
HID is consistently associated with emotional exhaustion, the core domain of burnout, and with depersonalisation. In a 2019 study of US surgical trainees, those experiencing mistreatment several times per month were three times more likely to report high burnout; 38.5% had high levels of emotional exhaustion or depersonalisation.
- Depression, anxiety, and PTSD
Among nurses and doctors, HID is linked to increased depression and anxiety. Sustained bullying can lead to PTSD symptoms, reported in more than half of those exposed. Job satisfaction also drops noticeably in toxic environments.
- Turnover and loss of skilled staff
HID contributes to people leaving the profession. Surveys show that up to 21% of nurses who exit nursing do so primarily because of bullying. These losses translate directly into staffing shortages and organisational instability.
Burnout is often framed as a resilience problem. Evidence shows it may be primarily an environmental problem, driven by bullying and other toxic workplace behaviours.
Interventional side effects
Recognition of HID has led to interventions which may be relatively cheap but are not necessarily simple or without side-effects. Like any intervention, attempts to reduce HID can backfire if applied carelessly, too broadly or rigidly, creating new problems:
- Over-policing and hyper-surveillance
If incivility becomes defined as “anything someone felt uncomfortable with”, harm is possible, such as excessive reporting, defensive communication, fear of saying the “wrong thing” and a decline in open, honest dialogue. This might reduce rather than increase psychological safety.
- Suppressing necessary clinical directness
High-acuity care, especially surgery, ICU and emergency medicine, requires clarity, decisiveness and direct communication. Urgent directives are not incivility. Treating them as incivility creates risk rather than safety.
- Misunderstanding humour and banter
Dark humour and team banter are often bonding and coping mechanisms. The problem is when humour is used to humiliate.
- Creating a fragile culture
Over-correction can create a reluctance to give feedback, instigate a fear of escalation, and lead to confusion about expectations.
Outcome and balancing measures
As with any improvement initiative, hospitals working to reduce HID should track both intended outcomes and unintended effects (balancing measures).
This means measuring whether HID decreases, and whether communication, confidence, and psychological safety improve – or unintentionally worsen.
Outcome measures include reductions in HID incident reports, improvements in teamwork climate, or better “speaking-up” scores. Balancing measures might keep track of whether direct communication is being suppressed, or staff are avoiding conflict resolution.
The aim is to eliminate predictable, sustained patterns of demeaning behaviour that affect cognition, safety and morale, while preserving the honesty and camaraderie that enable high quality work in stressful situations.
A story (based on real experiences)
“Anna” (not her real name) is an anaesthesiologist at a busy teaching hospital. One morning she was supervising two operating rooms when a junior nurse phoned her from the recovery unit sounding anxious about a patient whose blood pressure was drifting down. Anna was already behind schedule, an emergency case was waiting, and she took the call while walking quickly between theatres.
“Just repeat the fluid bolus – it’s standard,” she said, distracted, before hanging up. Her tone was sharper than she intended.
The nurse felt dismissed and unsupported. She asked another colleague to help, and by the time Anna returned to the unit, the atmosphere was tense. The nurse gave clipped answers; Anna was surprised and confused.
Later that week, Anna received a note through the hospital’s professionalism system asking for a reflective conversation. She was surprised, not recalling being rude. The facilitator listened, then gently pointed out that the nurse had been genuinely worried about the patient and had interpreted Anna’s brisk tone as irritation.
Anna felt embarrassed, but also relieved. No one accused her of misconduct; rather, the conversation helped her see how her haste, stress, and multitasking had changed the way she communicated. She reached out to the nurse afterwards, and they talked openly about the pressures of the unit. The relationship improved.
Anna now tries to pause before answering calls, especially when rushed. As she put it later, “I didn’t need to change my clinical judgement, just the way it’s received.”
Stories like Anna’s are common. HID is not always dramatic shouting or overt disrespect. It often happens in high-pressure moments where tone, timing, or stress distort the message. But those moments can affect trust, teamwork and patient care. When addressed supportively they open the door to better culture.
The main lesson: civility is a clinical competency
HID is not an acceptable personality quirk but a clinical risk factor. Respect, psychological safety, and reliable communication are components of safe care just as much as sterile technique, medication reconciliation, or technically perfect procedural steps.
One of the most powerful tools for improving safety, quality and staff retention is how we treat each other. Better behaviour is good medicine.
…….
Citations
Cooper et al., JAMA Surgery, 2019. “Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications”
https://doi.org/10.1001/jamasurg.2019.1738
Riskin et al., Pediatrics, 2017. “The Impact of Rudeness on the Performance of Medical Teams”
https://doi.org/10.1542/peds.2016-3848
Freedman et al., Journal of Advanced Nursing, 2024. “Incivility Toward Healthcare Workers: A Meta-analysis”
DOI: https://doi.org/10.1111/jan.15972
Li et al., PNAS, 2023. “Workplace Incivility and Patient Safety Outcomes Across 38 Units”
https://doi.org/10.1073/pnas.2302188120
Riskin et al., Joint Commission Journal on Quality and Patient Safety, 2019. “The Impact of Rudeness on Medical Team Performance in Daily Practice”
https://doi.org/10.1016/j.jcjq.2018.09.002
Kim et al., PLOS ONE, 2019. “Association Between Workplace Bullying and Burnout Among Clinical Nurses”
https://doi.org/10.1371/journal.pone.0226506
Verkuil et al., PLOS ONE, 2015. “Workplace Bullying and Mental Health: A Meta-analysis”
https://doi.org/10.1371/journal.pone.0135225
Zhou et al., Medicine (Baltimore), 2025. “The Impact of Workplace Bullying on Depression Among Clinical Nurses”
https://doi.org/10.1097/MD.0000000000041246
Nielsen et al., Aggression and Violent Behavior, 2015. “Workplace Bullying and PTSD: A Meta-analysis”
DOI: https://doi.org/10.1016/j.avb.2015.05.002
Shoorideh et al., J Med Ethics & Hist Med, 2021. “Incivility Toward Nurses: A Systematic Review and Meta-analysis”
https://jmehm.tums.ac.ir/index.php/jmehm/article/view/1060
Bilimoria et al., New England Journal of Medicine, 2019. “Discrimination, Abuse, Harassment, and Burnout in Surgical Residency”
https://doi.org/10.1056/NEJMsa1903759
Edmondson – Psychological Safety Framework
Gary — another excellent article. Please keep them coming.
Insurance-mandated reductions in appointment times, tighter oversight of medical practice, and broader financial pressures on clinics and hospitals may all contribute to the perception of HID behaviors among clinicians. Patient-experience evaluation scores collected at the end of each visit tend to keep physicians on their best behavior, at least from the patient’s perspective.
What remains less clear to me is how HID behaviors among healthcare professionals are actually tracked, escalated, or addressed within an organization. You mention that “outcome measures include reductions in HID incident reports, improvements in teamwork climate, or better speaking-up scores.” This makes me wonder whether emerging AI tools could help identify patterns across documentation, incident reports, and communication workflows—ultimately supporting more productive conversations about culture, teamwork, and reducing HID in clinical environments.