The Divided Hospital

(Photo by iStock/Ninoon) 

How doctors, nurses, and hospital staff get along can directly affect patient outcomes, researchers have found.

Office interpersonal dynamics are the substrate of all workplaces. In a hospital setting, the stakes are higher: Medical errors are a leading cause of death and injury. A new study examines the connection between “incivility”—medical workers being rude or disrespectful to each other—and rates of mortality and medical errors for patients under the hospital’s care.

Ren Li, an assistant professor of management at the Hong Kong Polytechnic University’s business school; Virginia K. Choi, a graduate student at the University of Maryland; and Michele J. Gelfand, a professor of cross-cultural management and organizational behavior at the Stanford Graduate School of Business, authored the study.

They analyzed data from a large Northeastern US hospital from 2015 and 2016, surveying 1,102 medical workers organized into 38 work groups and reviewing the records of 4,138 patients to see how group interactions affected medical outcomes. The researchers discovered that more rancorous interpersonal dynamics among the doctors and nurses in a unit led to higher rates of death and medical errors for their patients.

“A 10% increase in unit incivility was linked to a maximum 8.87% increase in healthcare-associated infection rates and a maximum 10.59% increase in mortality rates,” the researchers write.

Their study explored how the workers self-organized into homogeneous subgroups—and whether the group leaders were able to foster a culture of collaboration that broke down barriers and improved patient care.

A typical hospital work group, a team of doctors and nurses who work together on one ward or medical specialty, often includes both men and women of different racial or geographic backgrounds. Although the hierarchy is rigid—doctors are always in charge, in order of seniority, followed by nurses, then technicians and support staff—the way the team breaks down into subgroups by gender, ethnicity, or position within the leadership structure can affect the dynamics of the whole.

In some work groups, people of the same gender and ethnicity tend to hold the same professional roles and rely on their fellows for moral support when they run into issues with a different subgroup. It’s not uncommon to find that many or most of the nurses on a unit are women from minority races and ethnicities, while many or most of the doctors are white men.

When people don’t get along with a colleague or subgroup, they may turn to those they feel can empathize with their situation, rather than trying to resolve the conflict. The problem can permeate the medical workforce, as the study’s research assistants assigned to do observational studies at the hospital discovered, Li says. For example, a doctor told another that it was a nurse’s job to remind them when they forget to wash their hands, and the nurses rolled their eyes at one another. A nurse complained to her fellow nurses that doctors were giving her conflicting orders—but wouldn’t mention the issue to the doctors. Another nurse expressed hurt feelings to the other nurses when a doctor she’d worked with for years called her “Hey,” having forgotten her name.

Different work groups the researchers surveyed had varying levels of incivility, but in work units that featured what the researchers called “strong faultlines,” with a clear divide between subgroups of workers, a management culture that fostered collaboration in cases of conflict led to better patient outcomes. To achieve this result, the hospital would need to either train its unit leaders, usually doctors, in a collaborative management style, or hire new leaders who worked this way, Li says. In a group that uses this management practice, workers ideally consider themselves part of the hospital unit rather than part of their own particular subgroup first.

“The paper shows conclusively that the conflict culture of a team can have a life-or-death significance for medical patients when social conflicts can easily appear in teams,” says Michael Frese, a professor at the Asia School of Management and Leuphana University of Lueneburg, Germany.

The study has important implications for practitioners, according to Frese. A more diverse work group will not necessarily function better. Hospital leaders must iron out issues with how people work together before the positive effects of diverse teams on patients come to fruition.

Find the full study: “Ripple Effects of Hospital Team Faultlines on Patient Outcomes” by Ren Li, Virginia K. Choi, and Michele J. Gelfand, Proceedings of the National Academy of Sciences, vol. 120, no. 47, November 2023.

Read more stories by Chana R. Schoenberger.