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On the negative side, it did not take long to be reminded of the lack of civility some parents extend towards doctors and nurses.

One incident, where a mother was verbally abusive for an extended period despite my unconditional apology for the delay in her daughter’s outpatient appointment, left me wondering about how much incivility we should tolerate.

While most healthcare services have a ‘zero tolerance’ policy towards aggressive and threatening behaviour, there is little guidance for doctors with regards to where limits should be set around less severe verbal abuse.

As healthcare professionals, we are acutely aware of the stress associated with illness and the consequent need to tolerate reasonable expressions of this anxiety. However, in some cases, such as the outpatient visit for a minor and previously investigated complaint mentioned above, the patient or carer’s behaviour may be well out of keeping with any illness-related stress.

Two questions that arise in such situations are firstly how should healthcare professionals respond to such behaviour, and secondly, if they decide to place boundaries around these behaviours, will they be supported by their managers?

In considering these questions, it is important to realise that rudeness is not a neutral behaviour.

Experimental studies in various settings, including simulation studies in healthcare, have shown the negative effects of even a single exposure to rudeness.

Measurable reductions in task performance, creativity, flexibility and helpfulness (Porath & Erez, 2007) as well as diagnostic and intervention outcomes, and team performance have been reported (Riskin et al, 2017).

In fact, one study suggested that rudeness explained 39 per cent of the team level variance in general therapeutic outcomes in a neonatal intensive care simulation setting (Riskin et al, 2017). This suggests that rudeness may represent a significant ‘reversible’ iatrogenesis-related risk factor.

In addition, there is ample evidence in the literature that incivility in the healthcare work place is a major contributor to burnout (Lee et al, 2013).

So, how can we tackle the problem of rudeness and its dual effects on practitioner health and patient outcomes?

Obviously, it may be possible to institute interventions that enhance the defences of medical professionals to the cognitive distraction elicited by rudeness. However, it is uncertain what such a training program would entail and whether it could lead to long term ‘immunisation’ against the effect of rudeness.

Techniques that reduce sympathetic arousal such as mindfully focusing on the breath are certainly worth exploring and have the potential to improve healthcare professionals’ wellbeing.

However, uptake of such programs is unlikely to be universal. The alternative approach is to establish consistent and reasonable boundaries around patient and carers’ behaviour that are supported by the hierarchy of the healthcare institution.

The first step may be a heightened awareness around the frequency of rude encounters as well as their effect on team performance and patient outcomes. Institutions will need to find the balance between tolerating behaviours driven by patient and families’ stress and the impact of their behaviour on medical teams.

Without guidance and support from the highest level, doctors and nurses will continue to struggle with setting their own boundaries and therefore risk negative outcomes for their own health and the health of their patients. ■

References available upon request.