The Impact of Rudeness on Medical Team Performance: A Randomized Trial

Riskin. Pediatrics 2015:136(3), doi: 10.1542/peds.2015-1385

Clinical Question

  • Does a neonatal intensive care team who is affected by rudeness compared to no rudeness impair team members’ diagnostic and procedural performance?


  • Iatrogenic events occur in ~4% of hospital admissions with half of these being preventable and 14% resulting in death. These rates are higher in patients that are critically ill
  • Studies have suggested that the risk of iatrogenic events is increased by practitioner stressors. One such stressor may be rudeness


  • Randomised controlled trial
    • Stratified by unit and hospital
    • Randomisation performed by research assistant
    • ‘Randomly assigned to teams at the same time and shift of the day based on availability in the NICU’
    • Randomly assigned to the control or incivility group
  • Experimenter and the participants were blinded to the group allocation
  • Participants performed a 1-hour simulation in their own NICU followed by a workshop on team reflexivity
    • Simulation observed on webcam by ‘international world expert’
    • Managed pre-term infant with necrotizing enterocolitis who was in respiratory failure and shock, who then went on to develop a cardiac tamponade secondary to a central line
  • Assessor of performance blinded to group assignment (2 senior physicians and 1 senior nurse read written documentation and watched recorded simulation)
    • Performance rated on 5 point scale (1 = failed, 2 = poor, 3 = moderate, 4 = good, 5 = excellent) with descriptions and examples of indicative behaviour for each score. Diagnostic and procedural performance were assessed
  • Sample size calculation of 10-11 teams per condition – the power of the study was not stated


  • 4 Israeli Neonatal Intensive Care Units


  • Inclusion:
    • Neonatal team
      • Comprising of 1 physician and 2 nurses from the same unit
      • Mean occupational tenure of 10.6 +-8.6 years
      • Exclusion criteria: none stated
  • 24 teams of 3 randomised

Comparing intervention and control groups no significant difference in age, sex, hierarchal status, level of expertise, tenure of participants


  • Subjected to rude behaviour
    • Participants shown pre-recorded videos that they were told were live
      • Prior to starting simulation
        • Expert stated that he had “already observed a number of groups from other hospitals and he was not impressed by the quality of medicine in Israel”
      • Half way through simulation (at 10 minutes)
        • Expert stated “medical staff like those observed in Israel wouldn’t last a week in his unit” and that he “hoped they would learn and improve from the workshop but he hoped he would not get sick in Israel”
    • Participants rated the behaviour as rude with a mean score of 3.24/4


  • Not subjected to rude behaviour
    • Participants were shown similar videos as intervention groups but without the rude comments
    • Participants rated the behaviour as rude with a mean score of 1.21/4


  • Diagnostic performance – significantly lower in team exposed to rudeness
    • 2.65 vs. 3.18, p=0.005
  • Procedural performance – significantly lower in team exposed to rudeness
    • 2.77 vs. 3.26, p=0.008
  • Multivariate analysis demonstrated that~12% of the variance in medical performance was explained by rudeness
  • Standardised coefficients for mediation model
    • Rudeness was significantly associated with reduced
      • Information sharing
        • -0.51, 95% C.I. -0.87 to -0.15, p<0.01
      • Help-seeking
        • -0.38, 95% C.I. -0.7 to -0.08, p<0.05
    • Information sharing had a significant positive relationship with diagnostic performance (0.47, p<0.01) but not with procedural performance
    • Help-seeking had a significant positive relationship with procedural performance (0.41, p<.01), but not diagnostic performance

Authors’ Conclusions

  • Rudeness harms the diagnostic and procedural performance of practitioners


  • Randomised controlled trial
  • Blinding of experimenter, participants and assessors
  • Use of videos allowed standardised process
  • Moderate-to-high inter-rater reliability of judges
  • Good baseline balance between groups of study participants (e.g. expertise and experience)
  • If anything, the ‘rudeness’ was relatively mild and was not personally directed (comments were generic to Israel) yet still appeared to have a detrimental effect
  • The study is underpinned by a persuasiveness conceptual framework explaining how rudeness affects performance
  • Team member assignments were random, resembling the “flash teams” of people that may not have previously worked together that are common in hospital emergency responses


  • Randomisation process not clearly stated i.e was a computer random number generator used, or did the research assistant just pick?
  • Sample size calculation, demonstrating power of study, was not performed
  • Clinical expertise and training of judges in assessment was not specified
  • It was not stated if the assessment process has been validated
  • Although the findings of decreased performance were clearly statistically significant, the potential clinical significance of the deterioration in performance is uncertain
  • Effects seen in this simulated setting may differ from what would occur ‘in real life’
  • Study performed in a single country – staff in Israel may respond differently to rude behavior compared with staff in England

The Bottom Line

  • This randomised controlled trial demonstrated that rudeness was associated with significantly reduced diagnostic and procedural performance
  • Rudeness was significantly associated with
    • Reduced information sharing which in turn was associated with reduced diagnostic performance
    • Reduced help-seeking behaviour, which in turn was associated with reduced procedural performance
  • There are limitations in the methodology of this paper, however, this is the best available evidence. We should therefore consider rudeness to be a patient safety issue and aim to minimise this behaviour

External Links


Summary author: @davidslessor
Summary date: 25.07.18.
Peer-review editor: @precordialthump (Chris Nickson)

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