Naughty or Nice?
The impact of bad behavior on you, your organization and the bottom line

By Elizabeth Ziemba, President, Medical Tourism Training, Inc.

“Every job is a self-portrait of the person who does it. Autograph your work with excellence.”
– Author Unknown

Incivility is on the rise and it is having a negative impact on us, our organizations, the people we serve and the bottom line. In the international health travel sector, delivering excellent customer service and the best patient experience possible are characteristics of the most successful organizations. There is no room for bad behavior yet is exists and is widespread.

This article explores the growing problem of bad behavior in the work place. In this article, “bad behavior” will be defined with examples drawn from the health care sector. How such behavior impacts individuals, co-workers, customers and patients, and bystanders will be detailed. The costs of incivility are demonstrated in terms of financial damage as well as other equally important emotional and psychological costs. Finally solutions are offered to combat disrespectful and disruptive behavior.

What is “bad behavior”?

Impolite, rude, disrespectful, boorish, offensive – these words and more describe the way we have been treated and the ways we may treat others at work. We know bad behavior when we see or experience it. One definition is “the exchange of seemingly inconsequential, inconsiderate words and deeds that violate conventional norms of workplace conduct” (a). The definition and the conduct it describes are clearly subjective. What is offensive to one person may be humorous to another requiring sensitivity and awareness in our interactions.

There are categories of behavior that are, by general objective standards, unacceptable in the workplace. The 2011 poll administered across all sectors by Monster.com reveals strikingly consistent results. About 71% of all co-workers were rated to be “somewhat” to “downright rude”.

Typical offensive office behavior includes interrupting in person and telephone conversations; talking loudly in common areas; arriving late for appointments and meetings; failing to introduce people to each other; failing to return a phone call or email; and showing little or no interest in other’s opinions.

In their study (b), Leape et als identify a spectrum of bad behavior prevalent in US hospitals from “disruptive behavior” to “systemic disrespect”. While this study concentrated on the behavior of physicians, they are not the only individuals who engage in behavior that generates negative results.

From outburst and verbal threats to demeaning treatment, from refusal to do things in a particular manner to complete lack of cooperation, from disrespectful treatment by individuals to institutional tolerance of incivility, bad behavior impacts everyone who engages in it, is the object of it, or who witnesses it.

Consequences of Bad Behavior

Regardless of where bad behavior falls on the spectrum, disrespect generates numerous negative consequences. It can inhibit collegiality and cooperation essential for teamwork, stymie   communication, damage morale, and at its worst, threaten patient safety. Healthcare teams that do not function as a team can cause important information to be withheld, response times to be slowed, and feedback denied.

In health care settings, nurses seem to bear the brunt of much bad behavior from physicians, colleagues, and patients. For example, one study reports that 31% of nurses know a nurse who left a hospital because of disruptive physician behavior (c). Other studies support this trend of nurses leaving their jobs as a consequence of bad behavior. The expense to health care providers in terms of replacing these valuable health care workers is only part of the costs incurred by bad behavior.

According to Pearson and Porath, individuals who experience work place incivility:

  • Lose work time worrying about the incident and future interactions with the offender
  • Lose work time trying to avoid the offender
  • Experience a weakened sense of commitment to the organization
  • Reduce their efforts at work
  • Decrease the amount of time spent at work
  • Spend time thinking about changing jobs
  • Actually change jobs

Clearly, bad behavior has a negative impact on productivity at work, distracting people from their jobs and eroding their loyalty to their teams and organizations.

The costs of bad behavior extend beyond the individuals directly involved and spill over onto people who witness such incivility. Research (d) shows that witnessing incivility between employees and customers including patients provokes strong emotions including:

  • Telling friends and family about the incident
  • Viewing the organization in a less favorable way
  • Being less willing to use the organization’s products and services

Poor customer service involving bad behavior not only damages the relationship with the customer but also with anyone who witnesses it! Given that many patients especially international patients travel with accompanying family members, there are many important, influential witnesses to each health care interaction.

The Impact on Patients

The health care sector offers examples of how bad behavior impacts patients. Teamwork and communication suffer when disrespectful behavior pervades the work place. Patient treatment may be jeopardized and contribute to the rate of preventable harm, medical errors, and malpractice.

Patients tend to file malpractice law suits “because of poor medical care and how the patient feels about the doctor” (e). Doctors who are rude to patients tend to be sued more often while those who treat people with respect, take responsibility and offer options are able to avoid costly law suits and damage to reputation.

The JD Power National Patient Experience Survey (NPES) confirms that a better patient experience is reported when staff exhibit an ability to listen, express compassion and understand and mange emotional responses (f). In other words, a better patient experience is directly tied to interpersonal skills that are the opposite of bad behavior. Something as simple as saying “Thank you” to patients for using the organization’s services can have a direct positive impact on the bottom line. According to NPES, “patients that were thanked for choosing their hospital report an average of about 7 positive recommendations (6.99). For patients who say they were never thanked, the average number of positive recommendations fails to only 0.6″ (g).

It’s Not Limited to Doctors in the US

While the research cited relates to the United States, bad behavior exists universally. People everywhere want to be treated with respect as customers, patients, and employees. Recognizing bad behavior and its impact on individuals, organizations, and the bottom line is the first step to creating a healthy work environment.

Still not convinced that bad behavior matters? Let’s calculate the financial costs of incivility.

What are the costs of “bad behavior”?

The costs of bad behavior range from factors that are fairly easy to calculate such as malpractice law suits or the cost of replacing employees to other impacts that are more difficult to measure such as lost business or damage to reputation. Pearson and Porath attach dollars and cents to certain behaviors to drive home the point that the full spectrum of unacceptable work place behaviors costs your organization money and more.

Calculating the Costs

The following calculation, taken from Pearson and Porath’s book, is based on a US health care organization with gross annual income of just under $1 billion dollars. This medical center wanted to know how much its culture of incivility was costing the organization. While the center’s management knew there was a problem, my guess is that they had no idea of the enormous price tag attached to bad behavior.

Results: The total cost of incivility to this health care center is $70,911.390.55 USD per year!

You can use this same formula to calculate the costs to your own organization, large or small. Prepare to be surprised at the impact on the bottom line.

What are the costs to your organization?

Is all of this calculating and estimating giving you a headache? The costs of bad behavior to your organization should be giving you a migraine!

Whether you engage in a detailed calculation or spend a few minutes figuring out a rough estimate, the point is that incivility between and among co-workers, patients, customers and the witnesses to bad behavior is damaging your bottom line, your work force, and your reputation. And the costs may be greater than you imagined.

Superior customer service skills as well as the ability of your staff to deliver a better patient experience by listening, expressing compassion, and managing emotional responses cannot exist within a work place characterized by incivility (h).

What can organizations and individuals do to solve the problem of incivility in the workplace? Plenty! Let’s look at what organizations and individuals can do to create a team-oriented, polite environment where co-workers, patients and clients all receive top-notch customer service.

Change Starts with Committed Leadership

Creating a culture of respect requires strong leadership to consistently deliver the message that incivility in the work place will not be tolerated and then reinforce that message with actions to ensure that employees are inspired to practice respectful behavior (i).

Top leadership must recognize the problem and respond by creating a vision to transform the organization by establishing preconditions for respect. Leaders then set the example for the rest of the organization to emulate. Infrastructure must be developed or reshaped to include Codes of Conduct with a clear process for reporting and responding to complaints while protecting individuals from personal or professional repercussions (j).

Ten Steps to Organizational Change

According to Pearson and Porath(k), here are the top ten things an organization should do to create a civil workplace:

1. Set Zero-Tolerance Expectations.

“Treat everyone in our diverse community with respect and dignity”
– From the Mayo Clinic Mission Statement

Senior management must fully commit to civility standards through written vision and mission statements, credos, or Codes of Conduct. Expectations regarding behavior should be established and measured so that they can be corrected or rewarded according to well-articulated standards.

2. Look in the Mirror.

Top leadership and senior management must “walk the talk”. In other words, they must lead by example and start with a self-evaluation. Videotaping or recording your meetings and conversations can open your eyes to the way you treat people. So can 360-degree evaluations. Embark on a course of learning about your own bad habits as a way to improve your interpersonal and leadership skills.

3.   Weed out trouble before it enters your organization.

Prevention is easier than cure. Recruiting and screening potential employees, vendors, consultants and clients for bad behavior offenders can reduce problems before they start. Behavioral interview questions can be geared to this topic. Reference checks can reveal chronic bad behavior patterns while telephone and in-person interviews can raise red flags if the screening process is looking for clues to incivility.

4. Teach civility.

With the rise of technology, social skills are ignored or forgotten. Many people simply do not understand what civility means. Training programs such as the customer service programs offered by Medical Tourism Training focus on listening, conflict resolution, negotiation, and dealing with difficult people reinforced through role-playing. These positive people skills can then be incorporated into job descriptions, performance reviews and tied to promotions and compensation.

5. Train employees and managers how to recognize and respond to signals.

People can be skilled at hiding bad behavior so employees, especially managers need to be alert to signs of hidden incivility. Signals include nurses who refuse to work with particular doctors or complaints about individuals circulating through the grapevine. Satisfaction surveys and individual complaints are excellent sources of problems associated with rude or disrespectful behaviors.

6. Put your ear to the ground and listen carefully.

In other words, pay attention to relevant data such as rates of absenteeism and turnover rates. The reasons why employees miss work or why departments have high departure rates may be linked to bad behavior. Collecting this data and other feedback must be done in a safe environment where individuals are free from the fear of repercussion.

7. When incivility occurs, hammer it.

If people are good only because they fear punishment, and hope for reward, then we are a sorry lot indeed.”
– Albert Einstein

To create and maintain a civil work environment, accept civility and nothing less. That does not mean fire everyone who exhibits rude behavior but give opportunities to learn from excellent examples and to do better. And remember that zero tolerance extends to interactions with customers and patients. When employees see the organization refusing to accept bad behavior, the message will hit home quickly and powerfully.

8. Take complaints seriously.

It takes a great deal of courage for an individual to make a complaint against a co-worker especially one who may have power over the person’s employment, compensation or other terms of employment. There must be a “clear, explicit, well-understood mechanism for processing complaints and to respond consistently when violations occur” (l).

Management can be proactive by acting on data collected from various sources such as surveys and being open to discussions with employees about this sensitive subject. Find small complaints before they become big issues – or law suits.

9. Don’t make excuses for powerful instigators.

“Dr.  doesn’t mean any harm. He is just  .”

This rule is particularly challenging for organizations with high powered individuals such as physicians who have the largest volume of patients or the person who is related to an owner. It is easy to make excuses for these trouble makers but evasive responses such as moving them to another location rather than confronting the issue promises that the problems will continue. Take a strong stand and offer coaching, training, and, if necessary, implement stronger measures. An effective response is essential for everyone in the organization to comprehend that bad behavior will not be tolerated.

10. Invest in post-departure interviews.

Exit interviews give people the opportunity to evaluate their own experiences. These interviews can be rich sources of information about bad behavior and may take place at the end of the employment relationship as well as three or six months later.

Using these guidelines and common sense can begin the organizational transformation from naughty to nice.

Tips for Targets of Bad Behavior

“If you are going through hell, keep going.”
– Winston Churchill

What can you do if you are the target of incivility?

Targets of bad behavior have a variety of coping mechanisms and measures to protect themselves (m).

Going to work and being subjected to disrespect is stressful and possibly even threatening. Acknowledging to yourself that you are in this vulnerable state is the first step in deciding what to do. Before making a decision, seek the help of family and friends who have your best interests at heart and give yourself some time to decompress and relax. A clear mind will help you make a good decision about what to do next.

If you believe that further action is necessary, then seek out a mentor or advocate in the organization such as a human resources representative or your manager to report the behavior. Talk over the situation for coaching about how to handle the situation. If the behavior is egregious, it may warrant filing a formal complaint. Many times a skilled ally with good negotiating or conflict resolution skills can diffuse the situation.

Even if you cannot change the offender’s behavior, you can change your own attitude. Perhaps viewing your situation in a spiritual or religious framework will permit you to focus on your own abilities such as “What goes around, comes around. He will eventually do himself in with that kind of behavior”.

Of course, there is always the decision either to stay and deal with the situation or leave. Measuring the pros and cons of this decision is personal and depends on many factors in your life. Hopefully it will be a decision made after other options have been tried but before accepting the next opportunity, you will be wiser about finding a workplace where civility is honored.

Managing an Offender – even if that offender is you!

Do you manage an offender? Are you an offender? Change is possible once you or the offending person acknowledges that bad behavior is part of what you do and does not define who you are.

360-degree feedback – structured evaluations that are given from clients and co-workers at all levels – can provide invaluable insights. A picture is worth ten thousand words. Videotaping meetings and other workplace interactions can be enlightening. Once issues and patterns are identified, solutions are easier to create.

Training and coaching can provide candid advice based on experience and tailored to your individual situation. These activities reinforce your ability to change to enhance your professional life and gain the respect that you want in your work place.

Bad behavior in the work place exacts many costs, financial as well as emotional and psychological. Human beings want to be treated with respect but sometimes forget that respect must be earned. Or perhaps they never learned how to earn respect.

Strong leadership with a clear vision supported by training and coaching can create a positive environment where everyone delivers excellent customer service to each other, their patients, and customers.

Looking to go from naughty to nice? Medical Tourism Training offers a full array of on-site and on-line training and coaching solutions designed to deliver customer service skills throughout your organization.

Contact us today to design solutions that fit your budget. Our experienced trainers and coaches are waiting to help you meet your goals.


This article is based on my assimilation of the research and writing of these authors plus a dash of personal experience. It is a summary of their major findings and I am grateful to the authors for their fine work which I have liberally summarized. If you have time and interest, I encourage you to read their publications for additional insights and information.


(a) Pearson, Christine. Porath, Christine. The Cost of Bad Behavior – How Incivility is Damaging Your Business and What to do about i Portfolio Books. 2009. p.12.

(b) “A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians”. Leape, Lucien. Et als. Academic Medicine, Vol. 87, No. 7, July 2012.

(c) Saxton R, Hines T, Enriquez The negative impact of nurse-physician disruptive behavior on patient safety: A review of the literature. J Patient Safety. 2009,5:180-183

(d) Pearson, 105

(e) Pearson, 118.

(f) “Patient Perspectives on Outstanding Experiences: The Impact of Emotionally Intelligent Staff”, Richard Millard, White paper from The Beryl Institute, 2012

(g) Millard, p 10.

(h) Millard.

(i) Leape, Lucian et als. A Culture of Respect, Part 2: Creating a Culture of Respect, Academic Medicine, Vol. 87, N 7/July 2012. p 854.

(j) Ibid. 856.

(k) Pearson, p. 138 et seq. Summary of the information contained in various chapters of this

(l) Leape et als, 856.

(m) Pearson, Chapter 15, summary.

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Elizabeth Ziemba

Elizabeth Ziemba

President at Medical Tourism Training
With a diverse background in public health, law and business, Elizabeth brings a unique set of skills and experience to Medical Tourism Training with services including assessment tools, online and onsite training, workshops, and consulting services for governments, providers, facilitators, associations and others involved in medical travel.