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Rudeness upsets colleagues and poses risk to patients

Being on the receiving end of incivility is always unpleasant but in a healthcare setting it can be dangerous

Being on the receiving end of incivility is always unpleasant but in a healthcare setting it can be dangerous

  • Minor incivility by leaders and managers makes staff feel they are being screamed at
  • Rudeness affects quality of work and makes people less willing to help others
  • The Civility Saves Lives project, run by healthcare professionals, reveals how to challenge incivility with compassion
Picture shows two women in scrubs, the older one frowning at the younger one, who is looking at a folder. Being on the receiving end of incivility is always unpleasant but in a healthcare setting it can be dangerous.
Picture: iStock

When Denise Guzdz heard about the Civility Saves Lives project it struck a chord with her. Having been through bruising experiences in her own professional life, the senior nurse understood the wide-ranging and devastating effect that incivility can have. She decided to do something about it.

‘Nobody should be allowed to talk to someone in a way that makes them feel bad, whether it’s intentional or not. There are still too many instances of poor behaviour in the health service, and it has real and devastating effects on individuals, teams and patients. We all need to be aware of this, and the damage that incivility can cause.’

Some years ago she went through a particularly hard time when she was ostracised for speaking out after witnessing a senior nursing colleague’s incivility to a junior member of staff.

‘We have to do more to prevent incivility from happening in the first place’

Denise Guzdz, senior nurse and ‘freedom to speak up’ champion

‘I was on this roller coaster of witnessing behaviour and the consequences of it, and it took me on a journey where I was saying to myself, “This can’t be right.” I realised we had to do more for people who were victims of incivility. And we have to do more to prevent incivility from happening in the first place.’

Civility Saves Lives is a self-funded, collaborative project that aims to raise awareness of the potentially fatal impact of rudeness in healthcare settings, even of an apparently mild nature.

It was founded by emergency medicine consultant Chris Turner, who works at a trauma centre in the West Midlands, and involves a growing number of healthcare professionals who do their best to share its aims across the country.

Dr Turner was influenced by a compelling evidence base, notably from US academic Christine Porath, showing that incivility has a hugely detrimental effect, not only on the person at the receiving end but also on those who witness it, and ultimately on the patient as well.

‘If you are eye-rolling from a position of authority you might as well scream “shut up” to the people in the room’

Chris Turner, emergency medicine consultant and founder of Civility Saves Lives

How can staff being rude to one another compromise patient safety? One way is by making staff anxious and nervous, which affects their performance and leads to mistakes.

The importance of the atmosphere in the room – how staff were feeling when something went wrong – is seldom recognised.  Dr Turner gives the example of the conventional system response when someone is found to have miscounted swabs.

‘We’d end up trying to teach people how to count swabs, but we pay no attention to the fact that somebody had behaved in a way that made people feel uncomfortable in theatre, which is why the person was miscounting swabs. We weren’t looking at behaviour – we were just looking at the person at the end of a chain.’

When we think about rudeness or incivility that has a real impact, we might think about someone shouting or being openly or intentionally offensive. But even low-level behaviours can have a dreadful effect.

What you can do to tackle incivility

Senior nurse Denise Guzdz, who is a ‘freedom to speak up’ champion. Being on the receiving end of incivility is always unpleasant but in a healthcare setting it can be dangerous.
Denise Guzdz

Tips from senior nurse Denise Guzdz:

Be aware if someone is constantly belittling you, or you are constantly belittling someone else, or if someone is undermining or talking over others. The health service can be very hierarchical, but it’s important to value everyone’s contribution. Sometimes the band 2 will know more than the band 7 about a particular environment or situation, and it’s about receiving that information and valuing it.

Listen to what people are saying and how it’s being said – and who it is being said in front of.

Call out uncivil behaviour when you witness it where it is appropriate to do so – not usually in front of a patient unless they are at risk.

Don’t respond to incivility in a similarly uncivil tone, because that can escalate a situation and cause more conflict.

If at all possible deal with it straight away, or at the first and easiest opportunity.

Sometimes it’s appropriate to ask the perpetrator’s peer to have a word with them, using words like, ‘Could you just tell them how that made me feel?’

Build relationships in teams, for example hold debriefs at the end of a theatre list or clinical shift to give staff the opportunity to discuss whether anything has affected them negatively. This helps build trust.

 

‘Some of the incivility actions are so apparently minor, for example eye-rolling,’ says Dr Turner. ‘But if you are eye-rolling from a position of authority you might as well scream “shut up” to the people in the room because it has the same impact. If someone who I’m afraid to challenge rolls their eyes at me, I’m just going to clam up.’

He says this kind of low-level incivility also has a dampening effect on creativity. ‘There’s a reason why 80% of people never tell their great idea to their teams in the NHS, and that’s because they don’t feel psychologically safe to do so.

‘We’re all capable of thinking before we speak and we all have to think of the consequences of what we say’

Denise Guzdz

‘For me, a lot of the leadership in this is about how we create environments where people feel safe to speak – where they’re not going to be belittled for making an idea real by speaking it. How do we create environments where we as leaders might be able to hear those great ideas – it’s by being civil with each other.’

Ms Guzdz, who has been a nurse for 45 years, is currently patient safety and governance adviser in operating theatres with Sherwood Forest Hospitals NHS Foundation Trust, where she was previously a department leader.

She is also a ‘freedom to speak up’ champion. Her work as an ambassador with Civility Saves Lives involves delivering presentations on its work to organisations up and down the country, including her own, where the executive team has been extremely supportive.

The impact of rudeness

How rudeness or incivility affects the recipient, witnesses, patients and their relatives:

The recipient

  • 80% lose time worrying about rudeness
  • 38% have reduced quality of work
  • 48% reduce their time at work
  • 63% lose time avoiding the offender
  • 25% take it out on service users
  • 12% resign

Those who witness it

  • 20% decrease in performance
  • 50% are less willing to help others

The patient or relative

  • 66% feel anxious dealing with staff
  • 75% have less enthusiasm for the organisation

Rudeness includes belittling someone, talking over them, shouting, being non-co-operative, undermining someone, saying, ‘It’s always been like that’ or, ‘I didn’t mean it like that.’ Rudeness does not depend on whether someone intended to be rude but on whether the recipient interprets it as rudeness.

Source: Civility Saves Lives, based on research published in the Harvard Business Review

 

‘The very first presentation was to about 40 staff in theatre and it was so well-received,’ she says. ‘You could see the cogs going round as people realised “Oh, that’s why I felt like that,” or “That’s why I didn’t want to come to work,” and “That’s why I’m not putting myself forward for promotion.” People came up to me afterwards and said how much it had resonated with them, and then it just escalated from there.’

Part of the issue is that the health service is a high-stress area, particularly at the moment, she says. ‘You’ve got a lot of pressures in all settings. However, we’re all capable of thinking before we speak and we all have to think of the consequences of what we say.’

So what counts as uncivil behaviour? Dr Turner is quite clear that there’s a wide spectrum. ‘Cutting people off – telling them that we’ve tried that before, speaking over the top of people, belittling comments that aren’t always rude but make you feel stupid for saying something. And all the way to the other end, of course, which is the screaming, shouting, losing the rag stuff – the truly horrible stuff that is bullying and worse.’

Picture shows two young women in scrubs frowning during a conversation. Being on the receiving end of incivility is always unpleasant but in a healthcare setting it can be dangerous.
Picture: iStock

Expecting nurses to be ‘resilient’ and just ‘deal with it’ is part of the problem, he says. ‘What interests me is that for a long time an awful lot of the focus in the literature was on how nurses could stress-inoculate themselves to the negative behaviour, primarily of doctors but also from senior nurses – it’s sometimes said that nurses eat their young.

‘Once people start behaving in a way that makes us feel threatened it affects our cognitive abilities’

Chris Turner

‘How do you at a junior level stress-inoculate yourself from those at a senior level? It turns out that you really can’t. The amount of time and effort that goes into it… but it just doesn’t work, because we’re human beings, and once people start behaving in a way that makes us feel threatened it affects our cognitive abilities.

‘All that work to inoculate staff from the behaviour of others doesn’t work, but what does work is peer-to-peer respectful conversations that let people know that other folk felt distressed by whatever was going on.’

He has no time for people who claim that some staff are just not able to cope with overly assertive management – often excused as being ‘robust’.

‘Anyone who says “robust” is attempting to excuse behaviour that frequently borders on bullying. They are using authority to assert themselves and often in a style that leaves people around them feeling damaged.

‘The important thing is that this is about how the people around you feel. It’s not about intent. That’s difficult for folk because so much of the time the offence that is caused is unintentional, but to the recipient there is no difference between intentional and unintentional incivility.’

Dr Turner is clear, however, that while civility saves lives in most situations, sometimes the pressured environment of the health service calls for a different response.

‘Anyone who says “robust” is attempting to excuse behaviour that frequently borders on bullying’

Chris Turner

‘It can be the case that incivility saves lives as well,’ he concedes. ‘If things are really hitting the fan, and something needs to happen right now and for some reason – and this is vanishingly rare – people aren’t on the right page and are messing around rather than doing what needs to be done right now, then that would absolutely be the right moment to raise a voice, be authoritative and get things done. That may be perceived as incivility by some in the healthcare team.

‘But the important thing is that if you do have to go to those lengths, you need to talk about it afterwards. People have to understand what was going on – and you should also remember that you might be wrong. You can’t leave people damaged by that – you need to have the conversation at an appropriate moment so that people understand the motivation behind it.’

Workshops explore how people speak to each other

Civility Saves Lives runs workshops called Calling it out with Compassion, exploring how people might speak to each other, peer-to-peer, to make clear that people have been left distressed by something.

‘The core conversation is in three parts,’ explains the project’s founder, emergency medicine consultant Chris Turner. ‘The sole purpose of the conversation is to land the idea that people were distressed. You’re not asking somebody to change, or do anything – you just want them to know, because most professionals do not want to cause people distress, so they will change themselves.’

‘You might find out that somebody shouldn’t really be at work’

The first part of the conversation involves asking people how they are. ‘That’s an opportunity to find out that somebody might be in a terrible situation at home, for example, or have sick children, or a marriage that’s under pressure. You might find out that somebody shouldn’t really be at work at that point, and they need to have a chat with their boss to let them know what’s going on.

‘You may never get any further than that, but you’re checking in with people. The second part is, “What happened out there?” Then you hear the perspective of the person you’re talking about what happened, because it is never the same as that of the person who was offended.

‘The third part, if they haven’t recognised what’s been happening at this point, is that you let them know that people felt uncomfortable with something they were involved in.

‘They apologise, and then they change their behaviour’

‘And that’s it – it sounds so innocuous, it really sounds like such a fluffy conversation, but by the end of it the idea is that you have delivered the message that people were uncomfortable or unhappy with whatever happened, and that builds on the understanding that behaviour matters in terms of team performance.’

It’s important to make the conversation caring rather than blaming, he says. The usual response is that people will ‘go and sort it out’. ‘They go into service restoration mode – they make sure people are okay, they apologise, and then they change their behaviour.’


Jennifer Trueland is a health journalist

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