Combating Incivility in EMS Leadership & Promoting a Culture of Respect

Rudeness, disrespect, and incivility between providers can erode trust and can have a serious ripple effect on organizational culture, morale, and workplace satisfaction. These internal hazards occur in an already stressful field, leading to more stress, burnout, and decreased quality of patient care. 

Not All Hazards Are Physical  

To combat incivility in the workplace we first must define it, and put more language to the lived experiences many have had who could not recognize it. According to safety expert Dr. I. David Daniels, PhD, CSD, VPS, incivility in the workplace is behavior that is perceived as rude, disrespectful, and unprofessional and is classified in the literature as a psychosocial hazard.

Psychosocial hazards are “factors in the design or management of work that increase the risk of work-related stress and can lead to psychological or physical harm,” according to WorkSafe Australia¹.

Reflect on the mindset of an EMS provider who is experiencing volatile behavior from not only patients but also their direct supervisor. Will they be second-guessing themselves and not trusting others? If they have a concern about a patient’s situation, will they be less likely to ask for help out of fear of their peer or supervisor’s judgments and reaction? 

In a 2020 EMS Safety Forum interview with Liz Crowe, an advanced clinical social worker in Australia and now PhD, recounts in her studies of pediatric ICUs the top driver of staff burnout was not the horrific clinical challenges healthcare providers faced but it is the incivility they encountered from their coworkers that had the highest correlation to burnout.

“What really wears people out is incivility and leaders who don't call out incivility; it can spread like wildfire.” 

To build a culture of respect, compassion, and acknowledgment, Dr. Crowe suggests we start supporting others and recognizing when things go well. “All of us have to assume that what people need from us is our best because we don't know what others are going through. We are so quick to criticize, and continuously forget to compliment and acknowledge others.” 

How Incivility Effects Behaviors 

Workers were polled asking how they react to rudeness, abuse, stress, or a “volatile” boss, in a Harvard Business Review article, The Price of Incivility²: 

• 78% said that their commitment to the organization declined. 

• 63% lost work time avoiding the offender. 

• 48% intentionally decreased their work effort, and nearly the same decreased the time spent at work. 

• 38% intentionally decreased the quality of their work. 

• 25% admitted to taking their frustration out on customers.

“Incivility can take much more subtle forms, and it is often prompted by thoughtlessness rather than actual malice.” According to authors, Christine Porath and Christine Pearson, of the Harvard Business Review,  “Think of the boss who ‘teases’ direct reports in ways that sting, or the team leader who takes credit for good news but points a finger at team members when something goes wrong. Such relatively minor acts can be even more insidious than overt bullying because they are less obvious and easier to overlook—yet they add up, eroding engagement and morale.”

Examples of incivility in EMS include verbal abuse not only from patients or their families, but also belittling or bullying by coworkers or supervisors, and failure to respect the opinions or decisions of others. These actions can lead to decreased trust and collaboration among team members, and can negatively impact provider retention and patient outcomes.

Let’s Not Confuse With Burnout 

Research in this area is also related to moral injury being confused for burnout in the healthcare or first responder setting. Moral Injury³“ occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.”

"Incivility can have a ripple effect, impacting not only the person who was targeted but also their colleagues and the quality of patient care." 

To address incivility in EMS, it is important for organizations to have clear policies and procedures in place to address disrespectful behavior. Training programs for providers need to be offered to promote Affective Domain development — some would call these soft skills, I would argue they are essential skills such as emotional intelligence, self-compassion, effective communication skills, enhanced teamwork, and professionalism. Additionally, leaders at all levels should model respectful behavior and take a stand to address incidents of incivility when they occur. 

An Approach To Change 

Leaders can take the following steps to recognize psychosocial hazards and combat incivility in the workplace: 

1. Set clear agreements: Leaders can establish and communicate clear standards of professional behavior, outlining what is and is not acceptable in terms of communication and interactions among team members. Remember, unspoken expectations will lead to upset in organizations, leading to clearly stated agreements. 

2. Demonstrate acceptable behavior: Leaders serve as role models for accepted behaviors setting the bar for cultural norms, treating others with respect, and exhibiting professional conduct.

3. Address incidents promptly: When incidents of incivility occur, leaders should take prompt and decisive action to address them, using the policies and procedures in place to resolve the situation and prevent future incidents. 

4. Encourage and provide training: Affective Domain skills can build teamwork, mutual trust, and professionalism. Unfortunately, they have been given a bad rap and referred to as ‘soft skills.’ I would argue that these are essential skills for leaders at every level. Frontline caregivers to senior leaders can benefit from the tenets of Emotional Intelligence⁴ - self-awareness, self-control, social awareness, and social skills (relationship building). Focus on helping others develop self-care and self-compassion. 
    
   “From a biological and psychological point of view, the problem with the self-critic is that it can trip the switch to our stress response and challenge our mental well-being. On the other hand, self-compassion has been associated with lower levels of anxiety, depression, and body dissatisfaction.” Wendy Lund, BScN, MSc5

5. Create and encourage a supportive environment: Leaders can create a psychologically safe and supportive work environment through their communication where people can grow and thrive. Recognizing and encouraging ideal behaviors, and encouraging staff to work together as a team. Providing staff with opportunities to express their concerns so they can be heard and then addressed in a safe confidential manner. 

Going Upstream May Help

Not only can EMS leaders in organizations address these issues, but EMS educators and clinical preceptors can also address these situations early on.

“As educators, we MUST ensure ‘incivility’ does NOT begin in our classrooms,” says paramedic educator, Julianee Stevenson, who recently created model policies for addressing behaviors for her accredited paramedic program clients. “If you hear things about a faculty member, even in the absence of a formal complaint, you should (without making accusations) sniff around and make sure there isn’t a wildfire brewing!” Stevens continues, “The communication tips you can pick up from bona fide leadership training are invaluable to help you determine the actual reality in those types of scenarios.”

By taking a proactive approach to address incivility in the field of paramedicine, leaders can foster a more inclusive, enjoyable, and productive work environment, which can ultimately lead to improved patient care, provider satisfaction, and long-term employee retention.

Robbie MacCue, FP-C, MBA 

Robbie MacCue, FP-C, MBA, is the founder of the EMS Leadership Academy, and host of the EMS Leadership Summit, an annual virtual conference attended by over 14,000 people in 44 countries around the globe. Robbie served as the president of a non-profit EMS organization for 14 years in Upstate New York. Currently, he is a paramedic Assistant Chief with the Town of Colonie EMS Department. Robbie graduated with a master's degree from Case Western Reserve University’s Weatherhead School of Management in its Cleveland Clinic healthcare leadership program. For more information and resources, visit www.EMSLeadershipAcademy.com or www.EMSLeadershipSummit.com.

References: 

1. “Psychosocial Hazards Contributing to Work-Related Stress - WorkSafe.” www.worksafe.vic.gov.au/psychosocial-hazards-contributing-work-related-stress. ‌ 

2. Porath, Christine, and Christine Pearson. “The Price of Incivility.” Harvard Business Review, 19 Mar. 2019, hbr.org/2013/01/the-price-of-incivility. ‌ 

3. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447. PMID: 31571807; PMCID: PMC6752815. 

4. Bar-On, R., & A., P. J. D. (2000). In The Handbook of Emotional Intelligence: Theory, development, assessment, and application at home, school, and in the Workplace (pp. 343–362). essay, Jossey-Bass.  

5. Lund, Wendy, and Robbie MacCue. “EMS Self-Care for Supervisors: Manage Stress and Avoid Burnout.” EMS1.com, Lexipol, 22 Apr. 2021, www.ems1.com/wellness-week/articles/ems-self-care-for-supervisors-manage-stress-and-avoid-burnout-B4uDormB3G6XJ9Om/. Accessed 2 Aug. 2023.