Health care professionals today face a mountain of challenges in the workplace. We have more patients than ever, fewer clinicians, and more practices that include clinicians other than physicians. Our patients often delay care and thus are sicker when we tend to them. Patients have seemingly unrestricted access to us via messaging and have high expectations of the timing of our responses. Workdays are long and frenetic, and pajama-time charting and patient messaging are the status quo. With an environment such as this, it’s more crucial than ever to be mindful of how we work with our fellow clinicians.
As we assess our current health care landscape, it is no wonder that with all the stressors we face, we see incivility in the workplace affect how we deliver care to patients and how we feel about going to work each day. Clinicians experiencing incivility are more likely to be stressed, burned out, or exhausted, which may reduce their vigilance or increase dissatisfaction.This can lead to expensive attrition. Patients can discern when their clinician is rushed, tense, not thoughtful, and not supportive of others. Medical errors and diagnostic mistakes can occur when incivility impairs cognitive function. And we are all aware of the current rate of suicide among residents.
Once, when I was a new graduate, a physician who was having a difficult day threw a box of paper charts at me in a workroom. This action was quite damaging to me and solidly ensured that healthy collaboration would not occur; rather, it would be replaced by wariness, silence, and dodging. While this is extreme, it’s no worse than a clinician changing the orders of another just because they can, or dismissing the thoughts of a teammate during rounds.
As we expand our definition of a health care team, planning and defining that team’s practice is essential to establish respectful and supportive communication practices. In many instances, teams grow organically by bringing in additional clinicians and caregivers as needs arise: MAs and CNAs supplement nurses, and physicians are joined by NPs, PAs, CNMs, and CRNAs (collectively known as APPs). Interprofessional teams may also include specialized clinicians such as physical therapists, audiologists, psychologists, or athletic techs to address patient needs holistically. Indeed, it can be challenging to manage care with a multifaceted team when it is not clear who is assigned responsibility or attribution for the work. If careful planning isn’t undertaken at the outset, these situations can become rife with discontent.
Incivility is insidious and can stem from various sources, including traditional hierarchies, power dynamics, and entrenched training practices. One example would be the physician hierarchy and training traditions, which often perpetuate the notion that ‘it’s always been this way.’ Residents are frequently expected to learn under exhaustion and pressure, reinforcing a culture where incivility can thrive.
It is no surprise that incivility directly affects patient care and patients’ perception of their care by undermining teamwork and communication. When physicians refuse to refer to APPs, change APP orders, or seize wRVUs for the work of another for their personal compensation incentives, an environment of distrust and resentment is seeded. This can demoralize APPs and disrupt patient care continuity and quality.
Referring to one another in patient conversation can make or break a therapeutic and trusting relationship. For example, when a patient hears, ‘I’m sending you to my NP colleague,’ the patient begins a trust relationship and doesn’t feel that they are being passed to a lesser clinician. This is an entirely different conversation than when a scheduler might tell the patient, ‘Sorry, Dr. X is very busy, but you can see the PA; he’s not busy at all.’ It can be helpful to tell patients that clinician collaboration for their care is commonplace – this helps the patient feel that they have more resources for support. Basic positive practices to build respect include regular case conferences, journal clubs, and M&Ms where everyone on the team is encouraged to participate and judgment is off the table in place of learning.
Nurses have long found themselves at the bottom of the caregiver chain, deferring to physicians, not using their critical thinking skills, or being excluded from decision-making. Yet in the inpatient arena, the nurses are the ones who are the closest to the patient and spend the most time with them, thus illuminating critical details that significantly affect care plans. The rudeness and hierarchy dynamic of ignoring the contribution of others in this way can stifle collaboration and innovation and is also a form of incivility. Every team member brings something of value with them - do we take the time to recognize it?
Organizational and professional leadership can be crucial in perpetuating or mitigating incivility. The American Medical Association (AMA) recently launched a campaign against PAs entitled ‘Stop Scope Creep’, which expresses concerns about the expanding roles of non-physician clinicians including PAs. The campaign argues that the increasing scope of practice for PAs and other non-physician clinicians could potentially compromise patient safety and the quality of care they provide. It also advocates for only physician-led teams. The campaign attempts to influence legislation and regulations that govern the scope of practice for non-physician clinicians, advocating for policies that support physician oversight. When the American Association of Physician Associates (AAPA) wrote formal letters requesting meetings offering data about how the campaign had disparaged the profession and offering to collaborate and resolve these concerns based on evidence, their requests went largely unanswered.
Undermining professional roles in this way creates divisions within the health care community and pits physicians against PAs. Attempting to influence legislation to limit PAs' work could be perceived as an act of professional gatekeeping, also a form of incivility. A campaign such as this will negatively impact public perception of the PA profession, leading to mistrust and unnecessary tension between clinicians and patients. This is similar to rhetoric in many states opposing less restricted practice for APRNs. These restrictions hinder both patients and clinicians: they prevent patients from receiving high-quality care, and clinicians from exercising their full potential as highly trained, board certified professionals.
Leaders who fail to address incivility may inadvertently normalize it, creating a culture where such behavior is tolerated. On the other hand, leaders can promote a culture of respect and collaboration that can help reduce incivility and its negative impact on patient care. I am fortunate to work in an academic medical center where kindness, civility, and respect are prioritized, celebrated, and valued. Interprofessional teams and relationships are held to high standards, and, in most situations, patients are presented with a team of caregivers who work well together and display mutual respect and collegiality in providing patient-centered care. This is the essence of a highly functioning team.
It is absolutely possible to develop healthy teams. A culture where each person is respected and works to the top of their licensure and ability is a culture where people like to come to work, burnout is low, and patients sense well-being, collegiality, and trust. Outcomes are improved, and the patient is at the center of a team that cares for them rather than at the center of a whirling dysfunctional storm.
We must all strive for clarity, truth, and kindness in our professional interactions. By addressing our biases and behaviors, we can improve the quality of patient care. Our patients deserve nothing less.
How do you work across specialties in your practice? Share below in the comments!
Allison Dimsdale, DNP is a Nurse Practitioner in Durham, NC. She enjoys spending time with her children and grandchildren, husband, and ever-changing assortment of rescue hounds. She loves to kayak, and no longer cooks. Allison Dimsdale is a 2024–2025 Doximity Op-Med Fellow.
Illustration by Diana Connolly
