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Study workflow.
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Domain MERSQI item Score Max score Study design Single group cross-sectional or single group post-test only 1 3 Single group pre-test and post-test 1.5 Non randomised, two groups 2 Randomised control trial 3 Sampling Institutions studied: 3 1 0.5 2 1 3 1.5 Response rate, %: Not applicable <50 or not reported 0.5 50–74 1 >75 1.5 Type of data Assessment by participants 1 3 Objective measurement 3 Validity of evaluation instrument Internal structure: 3 Not applicable Not reported 0 Reported 1 Content: Not applicable Not reported 0 Reported 1 Relationships to other variables: Not applicable Not reported 0 Reported 1 Data analysis Appropriateness of analysis: 3 Inappropriate for study design, type of data 0 Appropriate to study design, type of data 1 Complexity of analysis: Descriptive analysis only 1 Beyond descriptive analysis 2 Outcomes Satisfaction, attitudes, perceptions, opinions, general facts 1 3 Knowledge, skills 1.5 Behaviours 2 Patient/healthcare outcome 3 Total possible scoreb 18 Study Year Country Setting Study concept Methods Participants Focus MERSQI score Westbrook et al.6 2021 Australia Seven metropolitan tertiary hospitals Incivility, bullying, extreme unprofessional behaviour Survey Nurses, doctors, clinical and non-clinical services, administrators (n=5,178) Prevalence, type and impact of unprofessional behaviours 9 Riskin et al.29 2019 Israel One general hospital Rudeness Qualtrics-based smartphone application (Qualtrics, Provo, UT, USA) Medical professionals (n=160) Iatrogenesis and lapses in patient safety, state depletion and team processes 10 Cooper et al.32 2019 USA Two academic medical centres Unprofessional behaviour Electronic reports Patients (n=13,653) Risk of surgical and medical complications 9 Katz et al.30 2019 USA Three academic hospitals Incivility Randomised control trials and surveys Categorical (CA) Year 1–3 anaesthesiology residents (n=76) Technical and non-technical performance domains, including vigilance, diagnosis, communication and patient management 12 Riskin et al.33 2017 Israel Mixed: hospitals Rudeness Simulation training, randomisation 39 NICU teams, each compromising two physicians and two nurses (n=156) Impact of rudeness on medical team’ performance and test interventions 9 Elhoseny and Adel34 2016 Egypt One hospital (medical, surgical, ICU, anaesthesia, A&E and pathology departments) Disruptive behaviour Questionnaire based on ACPE and QuantiaMD survey Physicians (n=183) Situation, culture 6.5 Maddineshat et al.31 2016 Iran Five general hospitals Disruptive behaviours Questionnaires analysed with SPSS version 13 software Physicians and nurses (n=155) Physician–nurse relationships and quality of care 8 Bradley et al.2 2015 England Three teaching hospitals Rude, dismissive and aggressive communication Focus groups and questionnaire designed by authors Junior doctors, registrants and consultants (n=606) Profession, situation and culture 7 Riskin et al.14 2015 Israel Mixed: hospitals Rudeness ACPE and QuantiaMD 24 NICU teams rated by three judges (n=72) Iatrogenesis and performance deficiencies among medical team members 7 Cochran and Elder5 2015 USA One academic medical centre Disruptive behaviour Interviews Scrub technicians, nurses, medical students, surgical residents and anaesthesiologists (n=19) Coping strategies used by perioperative staff 8 Rosentein and Naylor35 2012 USA 20 A&E departments Disruptive behaviour Questionnaires developed by authors Physician, nurses, secretaries or clerks, and A&E technicians (n=237) Personality, professions, culture and situations 8 Rosenstein and O'Daniel37 2008 USA 102 hospitals Disruptive behaviour Questionnaires developed by authors Physicians, nurses, administrative employees and others (n=4,530) Professions 7 Rosenstein and O'Daniel36 2005 USA 102 hospitals Disruptive behaviour Questionnaire developed by authors Nurses, physicians, administrators (n=1,509) Professions 8 A&E = accident and emergency; ACPE = American College of Physician Executives; ICU = intensive care unit; NICU = neonatal intensive care unit.
Summary
What is known? Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. What is the question? What is interprofessional incivility and what are its effects on medical performance, service and patient care? What was found? In total, 13 studies were included of heterogeneous origin, methodology and size (total participants = 26,534; mean MERSQI score = 7.8). Interprofessional incivility was common among physicians (77%) and nurses (65%) and had both psychological and clinical outcomes, resulting in stress (97%), compromised patient safety (53%) and quality of care (72%), and errors (70%). Junior staff were affected twice as often as consultants, with higher rates in radiology, general surgery, neurosurgery and cardiology. An impact on team performance was more frequently reported by nurses, junior employees and non-clinical staff. Disruptive surgeon behaviour increased anxiety in perioperative teams, leading to impaired performance overall. In patient care, incivility was associated with AEs (67%), medical errors (71%), mortality (27%), compromised patient safety (24.7%) and quality of care (35.8%). Patients whose surgeons had higher numbers of co-worker reports about incivility were at higher risk of complications. Strengths and limitations of the study Papers included were diverse in terms of their geographical setting, methodology and scope, which enabled assessment of the many effects of interprofessional incivility with different foci, as well as a more extensive overview of the topic.
Research was conducted with nurses, medical, managerial and administrative staff, provided that at least one consultant/physician was present. This revealed the interconnectedness of the phenomenon from different perspectives.
Most studies did not use a prescriptive measure for incivility, such as the Workplace Incivility Scale,38 and neither were participants usually provided with clear definitions of ‘incivility’, ‘disruptive behaviour’ or ‘unprofessional behaviour’.
Different understandings of the nature of incivility could introduce bias into self-reports of incivility exposure and studies that relied on surveys and questionnaire were based on subjective judgements and observations.
What is the implication for practice now? The impact of interprofessional incivility on medical performance, service and patient care appears systemic. Certain specialties might be more exposed, and higher work proficiency and seniority might be protective factors. The heterogeneity of the studies restricted the analysis and reliance on self-reports resulted in low MERSQI scores, although the quality of research improved in more recent studies. Quantitative methods for identifying and measuring incivility are lacking and further empirical research is needed. This could benefit the NHS and other stakeholders when designing targeted interventions. Witnessed incivility from a patient's perspective has also rarely been empirically investigated, and further exploration of this area is required. A dominant theme within patient complaints was ineffective or inadequate communication and its contribution to patient safety, misdiagnosis and patient/carer dissatisfaction. The undoubted link between poor communication and incivility implies that, until the issue of incivility is addressed across all parts of the care process, the implications for healthcare practice are significant.
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