Jones & Bartlett Learning Health Blog

    Sense, Sensibility And Civility

    Posted by admin on Oct 13, 2009 11:19:34 AM

    Many years ago when I worked as an IV therapist, I was frequently assigned to draw blood or restart IVs on patients in the ICU, CCU, Burn Unit, Pediatric ICU, or the Neonatal Unit. Patients in these areas were often unable to speak, unconscious, or comatose.  Despite their inability to respond verbally to my presence and my invasion of their body with needles, I was trained to treat every person as if they were alert and able to understand what I was saying. It was the courteous thing to do.

    One day I was asked to draw blood on a comatose patient in a private room on the Neurosurgical Unit. As I always did, I knocked as I entered the room, introduced myself, informed the patient why I was there, verified that I had the correct patient, and then described what I was doing as I placed the tourniquet on his arm and swabbed with alcohol. Just as I said, “I am about to put the needle in your vein. You will feel a sticking sensation,” the Chief Resident entered the room with his coterie of junior residents, medical students, and nurses.

    The Chief Resident said in a condescending tone, “He’s in a coma, he can’t hear you.”

    I replied, “Hearing is the last sense to go--even for people in a coma.”

    “Then,” the Chief Resident sneered, “you’d better be able to speak Russian, because that’s what he is.”

    “Ahh,” I said. “Thank you.” Then, in Russian, I said to the patient, “Hello, how are you?”

    The crowd of underlings burst into laughter and the crimson-faced Chief Resident stormed out of the room.

    This incident occurred over thirty years ago, and I know the training of our medical students and residents has improved with respect to the appropriate treatment of patients. The Liaison Committee on Medical Education accreditation standards speak to the clarity and logic of interpersonal interactions, the sense, if you will:

    There must be specific instruction in communication skills as they relate to physician responsibilities, including communication with patients, families, colleagues, and other health professionals. (LCME, 2008, p.9)

    And,  the  Accreditation Council on Graduate Medical Education (ACGME) common program requirements speak to the emotional side, i.e., the sensibility, of patient care:

    Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. (ACGME, 2007, p. 8)

    But what of civility?

    Nursing has addressed the issue of civility directly in its document, The Essentials of Baccaulaureate Education for Professional Nursing Practice:

    Also, inherent in accountability is responsibility for individual actions and behaviors, including civility. In order to demonstrate professionalism, civility must be present. Civility is a fundamental set of accepted behaviors for a society/culture upon which professional behaviors are based (Hammer, 2003). (AACN, 2008, p. 26)

    If two of the largest professions in healthcare have embraced the concepts of courtesy, civility and compassionate care, then why do we still have complaints about the lack of civility in some health care settings? Is it because once we are in the fast paced, pressure cooker environment with declining revenue dollars we forget our manners? Does this environment make it easier to be curt with co-workers, to slight someone, and not apologize? Or if we do apologize, do we blame it on technology or on being in a rush? Subtle and not-so-subtle forms of incivility can cause psychological, physiological and emotional distress, as well as patient dissatisfaction (Cortina, Magley, Williams, & Langhout, 2001; Meterko, Mohr, Charns, Warren, & Hodgson, 2005).  These, in turn, can lead to burn-out, job dissatisfaction and turnover (Lim, Cortina, & Magley, 2008). It is expensive to recruit new health care workers--and there are costs incurred that are difficult to measure, such as decreased productivity of co-workers, loss of patients, and loss of revenues (Buchbinder,  Wilson,  Melick, &, Powe, 1999; Buchbinder,  Wilson,  Melick, &, Powe, 2001).

    At the undergraduate level, many universities have embraced the concept of Civility Education, and some now have Offices of Student Conduct and Civility Education. The topic is a fertile one: P.M Forni wrote On Civility and founded the Johns Hopkins Civility ProjectTalk to the Hand by Lynne Truss is a humorous version of why we should be civil to each other, and Giovinella Gonthier and Kevin Morrissey have published Rude Awakenings: Overcoming the Civility Crisis in the Workplace. There is no lack of educational material on this topic, yet few health care organizations have civility policies and few health care administrators are educated in how to create a culture of civility. Health care managers and providers are rarely required to take a specific course on the topic.  Many states mandate specific types of continuing education credits that must be completed to maintain a license. Perhaps it is time to consider adding at least one contact hour of civility education per year to remind us all that a well run health care organization requires sense, sensibility, and civility.

    Sharon B. Buchbinder, RN. PhD
    Professor and Chair
    Department of Health Science
    Towson University
    Towson, MD

    Sharon Buchbinder is an Adjunct Professor of Nursing at Stevenson University in the Graduate and Professional School , and former chair of the Association of University Programs in Health Administration (AUPHA).  She is also the author of two books from Jones & Bartlett: Introduction to Health Care Management and Career Opportunities in Health Care Management.


    Here are some references if you are interested in this topic.

    Accreditation Council on Graduate Medical Education (ACGME). (2007, July 1) Common program  requirements. Retrieved on October 8, 2009

    American Association of Colleges of Nursing (AACN). (2008, October 20).  The Essentials of Baccalaureate Education for Professional Nursing Practice. Retrieved on October 8, 2009

    Buchbinder, S.B., Wilson, M.H., Melick, C.F., Powe, N.R. (2001). Primary care physician job satisfaction and turnover. American Journal of Managed Care; 7: 701-713. Retrieved on October 8, 2009

    Buchbinder, S.B., Wilson, M.H., Melick, C.F., & Powe, N.R. (1999). Estimates of costs of primary care physician turnover. The American Journal of Managed Care; 5:1431-1438. Available at:

    Cortina, L.M., Magley, V.J., Hunter Williams, J., Langhout, R.D. (2001). Incivility in the workplace: Incidence and impact. Journal of Occupational Health Psychology. 6: 64-80.

    Forni, P.M. (2002). Choosing Civility: The Twenty-Five Rules of Considerate Conduct.  New York (NY): St. Martin's Press.

    Gonthier, G.  with Morrissey, K. (2002) Rude awakenings: Overcoming the civility crisis in the workplace. Chicago (IL): Dearborn Trade Publishing.

    Liaison Committee on Medical Education (LCME). (2008, June). Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Retrieved on October 8, 2009 .

    Lim, S., Cortina, L.M., & Magley, V.J. (2008). Personal and workgroup incivility: Impact on work and health outcomes. Journal of Applied Psychology; 93: 95-107.

    Meterko M., Mohr D., Charns M., Warren N., & Hodgson M. (2005).  Civility among healthcare employees: The impact on patients. Abstr AcademyHealth Meet. 22: abstract no. 3690. AcademyHealth. Meeting,  Boston, Mass.

    Truss, L. (2005). Talk to the hand: The utter bloody rudeness of the world today, or six good reasons to stay home and bolt the door. New York (NY): Gotham Books.

    Topics: allied health, public health education, health professionals, Sharon B. Buchbinder, Essentials of Baccalaureate Education for Professi, Liaison Committee on Medical Education, medical students, Public health management, residents, Sharon Buchbinder Blog, Accreditation Council on Graduate Medical Educatio, civility, communication skills, courtesy

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