The surge in rude behavior that accompanied the COVID-19 pandemic prompted many health systems to revisit workplace conduct standards, invest in de-escalation training and strengthen employee safety efforts.
After several years, have those efforts worked?
The answer is mixed. Health system leaders, workplace experts and recent research suggest meaningful progress has been made inside many organizations, even as incivility remains a broader workplace challenge. The Society for Human Resource Management’s Civility Index found workplace incivility rose 21.5% in the first quarter of 2025 compared with the same period a year earlier, reaching one of the highest levels recorded since the index launched.
Interviews with leaders and experts suggest the organizations seeing the greatest progress have treated professionalism and respect as ongoing leadership priorities rather than temporary pandemic-era initiatives.
Wendy Fournet, EdD, executive vice president and chief administrative officer at Erlanger Health System in Chattanooga, Tenn., said the state of the issue at her organization today looks different from the peak of the pandemic.
“Two to three years ago, one of the questions asked in our internal risk survey was, ‘What are your major concerns? What are the major risks?’ And the No. 1 answer was psychological safety,” Dr. Fournet said. “But I think we’ve seen a change in that now.”
Erlanger has pursued what she describes as a back-to-basics approach: revamping standards of behavior, investing in leadership development and weaving accountability into the culture from the C-suite down. The organization is on a high-reliability organization journey, which has helped establish a shared framework for how people are expected to treat one another regardless of role or tenure.
Training leaders to have difficult conversations has been a particular focus. Erlanger has also created an emerging leaders program that begins teaching leadership skills before employees are placed in a formal leadership role.
“What has worked is sometimes it’s nothing new, but sometimes we promote people and we don’t give them the tools they need,” Dr. Fournet said. “They might be a rock star clinician but have never been a manager or nurse manager. So I think it’s starting early, teaching people, going back and doing some training around customer service and accountability.”
Alignment across the executive team has been the most consequential lever.
“The entire C-suite is on the same page,” she said. “If we’re hearing things, we’re holding people accountable, and I think that’s where I’ve seen the most change in culture. It’s something that we talk about weekly.”
The results have been measurable. Patient satisfaction scores have improved, and employee engagement scores rose in a recent survey that included both employee and community positions. Town halls, restructured into smaller huddle formats, have given staff a more accessible outlet.
One shift Dr. Fournet has noticed is not in behavior itself but in the willingness to report it.
“Two to three years ago, people just weren’t comfortable; they just didn’t want to speak, didn’t want to talk about it,” she said. “But giving them the tools needed and giving them the OK to address things, I’ve seen a difference. That means hotline calls are up, but I’d rather that, because that tells me you’re comfortable being able to say something and address it.”
Tina Jackson, chief people officer at Beaufort (S.C.) Memorial, a 201-bed nonprofit community hospital, offered a view from a different vantage point: a smaller organization navigating the same pressures with fewer resources. She said the hospital has felt increases in workplace tension, incivility and workplace violence, and has responded by building reporting infrastructure and eliminating barriers that kept staff silent.
“We report incidents, analyze patterns with a multidisciplinary team and put safety plans in place while removing barriers for employees to report any incidents of incivility or violence,” Ms. Jackson said. “We’ve shifted our culture surrounding reporting these incidents, encouraging staff to report. The more we understand these incidences, the closer we are to fixing the problem.”
She specifically pointed to the establishment of a workplace violence committee, a multidisciplinary group that meets weekly to analyze the variables surrounding incidents and identify patterns. After three decades in the profession, Ms. Jackson said she has never seen workplaces carrying the weight they carry today — and that the need for strong leadership has never been clearer.
Gerald Hickson, MD, founding director of the Vanderbilt Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn., has spent more than 30 years studying why some clinicians attract a disproportionate share of complaints and how to intervene effectively. He drew a distinction that he said shapes how health systems should approach the problem.
“I have a little exception with that notion [of civility], because some of the nastiest people that I’ve ever had to deal with in life have been very civil,” Dr. Hickson said. “So we continue to come back to the concept of respect — respect for patients and families, respect for co-workers, respect for established safety practices, of which civility is a very important part.”
The distinction has practical implications for how organizations design interventions. Programs focused only on surface behaviors miss the underlying dynamic. Respect, as Dr. Hickson frames it, encompasses how seriously team members take one another’s concerns, whether they honor safety protocols and whether they stay engaged when it is inconvenient.
Research on what happens when that breaks down shows the implications. Studies conducted by Vanderbilt researchers have found that patients who receive care from physicians modeling disrespect are 20% to 30% more likely to experience avoidable surgical and medical complications and death.
As for improving clinicians’ attitudes toward respect, a paper published in 2026 in the Journal on Quality and Patient Safety by Crane et al., with a companion editorial co-written by Dr. Hickson and William Cooper, MD, offered an encouraging finding: Among 308 clinicians referred to the Colorado Physician Health Program for persistent or severe professionalism concerns, approximately 95% successfully completed their participation — including evaluation and monitoring — and received a clinical determination that they were safe to practice without further program intervention.
“There’s this notion that, gosh, Hickson’s been behaving this way for 30 years and he is not going to change now,” he said. “Well, they won’t change if we don’t engage them, they won’t change if we don’t get the right resources for them, because it’s about their wellness as well.”
Part of what has changed in recent years is who owns the problem. Dr. Hickson, Dr. Fournet and Ms. Jackson all pointed to human resources and people leadership as structural partners in this work.
Dr. Fournet described an organizational development team assigned almost like a business partner model, working directly with specific departments and leaders.
“If something is going on, they can help address it through coaching, through role playing,” she said. “I’ve seen an increase in the usage of that, and it does make a difference.”
Dr. Hickson was more direct about what happens when HR is siloed out of safety and quality conversations.
“HR has to be a part of a health system safety team, because if individual team members are not healthy, the teams are not healthy,” he said. “Having them at the table — clinical leadership, HR leadership, senior leadership of the institution — it’s all in, or we’ve got a problem.”
One area where both Dr. Fournet and Dr. Hickson pointed to ongoing vulnerability is the entry point for new nurses. Nurse residency programs, Dr. Fournet said, have helped address the friction between experienced and newer nurses by giving new hires a dedicated development track that buffers them from some of the pressure dynamics on the floor.
Taken together, the picture that emerges from these conversations is one of real but uneven progress, with outcomes tracking closely to whether organizations treated the issue as infrastructure rather than initiative.
“Institutions without a defined plan will get there, they’re just not going to get there fast,” Dr. Hickson said. “[Approximately] 3% to 5% of members walk in the door and, for a host of reasons, either come in unhealthy or because life throws them challenges. All of those things are why you never can make the challenge go away, but what you’ve got to do is have a plan for early identification and intervention on those individuals who are struggling.”
The organizations that get there, in his assessment, have stopped treating professionalism as a periodic initiative and started treating it as part of how the institution runs.
“The organizations that get that and build the plan, they get results, and they’re going to sustain the results,” he said. “Those who think this is another form of patient satisfaction, and that’s all they deal with in an honest way, they will continue to struggle.”
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