The Impact of Rudeness on Medical

Team Performance: A Randomized Trial

Arieh Riskin, MD, MHAa,b, Amir Erez, PhDc, Trevor A. Foulk, BBAc, Amir Kugelman, MDb, Ayala Gover, MDd, Irit Shoris, RN, BAb,
Kinneret S. Riskine, Peter A. Bamberger, PhDa

Iatrogenesis often results from performance deficiencies among

BACKGROUND AND OBJECTIVES: abstract
medical team members. Team-targeted rudeness may underlie such performance deficiencies,
with individuals exposed to rude behavior being less helpful and cooperative. Our objective
was to explore the impact of rudeness on the performance of medical teams.
METHODS:Twenty-four NICU teams participated in a training simulation involving a preterm
infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were
informed that a foreign expert on team reflexivity in medicine would observe them. Teams
were randomly assigned to either exposure to rudeness (in which the expert’s comments
included mildly rude statements completely unrelated to the teams’ performance) or control
(neutral comments). The videotaped simulation sessions were evaluated by 3 independent
judges (blinded to team exposure) who used structured questionnaires to assess team
performance, information-sharing, and help-seeking.
RESULTS: Thecomposite diagnostic and procedural performance scores were lower for members
of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [P = .005] and
2.8 vs 3.3 [P = .008], respectively). Rudeness alone explained nearly 12% of the variance in
diagnostic and procedural performance. A model specifying information-sharing and help-
seeking as mediators linking rudeness to team performance explained an even greater portion
of the variance in diagnostic and procedural performance (R2 = 52.3 and 42.7, respectively).
Rudeness had adverse consequences on the diagnostic and procedural
CONCLUSIONS:
performance of the NICU team members. Information-sharing mediated the adverse effect of
rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on
procedural performance.

a
Recanati School of Business, Faculty of Management, and eSackler School of Medicine, Tel Aviv University, Tel Aviv, WHAT’S KNOWN ON THIS SUBJECT: Rudeness is
Israel; bNeonatology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion, Israel Institute of
Technology, Haifa, Israel; cWarrington College of Business Administration, University of Florida, Gainesville, routinely experienced by hospital-based medical
Florida; and dNeonatology, Lady Davis Carmel Medical Center, Haifa, and Rappaport Faculty of Medicine, Technion, teams. Individuals exposed to mildly rude
Israel Institute of Technology, Haifa, Israel
behavior perform poorly on cognitive tasks,
Drs Riskin, Erez, and Bamberger conceptualized and designed the study and drafted the initial exhibit reduced creativity and flexibility, and are
manuscript; Mr Foulk conducted the initial analyses and reviewed and revised the manuscript; less helpful and prosocial.
Dr Kugelman, Dr Gover, and Ms Shoris designed the study, coordinated data collection, and critically
reviewed the manuscript; and Ms Riskin designed the data collection instruments, coordinated and WHAT THIS STUDY ADDS: Rudeness had adverse
supervised data collection, and critically reviewed the manuscript. All authors approved the final
consequences on diagnostic and procedural
manuscript as submitted and agree to be accountable for all aspects of the work.
performance of members of the NICU medical
www.pediatrics.org/cgi/doi/10.1542/peds.2015-1385
teams. Information-sharing mediated the
DOI: 10.1542/peds.2015-1385
adverse effect of rudeness on diagnostic
Accepted for publication Jun 22, 2015 performance, and help-seeking mediated the
Address correspondence to Arieh Riskin, MD, MHA, Department of Neonatology, Bnai-Zion Medical effect of rudeness on procedural performance.
Center, 47 Golomb St, POB 4940, Haifa 31048, Israel. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics

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PEDIATRICS Volume 136, number 3, September 2015 ARTICLE
Iatrogenesis refers to an adverse rudeness source fails to moderate its teams were randomly assigned to the
patient condition associated with deleterious effects on control or the incivility condition.
medical treatment.1 Iatrogenic events performance.20,21 Such randomization procedures are
include diagnostic error or delay, Using a simulation-based experiment, common in social science research in
dosing and procedural errors, and we explored the impact of rudeness general and incivility research in
failure to identify and respond to on the performance of NICU team particular.20,21 Randomization was
diagnostic or treatment errors in members. Our hypothesis was that stratified according to unit and
a timely manner.1–4 In nearly 4% of interrelating processes essential for hospital and was based on a sample
hospitalizations, the treatment itself collaboration are adversely affected size calculation of 10 to 11 teams per
when medical professionals are condition. Randomization was
causes morbidity, with one-half of
victims of others’ rudeness, thus performed by a research assistant.
these events being preventable and
impairing members’ diagnostic and Both the experimenter and the
14% resulting in death.5,6 Studies
procedural performance and participants were blinded to the
suggest that the rate of iatrogenic
heightening iatrogenic risk. condition assignment. Thirty-nine
events among hospitalized pediatric
participants were in the rudeness
patients is substantially higher, and exposure group and 33 were in the
that the critically ill, such as those METHODS control group. Demographic
hospitalized in NICUs, are at particular composition of the group did not vary
risk.2,3,7,8 Although research has Study Design significantly across conditions.
tended to focus primarily on patient- This study was a randomized, double-
related factors (eg, age, weight),1,8–11 blind trial. It was approved by the Procedure
studies suggest that practitioner institutional review board of Tel Aviv Participants were invited to take part
stressors may also heighten iatrogenic University. in a 1-hour simulation using
risk.12–14 a medical mannequin in their own
Participants NICU to be followed by a workshop
One such stressor may be rudeness,
a relatively mild form of interpersonal Seventy-two NICU professionals on team reflexivity. This workshop
aggression or incivility. At least 1 organized in teams (each comprised 1 was a collective activity in which
study3 speculated that such subtle physician and 2 nurses from the same team members reviewed their work
contextual stressors may be linked to unit) were recruited from 4 Israeli and developed ideas for performance
iatrogenic events by affecting medical hospitals. Ages ranged from 25 to improvement22; it was led by the
professionals’ cognitive processing (at 60 years, with a mean age of 37.2 6 7.5 experimenter, himself a NICU
the individual level) and years (median: 35.0 years; physician. The experimenter
communication processes (at the team interquartile range: 31.5–41.0). informed participants that he was
level).3 However, to date, there is no Participants had a mean occupational working with a visiting head of a US
empirical evidence to support such tenure of 10.6 6 8.6 years and ICU who is also a leading expert on
claims. Studies estimate that 98% of a mean tenure of 7.7 6 7.3 years in team reflexivity. The experimenter
employees experience incivility, with their current NICU. All participants then showed the participants a short
50% experiencing these behaviors at provided a priori written informed video in which a confederate playing
least weekly.15 Customers, clients, and consent for this simulation-based the role of the expert explained what
patients serve as the primary study on behavioral impacts on NICU team reflexivity is and how it may be
perpetrators of incivility,16,17 teams’ performance, and all used to enhance team performance.
particularly in high-intensity, service- participants were debriefed upon the After consenting to participate in the
oriented organizations such as study’s conclusion. study and being observed by the
hospitals.12,18,19 Scholars have visiting expert via a live Webcam, the
distinguished among 3 main types of Randomization experimenter told participants that
rudeness encountered by medical To ensure that team knowledge, before starting, the visitor would like
practitioners based on the rudeness skills, and abilities, as well as other to greet them. The experimenter then
source,19 namely hierarchical performance-shaping factors (eg dialed a fictitious number and played
rudeness (enacted by an authority [eg, stress, fatigue), were distributed a prerecorded (although ostensibly
department head, charge nurse]), peer equally across conditions, 2 live) message on the telephone, which
rudeness (enacted by a member of the randomization methods were applied. served as the first part of the
medical team), and client rudeness First, participants were randomly rudeness manipulation. Specifically,
(enacted by patients or someone assigned to teams at the same time the expert told participants that he
associated with them). However, and shift of the day based on had already observed a number of
psychologists have shown that the availability in the NICU. Second, groups from other hospitals in Israel,

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488 RISKIN et al
and compared with the participants their diagnosis and then execute the presented to all judges in the same
observed elsewhere, he was “not orders given by the physician. The order, with this order determined
impressed with the quality of team then continued to the second randomly. Using a 5-point scale (1 =
medicine in Israel.” This manipulation phase of the simulation. Participants failed to 5 = excellent), judges rated
was designed to be similar to 1 received additional patient-related participants’ individual performance
previously tested among students in information and continued to provide along items relating to 4 parameters:
a psychology laboratory20 and was treatment for another 10 minutes, at diagnostic performance, procedural
specifically scripted to avoid making which point the experimenter ended performance, information-sharing,
any reference to the participants’ the simulation and initiated the team and help-seeking. Descriptors and
competence or performance. In the reflexivity exercise. examples of indicative behaviors
control condition, the expert were presented to the judges before
mentioned that he had observed other Simulation Task applying their ratings to enhance
professionals but did not insult the The simulation involved a neonate interrater reliability.
broader group to which the mannequin in an incubator connected Diagnostic performance was
participants likely identify (ie, Israeli to standard NICU monitors. measured by using 9 items: diagnosed
medical professionals). After listening Participants were faced with respiratory distress, diagnosed shock,
to the message, participants proceeded a preterm (28-week) infant who at suspected infection, diagnosed NEC,
to the actual simulation (described in 23 days had developed rapidly general diagnostic skills stage 1,
the following text). Each participant progressing necrotizing enterocolitis diagnosed deterioration, suspected
then received a separate packet (NEC). In the first phase of the perforation of bowel, diagnosed
containing information regarding simulation, participants were required cardiac tamponade, and general
initial symptoms and medical history. to: (1) identify the acute deterioration diagnostic skills stage 2.
Participants were given 10 minutes to in the infant’s condition, initially
work on the first part of the scenario. Procedural performance was also
expressed as multiple apneas and
measured by using 9 items:
After 10 minutes, participants were bradycardias; (2) identify that the
performed resuscitation well,
asked to stop, and the experimenter infant was in respiratory failure and
ventilated well, verified place of tube
contacted the expert a second time to shock, and respond promptly by
well, asked for the right laboratory
see if he had any comments thus far. providing the appropriate
tests, asked for the right radiographs,
This interaction with the expert resuscitative (ventilation) and
gave the right resuscitation
served as the second and final supportive (intravenous fluids and
medications, stopped percutaneous
component of the rudeness initiation of antibiotics) treatments;
central line infusion on time,
manipulation. Again following a script and (3) diagnose the neonate’s
prepared and performed
written to avoid any reference to the underlying morbidity (sepsis and/or
pericardiocentesis, and general
performance of the target team in the NEC). In the second phase in which the
technical skills.
rudeness condition, the visiting neonate’s condition further
expert commented that while he liked deteriorated due to cardiac tamponade Information-sharing was measured
some of what he observed during his stemming from a leaking central line, with a single item23; namely,
visit, medical staff like those observed the participants faced both diagnostic “Participant #_ shared quality
in Israel “wouldn’t last a week” in his (ie, rule out intestinal perforation and information vital for treatment in
department. He added that while he identify cardiac tamponade as the a timely manner.”
hoped participants could improve cause for deterioration) and Help-seeking was measured with
and learn more from the workshop, procedural (resuscitation and a single item24; namely, “Participant #_
he also hoped that he would not get pericardiocentesis) challenges. appeared comfortable seeking help
sick while in Israel. In contrast, the from his/her teammates when needed.”
expert simply commented to the Measures
control group that he hoped Three independent NICU staff Manipulation Check
participants could improve and learn (2 senior physicians and 1 experienced Analysis of variance with rudeness
more from the workshop. After nurse), blinded to the experimental condition as the independent variable
listening to this second message, intervention, reviewed participants’ and perceived rudeness (assessed on
participants were given 10 to written documentation (ie, diagnosis, the basis of a 4-item measure
15 minutes to continue their treatment orders) and watched the recorded validated in previous research20,21,25
of the infant. Physicians were asked simulations (edited to protect and with a = .93) as the dependent
to submit a written diagnosis and participants’ identity). variable indicated that participants
recommend a course of treatment. Videorecordings and other materials rated the confederate as significantly
Nurses were also asked to submit from all the simulations were (F[1,70] = 93.76, P , .01) more rude in

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PEDIATRICS Volume 136, number 3, September 2015 489
490
RESULTS
Statistical Analysis

confidence intervals.27
diagnostic and procedural
and procedural performance
consistency among raters) was

item could be averaged across

correlation coefficients (ICC[1])

some endogenous variable may

Table 1 presents the mean, SD,

indirect effects. Because indirect
team-level variance into account
before calculating the direct and
operate through an intermediary
assessed by calculating intraclass

performance indices. Multivariate

items into their respective overall

mechanism (ie, an indirect effect).

otherwise indicated. Because each

analyses were conducted by using

measures, with a $ .80 indicating

MPlus achieves this goal by taking

An ICC(1) $0.10 indicated that the

effects have a skewed distribution,

by 3 judges, reliability (the relative

(Monte Carlo method) was used to

intercorrelation, and ICC(1) values.

participant’s performance was rated

items included within the diagnostic

conducted by using Student’s t test.
judges.26 Comparisons of diagnostic

designed to test nested complex path

All analyses were conducted by using
rudeness manipulation was effective.

Statistical significance was set at .05.

IBM Corporation, Armonk, NY) unless

Statistical Computing, Vienna, Austria).

Los Angeles, CA), which is specifically

a 2000 iteration resampling approach

models and assess the degree to which
and procedural performance scores in

estimate indirect effects and their 95%

sufficient reliability to aggregate these
Cronbach’s a was calculated for all the
the rudeness and control groups were
0.43). This finding confirmed that the
than in the control condition (1.21 6
the rudeness condition (3.24 6 1.14)

the effect of an exogenous variable on

(R version 2.15.0, The R Foundation for

MPlus version 7.2 (Muthén & Muthén,

SPSS version 19.2 (IBM SPSS Statistics,

TABLE 1 Means, SDs, Correlations, and ICC(1)s for Individual-Level Score Variables (N = 72)
Variable Mean SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1. Diagnosed respiratory distress 3.28 1.03 (0.15)
2. Diagnosed shock 2.44 1.25 0.36 (0.13)
3. Suspected infection 3.09 1.07 0.57 0.35 (0.12)
4. Diagnosed NEC 2.83 1.10 0.47 0.69 0.50 (0.65)
5. Good general diagnostic skills (1) 3.06 0.88 0.76 0.60 0.68 0.77 (0.23)
6. Diagnosed deterioration 3.77 0.86 0.39 0.31 0.35 0.40 0.55 (0.17)
7. Suspected perforation of bowel 2.24 1.25 0.35 0.39 0.38 0.57 0.49 0.40 (0.57)
8. Diagnosed cardiac tamponade 2.62 1.44 0.37 0.26 0.46 0.51 0.49 0.47 0.39 (0.78)

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9. Good general diagnostic skills (2) 2.72 1.20 0.57 0.50 0.57 0.70 0.75 0.66 0.55 0.84 (0.35)
10. Performed resuscitation well 2.74 0.83 0.03 0.20 0.01 0.25 0.18 0.37 0.29 0.27 0.30 (.46)
11. Ventilated well 3.20 0.89 0.63 0.27 0.53 0.35 0.63 0.37 0.36 0.43 0.52 .18 (.63)
12. Verified place of tube well 3.17 0.91 0.48 0.34 0.52 0.38 0.66 0.46 0.25 0.37 0.49 .22 .53 (.23)
13. Asked for right radiograph 3.12 1.38 0.42 0.29 0.52 0.49 0.55 0.59 0.57 0.61 0.71 .29 .31 .31 (.34)
14. Asked for the right laboratory tests 3.48 0.95 0.44 0.43 0.52 0.49 0.57 0.46 0.48 0.46 0.53 .24 .44 .50 .64 (.24)
15. Gave right resuscitation medications 3.35 0.98 0.28 0.29 0.40 0.33 0.40 0.52 0.31 0.34 0.46 .42 .28 .29 .56 .27 (.19)
16. Stopped percutaneous central line on time 2.64 1.42 0.11 0.13 0.20 0.22 0.22 0.22 0.14 0.48 0.46 .23 .27 .34 .30 .15 .42 (.46)
17. Prepared and performed pericardiocentesis 2.47 1.48 0.37 0.34 0.33 0.56 0.47 0.41 0.36 0.78 0.76 .20 .31 .24 .73 .44 .48 .45 (.63)
18. Good general technical skills 2.87 0.85 0.49 0.29 0.42 0.51 0.59 0.61 0.48 0.75 0.82 .51 .50 .44 .69 .45 .63 .52 .77 (.47)
19. Information-sharing 3.28 0.85 0.57 0.38 0.47 0.45 0.60 0.69 0.43 0.49 0.68 .32 .32 .39 .47 .59 .41 .14 .43 .59 (.25)
20. Asked for help 3.66 0.68 0.43 0.45 0.58 0.43 0.60 0.58 0.37 0.38 0.56 .31 .34 .44 .53 .61 .54 .14 .42 .55 .73 (.10)
Correlations .0.23 are significant at the P , .05 level. Correlations .0.30 are significant at the P , .02 level. ICC(1) values for each variable in the study are reported in parentheses along the diagonal.

RISKIN et al
ICCs indicated mostly moderate to [P , .05], respectively) and significant, DISCUSSION
high interrater reliability, thus suggesting that rudeness negatively Despite some modest improvements
supporting aggregation of influenced these collaborative in patient safety since the publication
information-sharing and help-seeking processes. Information-sharing had of the Institute of Medicine’s 1999
to the team level. a significant positive relationship with report To Err Is Human, major
Tables 2 and 3 report results of the diagnostic performance (estimate = disparities remain between patient
mean comparisons between the 0.47; P , .01) but not with procedural safety objectives and
control and rudeness groups for the performance, and help-seeking had achievements.28–31 For example,
diagnostic and procedural a significant positive relationship with recent studies estimate that patients
performance measures. As shown, the procedural performance (estimate = are exposed to at least 1 medication
majority of the individual performance 0.41; P , .01) but not diagnostic error per day4,32 and report
items were negatively affected by performance. numerous cases of retained surgical
rudeness. Furthermore, overall items.4,33 We suspect that 1 major
diagnostic (a = .90, ICC = 0.19) and Neither the 95% confidence interval reason for this gap is because many of
procedural (a = .83, ICC = 0.35) for the indirect effect of rudeness on the improvements were directed at
diagnostic performance mediated by refining systems and
performances were both negatively
information-sharing ([–0.49 to –0.05]) technologies11,14 while neglecting
affected by exposure to rudeness. In
nor the indirect effect of rudeness on human/relational factors.4,34
addition, a multivariate analysis of
procedural performance mediated by
variance comparison of means Our results highlight the potential role
help-seeking ([–0.36 to –0.02])
(multivariate F[2,69] = 4.62, P = .013, of human interaction in iatrogenic
contained a zero, further supporting
h2 = 0.118) suggested that a model with events, indicating that occurrence of
the hypothesized relationships
rudeness predicting the 2 performance even a mild rudeness can have adverse
presented in Fig 1. It thus seems that
measures simultaneously was consequences on the diagnostic and
rudeness reduced information-sharing
significant and explained ∼12% of the procedural performance of NICU team
among the physician and the 2 nurses,
variance in medical performance. members. Indeed, many of the ratings
which, in turn, harmed their diagnostic
Other factors (eg, age, gender, received by members of the rudeness
performance. Similarly, rudeness
hierarchical status, level of expertise, group were between 2 (poor) and 3
reduced helping among the team
tenure of participants) were not (moderate) (Tables 2 and 3),
members, which, in turn, explained the
significantly different between the suggesting that the judges saw
reduction in their procedural
teams and could not explain the evidence of potentially harmful
performance. The estimated model
differences in medical performance explained substantial variance in practice. Moreover, they show that
(data not shown). diagnostic performance (R2 = 52.3), as even the mild incivility common in
We next explored the mediating well as in procedural performance medical practice can have profound, if
processes through which rudeness was (R2 = 42.7). We also estimated a model not devastating, effects on patient care.
expected to influence performance including only rudeness and found But what underlies the impact of mild
(Fig 1, Table 4). The relationship of that it alone explained 10.0% of the incivility on potentially risky medical
rudeness to both team information- variance in diagnostic performance practice? Psychologists have found
sharing and help-seeking was negative and 11.2% of the variance in rudeness to interfere with working
(estimate = –0.51 [P , .01] and –0.38 procedural performance. memory; that is, the “workbench” of
the cognitive system where most
TABLE 2 Comparison of Mean Diagnostic Performance Variables (N = 72) planning, analyses, and management
Variable Control Group Rudeness t Test P (One-Tailed) of goals occurs.35 Thus, rudeness
(n = 33) Group (n = 39) exposure can adversely affect the
cognitive functions required for
Mean SD Mean SD
effective diagnostic and medical
Diagnosed respiratory distress 3.39 1.07 3.20 1.00 0.772 .2215 procedural performance. However,
Diagnosed shock 2.88 1.32 2.08 1.08 2.836** .003
results from the mediation analyses
Suspected infection 3.13 1.01 3.06 1.13 0.272 .3935
Diagnosed NEC 3.08 1.23 2.62 0.95 1.76* .0415 indicate that aside from any effects
Good stage 1 diagnostic skills 3.22 0.99 2.91 0.75 1.498 .0695 that rudeness may have on individual
Diagnosed deterioration 4.05 0.75 3.54 0.89 2.562** .0065 cognitive processing, rudeness
Suspected perforation of bowel 2.60 1.47 1.94 0.96 2.297* .0125 exposure may also weaken the very
Diagnosed cardiac tamponade 3.18 1.30 2.15 1.40 3.214** .001
collaborative processes (information-
Good stage 2 diagnostic skills 3.13 1.21 2.35 1.07 2.881** .0025
Overall diagnostic 3.18 0.92 2.65 0.69 2.796** .00035 sharing and help-seeking)36,37 that
*P , .05, **P , .01. might otherwise allow teams to

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PEDIATRICS Volume 136, number 3, September 2015 491
TABLE 3 Comparison of Mean Procedural Performance Variables (N = 72) may be even greater if the source of
Variable Control Rudeness t Test P (One-Tailed) rudeness is a medical colleague rather
Group Group than a visiting outsider; if the intensity,
(n = 33) (n = 39) length, and frequency of rudeness are
Mean SD Mean SD greater; and if the rudeness is
Performed resuscitation well 3.05 0.84 2.49 0.73 3.00** .002 specifically directed at the target.
Ventilated well 3.43 0.94 3.01 0.81 2.029** .0023 Further research to investigate such
Verified place of tube well 3.56 0.88 2.85 0.82 3.492** .0005 variations in rudeness is needed. In
Asked for right radiographs 3.29 1.23 2.96 1.50 0.994 .162 addition, although we found no
Asked for right laboratory tests 3.78 0.89 3.24 0.94 2.382* .01
Gave right resuscitation medications 3.55 0.81 3.17 1.08 1.639 .053 evidence of individual differences (eg,
Stopped percutaneous central line on time 2.95 1.35 2.36 1.44 1.764* .041 age, gender) influencing participants’
Prepared and performed pericardiocentesis 2.71 1.55 2.24 1.39 1.301 .099 susceptibility to the performance
Good general technical skills 3.17 0.88 2.61 0.73 2.869** .0025 effects of rudeness, further research in
Overall procedural 3.26 0.72 2.77 0.67 2.974** .0002
this area is also needed.
*P , .05, **P , .01.
Our findings also reflect an important
advance in understanding how
compensate for the diminished risk factor for iatrogenesis, and that in rudeness exerts its toll. We have moved
performance of 1 or more of their taking steps to enhance patient safety, from simply confirming what many
members.4,34 policy makers should begin to consider physicians already implicitly
Overall, we found rudeness explained the role played by the subtle and understand regarding the adverse
52% of the variance in diagnostic seemingly benign verbal aggression to performance-related effects of
performance and 43% of the variance which medical professionals are rudeness to unraveling just how these
in procedural performance. In subjected on a routine basis.18,19 effects operate. In this regard, the
comparison, recent meta-analyses Nevertheless, our findings may reflect results of our mediation analyses make
found that structural factors such as just the tip of the iceberg of the intuitive sense in that one would expect
the presence/absence of computerized deleterious effects of incivility that diagnostic performance (a very
order entry systems explained just runs rampant in health care cognitive process requiring information
12.5% of the variance in medication organizations.19 Although our exchange) to be susceptible to the
error38 and chronic sleep loss manipulation came from an external effects of rudeness on information-
explained just 23% of the variance in source, was very short in duration, and sharing among team members.
physician clinical performance.39 We not target-specific, its impact was Similarly, given the central role of
concluded from these findings that notable with regard to both diagnostic technical proficiency in procedural
greater attention should be paid to day- and procedural performance. It is performance, it makes sense that help-
to-day social interaction as a critical possible that impaired performance seeking, which is a primary means by

FIGURE 1
Path model of the effect of rudeness on performance, mediated by information-sharing and help-seeking. Numbers denote standardized coefficients for
the mediation path shown by the arrow. The relationship between information-sharing and help-seeking was 0.37.* The relationships between in-
formation-sharing and procedural performance and between help-seeking and diagnostic performance were not significant. *P , .05, **P , .01.

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492 RISKIN et al
TABLE 4 Standardized Coefficients for Mediation Model (N = 72)
Variable Information-Sharing Help-Seeking Diagnostic Performance Procedural Performance

Estimate 95% CI Estimate 95% CI Estimate 95% CI Estimate 95% CI

Rudeness –0.51** –0.87 to –0.15 –0.38* –0.70 to –0.08 –0.17 –0.46 to 0.10 –0.22 –0.50 to 0.23
Information-sharing (mediator 1) 0.47** 0.20 to 0.72 0.21 –0.21 to 0.55
Help-seeking (mediator 2) 0.32 –0.03 to 0.64 0.41** 0.05 to 0.85
*P , .05, **P , .01.

which individuals achieve mastery, simulations are becoming more participating teams from the NICUs of
serves as a primary linking mechanism. widespread in medicine as an the following hospitals in Israel
More research is needed to gain investigative tool.44,45 Second, (names of directors and charge
a better understanding of the efficacy because the study was conducted in nurses are listed after the name of
of interventions aimed at reducing the only 4 hospitals in 1 country, further each hospital): Bnai Zion Medical
threat posed to patient care by research is required to assess the Center, Haifa: Professor David Bader
rudeness directed at medical broad-scale generalizability of our and Ms Frida Mor; Haemek Medical
personnel. In particular, research is findings. Third, despite evidence Center, Afula: Dr Dan Reich, Dr Clary
needed on the prevalence and source that the impact of rudeness is not Felszer-Fish, and Ms Ineam Gander;
of such events. To the extent that such conditioned according to Lady Davis Carmel Medical Center,
events stem largely from the behavior source,20,21 our findings may not be Haifa: Professor Avi Rotschild and Ms
of colleagues toward one another, generalizable to rudeness stemming Lior Shaked; and Lis Maternity
training and administrative from other, nonauthority sources. Hospital, Sorasky Medical Center, Tel
interventions might be adopted to Aviv: Professor Shaul Dolberg,
CONCLUSIONS Professor Dror Mandel, and Ms Inbal
increase awareness of the risks
associated with such behavior, and shift Although the rude behaviors Yarkoni. The authors also thank
the behavioral norms underpinning regularly experienced by medical Professor Dov Eden from Recanati
such behavior. To the extent that such practitioners can seem benign, our School of Business, Faculty of
events are more externally driven (ie, findings indicate that they may Management, Tel Aviv University, for
patient- or family-based), interventions result in iatrogenesis, with his insightful and helpful comments
aimed at enhancing caregiver resilience potentially devastating outcomes. on an earlier version of the
should be examined. Not only does rudeness harm the manuscript.
diagnostic and procedural
Our study has several limitations. performance of practitioners, it also
First, given the simulation-based seems to adversely affect the very ABBREVIATIONS
study design, external validity may collaborative processes that might
be questioned. Nevertheless, ICC: intraclass correlation
otherwise allow for teams to coefficient
hospital-based research on incivility compensate for these effects.
and its consequences19,40–43 NEC: necrotizing enterocolitis
suggests that our findings are
consistent with the “real world” and, ACKNOWLEDGMENTS
if anything, underestimate the The authors thank the directors,
magnitude of effects. Moreover, charge nurses, and members of the

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Bamberger has received support from the Israel Science Foundation (research grant no. 1217/13) Israel Academy of Science and Humanities for the
submitted work.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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VIRTUAL FIELD TRIPS: All of my children attended the local public middle and high
schools. Since they were all fairly close in age, we experienced the same field trips
several years in a row. For example, each year the fourth grade went to a local stream
to investigate the flora and fauna, the fifth grade went to Saratoga, NY to investigate
Abenaki culture, and the sixth grade visited the Space Center in Montreal. As an
infectious disease specialist, I see many children going with their high school classes
to countries in Central America to either enhance their understanding of Spanish or
biology. However, field trips in the future may look quite a bit different. As reported in
The Wall Street Journal (Video: June 19, 2015), several schools are now using
videoconferencing rather than busses to connect students to educational and
culture events. For example, students in a classroom in New Jersey can videocon-
ference with an educator working in a chimpanzee enclosure in England or an
aquarium in Florida. Some museums even allow distant students to control a robot
in the museum, so that the controllers can turn the video camera attached to the
robot in any direction to better see things in which they are most interested. The
benefit is that the schools do not have to actually pay the fees involved in trans-
porting the students. Moreover, the students can experience or view far more events
or artifacts than they could otherwise. Students and educators generally like the
arrangement. One downside is that students cannot wander and explore personal
interests. Videoconferencing may not replace all field trips in public schools, but it
certainly is an appealing adjunct for student education.
Noted by WVR, MD

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PEDIATRICS Volume 136, number 3, September 2015 495
 The Impact of Rudeness on Medical Team Performance: A Randomized Trial
Arieh Riskin, Amir Erez, Trevor A. Foulk, Amir Kugelman, Ayala Gover, Irit Shoris,
Kinneret S. Riskin and Peter A. Bamberger
Pediatrics 2015;136;487; originally published online August 10, 2015;
DOI: 10.1542/peds.2015-1385
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All
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 The Impact of Rudeness on Medical Team Performance: A Randomized Trial
Arieh Riskin, Amir Erez, Trevor A. Foulk, Amir Kugelman, Ayala Gover, Irit Shoris,
Kinneret S. Riskin and Peter A. Bamberger
Pediatrics 2015;136;487; originally published online August 10, 2015;
DOI: 10.1542/peds.2015-1385

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/136/3/487.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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