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Being treated rudely at work can have a horrible impact on us. Unfortunately it’s an all too common experience if you work in healthcare. And the consequences can reach far beyond the individual – affecting teams and patient care.
In today’s episode Paula talks to Dr Chris Turner (Consultant in Emergency Medicine and co-founder of Civility Saves Lives) about his work understanding and tackling incivility in healthcare.
Civility Saves Lives website: www.civilitysaveslives.com
Learning from Excellence website: www.learningfromexcellence.com
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Transcript
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Paula Redmond: Hi, I’m Dr. Paula Redmond, a clinical psychologist, and you’re listening to the When Work Hurts Podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis facing health care professionals today and to provide hope for a way out through compassion, connection, and creativity. Join me as I talk to inspiring clinicians and thought leaders in healthcare about their unique insights and learn how we can support ourselves and each other when work hurts.
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Can you think of a time when someone was rude to you at work? I’m guessing you probably can, especially if you work in healthcare. These interactions can feel like a real punch in the guts and can stay with us long after the moment has passed. In this episode, I spoke with Dr. Chris Turner, who is a consultant in emergency medicine in Coventry and cofounder of Civility Saves Lives. He unpacks the far-reaching impact that rudeness at work can have and how to respond to it. I began by asking him about how he got into this work.
Chris Turner: I suppose there’s different strengths. Obviously, there’s being an emergency medicine consultant in a major trauma center and it’s a privilege all of its own. One of the things that fell out of that in the last, probably seven years or so has been this idea that behavior matters in the context of work. It doesn’t just matter on an individual level. It matters on a team level. It matters at an organizational level. It matters for patient safety.
It matters all over the place.
One of the starting places for me was, I don’t know, maybe you recognize this. When you go to work and you have an interaction with somebody and you feel like crap afterwards and you go, “Oh. Oh, that was awful.” Then you finally feel this weird internal shame and a bit angry at yourself because you haven’t dealt with it. Then you think to yourself, “You know what? Maybe I’m too soft to work around here. Maybe I’m not the right person for this kind of environment.”
What happened for me was that I was actually having a chat with a guy called Trevor Dale who runs a human factors organization, and Trev’s a pal of mine. We were talking about the work that was beginning to emerge that said that behavior mattered. I went and read the Christine Porath work on this. It was such a light bulb moment when I realized that those moments when I feel maybe I’m not tough enough, maybe I’m too soft, it’s not just me, it’s other people as well. This is the human condition. This is how we respond to those moments when people treat us in ways that feel disrespectful.
Realizing that opened doors to a whole world of thinking about this stuff differently because if it’s not just me, if it’s you as well, if it’s other people, then what impact is this having on our ability to do our thing, no matter what our thing is? It could be health care, but it could be outside health care as well. Then thinking more about teams and stuff like that.
At the same time, as I was reading about this stuff, I was still at that time doing investigations into critical incidents in the workplace. I had noticed how seduced we are by blame. How we find somebody who seems to have done the wrong thing. Then we basically stand around, point the finger sometimes with the arm that’s so rigid that the finger is shaking at the end of it. We say, “Hey, it’s their fault.” That feels quite nice. If it’s not you, on some levels. You feel like you’re absolved from it.
Then to realize that the behaviors of that person were sometimes driven through the interactions they were having with other folk was, it was a moment of unfolding complexity and my understanding of what was going wrong when things went wrong. That just started to snowball. I had a conversation with Joe Farmer. Joe had been my F1, not my F1, the F1 in the department. I owe nobody. He’d been the F1 in the department. He’d asked to come and see me a few months afterwards.
I have to say I felt a bit anxious because Joe is a fairly quiet guy and that he’d had asked to come and see me a few months afterwards, I was thinking, “Have I really offended you at some point, did I say or do something? The reason that you’re coming to speak to me is because you finally want to get this off your chest,” which is a slightly paranoid perspective to take on this. It does happen occasionally. People come see and I couldn’t really see the reason why Joe would want to come and see me anyway.
He came and saw me. We had a coffee and he said, actually what he was interested in was he wanted to do a project. He didn’t know what project he wanted to do. That he knew that I was interested in unusual aspects of work about how we treat each other. I was interested in what environment do we create for each other.
It just happened in that conversation, we started to have a discussion about something that had happened to him years previously when he’d been in theater. He had seen a doctor that he liked and respected, who was massively supportive to him, came in, who was the registrar, went to do an operation with the consultant present started off fairly confidently.
The consultant was not in a good place. The consultant surgeon kept poking and poking and poking verbally at this doctor. Eventually, the other doctor’s performance started to drop off. His registrar’s performance dropped off. As it dropped off, Joe became aware that the consultant was more and more hostile. Eventually, it got to the stage where the registrar was completely unable to do the job. This is a job that Joe knew that they could do. They were completely unable to do it and the consultant took over.
The thing that resonated was I had just read the evidence or some of the evidence on this about how when you’re put under lots of pressure, your brain closes down, and actually, your hand-eye coordination closes down, your decision-making drops off. We thought, “You know what? Maybe we could do a talk or two about this. Maybe people would be interested to understand the impact that this has on performance.” Joe’s in training to be a psychiatrist, so it fits in his world a little bit.
Then we had a chat about what we would do. I think branding and marketing have become important. Branding is important. If you want people to walk away and remember the thing, you have to give them a title. We sat and we talked about the title of Civility Saves Lives for a long time. We came up with Civility Saves Lives really early on and really early on– and we discarded it because at the time, we didn’t think that people would get what the word civility meant. In fact, for the first couple of years, we got a lot of people saying, “What is this word, civility?”
We ourselves were seduced by the negative messaging. You do see people using this. The classic is, “Don’t be a dick.” Yes, fine. When we went through, “Don’t be a–” You could basically name any primary or secondary sexual characteristic, and it so happens that you can be any– don’t be any of those things.
What happened was that gradually, we came to the conclusion that this wasn’t the approach. This negative approach wasn’t the right way to do it because A, people don’t come to work to be that person. A lot of people don’t believe they’re being that person, even in the moment when others might see them that way.
The second, probably more important thing was we were aware of and enjoying the Learning from Excellence movement, which comes out of Birmingham Children’s Hospital in Adrian and Emma Plunkett. Learning from Excellence is a prosocial movement. It says, “How are we going to learn from the good stuff? Not stop having the bad stuff, not stop doing the bad stuff. It’s what’s the good stuff? Let’s run with it.
Instead of don’t be a dick, we ended up with Back to Civility Saves Lives. That’s what we called it. Then we start doing a few talks, and Joe does talks. I do talks. A bunch of other people do talks. People now use Civility Saves Lives as a logo and a platform around the world. We don’t control it in any way. It’s all creative commons. People can use it in any way they like.
I’m really glad we chose to do it like that because I tell you what, trying to control this is basically it does its own thing. It’s organic, it spreads. If it resonates, people talk about it and they can use the logo, not use the logo. They can approach it from whatever way they like. The whole thing basically runs on trust and good intention. I know that every so often people will do it in a way that I would be uncomfortable with and I’ve just had to learn to live with that.
Paula: How do you define civility or incivility.
Chris: In the eyes of the beholder. [chuckles] This is something that’s really uncomfortable for people when they say I didn’t mean to be uncivil. I truly get that. I could say something to you just now which I would mean with warmth, possibly even what I thought was wit, and you might find that quite offensive. You might find it disrespectful that I said that to you. I just said the don’t be a dick thing. You might go, “Oh.” That might be an ouch moment for you.
There’s literally no intent to offend on my part when I say that. The problem with all this stuff is it’s not about my intent. It becomes about how things land. We see it happening time and time and time again that when something lands and people find it disrespectful, they tend to think the other person’s being deliberately disrespectful and that’s a big bear trap. That’s generally not what’s happening.
That’s the thing that has the impact on their ability to think. Whether you’re a witness, whether you’re the recipient. Actually, occasionally sometimes when you do it, what happens is that as the person who’s seeing it or hearing it, it’s having an impact on your cognitive ability, your hand-eye coordination, your desire to help other people. That’s problematic for the whole team if we’re relying on the team all performing at their best.
Paula: I can certainly resonate with that in terms of– I worked in mental health care for a long time and you deal with difficult stuff every day, but so often, the stuff that you’d bring home was the interactions when you felt that someone was rude to you. I was in a team where we had to move buildings and then sharing space with other people, really difficult and all of those kinds of tensions that would sometimes come out in rude behavior were the things that made going to work really hard, and as you say, take up a lot of headspace, a lot of cognitive labor to manage that.
Chris: Sometimes if I’m running workshops of people, at the beginning if we’ve got time, then we’ll start off with a good day-bad day of work. What makes a good day? What makes a bad day? It’s an exercise that lots of us have done many times.
It’s still frequently very useful though because once we start to look at what makes a good day at work, if you’re working in a system that works a little bit, and this changes when your system is broken, if you’re working in a system where you can process the thing that you do, whatever that is, then the thing that makes a good day at work tends to be about relationships. It tends to be about who we are to each other and how we felt, our emotions at the end of the day, for good or for bad.
This does change a tiny wee bit when you work in a system that is frankly screwed. In my world, in emergency medicine at the moment in the UK and actually around the world, there’s a huge problem with getting patients through our departments because hospitals are full. Where do the patients go once we’ve seen them? Well, sometimes nowhere.
In that setting, capacity causes people tremendous distress, but so do relationships, and relationships crumble in that setting and we treat each other less well partly because we make assumptions about other people’s intentions and the things that they’ve done. We don’t think that people are trying to help us and we get angry at each other and we judge. I suppose, I realize I’m drifting a wee bit from the start of this, but one of the big messages for me that I’ve learned over the years is if I can suspend judgment about the intention of other people, and I’ve got various ways to try and do that with myself, if I can suspend judgment about it, then I can ask questions to understand what’s going on in their world.
Actually, the world isn’t as negative as I think it is and people aren’t trying to screw me over and make my life harder. They’re just trying to do things from their own perspective in ways that make things better for them possibly without recognizing the impact it has on my world. An awful lot of this nowadays for me, if I get into these conversations and I feel that somebody’s being offensive to me. I’ve trained myself and been trained by others to pull my lens back a bit and go, “What do I really know? What do I absolutely know about this? How much of this is me superimposing assumptions and judgment on people. Can I think of the question that’s going to unlock the conversation so that I understand this situation better?”
Paula: I guess there’s something there about being able to depersonalize the situation so that you’re feeling less offended or it feels less personal. Is there a danger of that becoming overly permissive if we’re very understanding of why someone might behave in this way? How do we tackle it then it gets a bit slippery?
Chris: That’s a brilliant question. The risk of being overly permissive and the risk of then being hacked off at yourself for letting things happen around you. I think we drift quickly into the relationships that we have with people that allows us to let them know that things are not okay. For me, the way that this runs in my head and actually the way we teach people to do it is if somebody says or does something that you find offensive, that you find wrong, then part of the deal is to find a way to let them know that.
Once they know that, and in a nonjudgmental way, so you’re saying how you feel rather than how you’re very familiar with this, but it’s how I feel rather than what you did to me rather than ascribing intent to somebody else, then you’ve let them know, you set your stall. If they then continue to do that thing, then that’s a conscious choice on their part to either keep doing it or to not respect you. That changes the dynamic of that. Can I just run with that for a second or two? Is that okay?
Paula: Yes.
Chris: When Priti Patel got done for having bullying behavior, not being a bully, having bullying behavior, when she got into trouble for that, a number of times people asked me about it afterwards when we were in the Q&A session of things, and they’re saying, “But Priti Patel, shouldn’t she just be punished for that?” My take on that’s a wee bit different. I think that Priti Patel, if she was behaving in a way that other people felt was bullying, then the organization, not necessarily the people who were bullied, but the organization had a duty to let her know that that was how that was being perceived.
Once she knew that that was how it was being perceived and she continued to behave in that way, a way that was regarded as being bullying, then I think there’s a space there for punitive measures eventually. Much more into restoration than retribution, but I think there becomes a space for punitive measures. The idea that other people just know how they’re coming across is deeply attractive and completely wrong an awful lot of the time.
One of the nice things about me being able to talk about this is I’m a member of the Labor Party. I’m not coming at this from a political perspective where I have a desire to protect and support somebody from another political party, but I do have a desire to understand. I have a desire to give everybody the chance to be the best versions of themselves. We don’t do that by trapping people in their worst behaviors and defining them through that and not allowing them to reflect and to make amends and to behave differently.
Paula: I guess what comes to my mind in relation to that is something about power though, that to go to someone and say, “You’ve offended me.” if there’s a strong dynamic there, if they have more power is really hard.
Chris: Damn right. I think we screw this up. I think we screw this up on a global corporate level and I don’t think it really matters what organization you deal with. I think people in positions of power do not recognize the position of power that they’re in a lot of the time. I think there are a lot of permissive leadership behaviors where people behave certain ways and they believe in their heart that, “Hey my door is always open. Anybody can come and talk to me.” What they don’t recognize, and I speak to chief execs about this, they say, “My door is always open.” Say your door is open, but that is a cliff face to cross the threshold. There’s nothing easy in that.
One of the things that we do when we’re dealing with people and say, “Hey, you’ve got to call out this stuff”, is we put the responsibility onto the person who feels offended to tell the other person. There’s a whole world of issues within that. One of them is that, we know from work done by people like Kruger and Epley in 2005, we know that when somebody talks to us and treats us in a certain way, no matter the way, we believe that we understand 90% of the intent of that. We absolutely think that we get it. That’s whether it’s by email or whether it’s face-to-face.
Actually, the numbers for this when it’s face-to-face, it’s about 78%. When it’s by email, it’s 56%. Actually, we’re having these interactions with people, probably we are convinced we know the intent of the other person and yet we’re wrong. We’re wrong an awful, awful, awful, lot of the time.
If it becomes my responsibility to talk– Paula I’m going to make you into the bully. Paula Redmond, the bully. Paula’s treated Chris like crap. Paula is the boss and she struts her stuff and we have an interaction. Paula thinks this is a normal interaction. I on the other side, I’m devastated. Chris has been crushed. “You are the worst podcast guest ever Chris. We’re not going to publish this, because honest to God, what a load of crap.” You think you’re delivering a piece of information to me with your own form of candor. You think in your head, “This is the kindness, let him know this.” I am devastated.
You walk away from that conversation, and a lot of the time you will feel fine about that because you think what you did was– you might even think that was compassionate and I am destroyed. I then go to somebody else. Charlotte’s the producer and I go to her. She’s in HR and she says, “All right Chris, we have the stuff for you. We are going to put you on our crucial conversation course. In fact, did you know what? We’ve got an advanced one called difficult conversations and we have a special module. We call it Speaking Truth to Power.”
That is just slightly corrupt to work on speaking truth to power clearly but this is what organizations do. They put the responsibility back onto the shoulders of the supposed victim. At the end of this, it becomes my responsibility to come and talk to you to tell you that what you said made me feel like crap. The problem within this is I still believe you deliberately treated me like crap. I have 90% certainty around this.
Effectively, I’m being asked to go and speak to my aggressor who I assume deliberately was aggressive towards me. I am saying, “Hey Paula, you know how you hurt me? You know you tried to hurt me? Well, it worked.” What am I doing there apart from empowering the person who tried to hurt me? Unsurprisingly, people don’t do it. In fact, they then feel guilt about not doing it because they think, “Am I so weak I can’t go and have this conversation?” No, you’re normal. You’re normal and we don’t take ourselves into that arena very easily.
Where the evidence sits around this for me is a fascinating place and this guy called Jerry Hickson in Nashville, Vanderbilt Uni. Jerry Hickson’s a pediatrician. In the days before we used Zoom and Teams and all the rest of it, which was a mere three and a half, four years ago, I went to Nashville to see Jerry Hickson for an hour because his work is mind-blowing. What Jerry Hickson said, and he is just the loveliest man. You meet people and you go, “Oh, will you just like be a kind of you just be a kind of surrogate dad for me or something?”
I went to see Jerry Hickson and what he’s done is introduced this system where Paula and Chris have a negative interaction. I perceive it as negative interaction, usually down a hierarchy. It’s not my responsibility to come and tell you, because when I do come and tell you I either deliver it poorly or I don’t come and they use a second messenger. This second messenger is a person who’s trained to listen to my perspective and then they will come and speak to you, Paula.
When they come and speak to you, they aren’t going to bring the emotion that I’ve brought to the table. They’re coming to speak to you and they have two purposes when they come and speak to you. The first one is to care about you in the conversation. That’s counterintuitive, but they’re going to care about you because pretty much nobody wants to cause other people offense.
The second bit is that they’re going to land a piece of information with you almost always. The piece of information is that, “After you and Chris had the conversation the other day, Chris was really upset. I know you’d want to know.” That’s it. There’s no, “And what you’re going to do about it?” There’s no, “You’re a bad person.” There’s no judgment in there. It is deliberately just a piece of information transfer. Then it’s your choice what you do with that.
When I went to see Jerry, and we talked about it at that time, they’d been running this in 150 to 200 hospitals across America for about 10 to 15 years, but with various ones coming on along the time. They had had 37,000 what they call “Cup of Coffee conversations”. Only 2,000 people repeat offended. They had a second cup of coffee conversation at that point. Again, this is all peer-peer. This is not authority interventions at this point.
A second cup of coffee conversation, they were down to 267. That is the first level at which the boss got involved about this stuff. These were all doctors. If I’m honest, people might trust doctors, but they frequently also think that doctors are arrogant. Depending on which system you work in and which specialty people do that varies, but Jerry Hickson’s work was completely mind-blowing from my perspective.
It’s this idea that you put the responsibility onto somebody’s shoulders to do that probably doesn’t work for a lot of us, but getting a second messenger who’s not in it for the fight, who’s in it with respect, who’s in it to support, seems to completely change the dynamic of how we do this. We’ve been talking with people about that around the country for the last few years.
There are organizations– Rabia Imtiaz in Kettering, she runs this system at a board level. She’s their medical director, and they have a system that they run at their board level so that people hear about things and aren’t blundering through life making the same mistake over and over and over again without anybody ever telling them.
Paula: Wow, I know that in my experience it’s felt like the options are to confront the person or a formal complaint. That whole procedure is equally if not more traumatizing, than those original difficult interactions for everybody.
Chris: Yes. The formal complaint route is absolutely well-meaning and an absolute disaster. Christine Porath, again, weirdly looks at this stuff too. 85% of people when they go through the formal complaint route, whether they are the complainant or the supposed perpetrator, 85% of people come out of that process feeling unsatisfied with what just happened. That’s a pretty horrible space to be occupying.
I’m going to talk about something that’s a wee bit current. I know people might watch this or listen to this a long time in the future, but at the moment there’s the Wagatha Christie footballer’s wives thing going on in the UK. I watch this unfolding with ever greater horror at the impact that this is having on every single actor. It doesn’t matter whether it’s one side or the other side. This is turning into, “He said, she said” It’s an horrific mess that I do not see people coming out of. I don’t see anybody coming out of this. Somebody will probably win, I guess, but I don’t see anybody coming out with more value in their life. I see everybody as being diminished by the process that these guys are going through.
I think that when people go through adversarial HR processes, that people tend to get diminished and they tend to drag on and on and on with terrible consequences for the people who are involved in it. Particularly the guys who get sent off on gardening leave.
We have this thing in the NHS, and I might be about to trample all over some kind of employment law, but I’m going to say it anyway. We have this thing in the NHS. When somebody gets sent off on gardening leave, you get told to not contact them. Nobody must have any contact with this person. I got to say, in the best Civility Saves Lives words, bollocks to that.
If you are a human being who’s defined by their jobs and lots of us are, and then you get told that you can’t go and do that job. That you’re sitting at home and your colleagues who care about you are being told that they cannot contact you. That’s a lot of rubbish. Everybody in that situation deserves somebody to reach out and look after them. Anytime I’ve ever been aware of it happening within my work and you’re not always aware. Anytime I’ve been aware of it, I’m straight on the blower.
Check in with them, let them know that people are thinking about them. Even if they’re thought to have done something bad, you still check in with them because being isolated in these situations must be its own little form of personal hell and a punishment before anyone’s decided if something’s actually really happened. I think the way that we deal with this is counterproductive and unhelpful an awful lot of the time, but it is what it is.
Paula: It feels to me like another example of how the system dehumanizes people– Just as you were saying, how all this splitting happens and it becomes very difficult to see people as humans with all of their needs and complexities. People are really, as you said, diminished. It’s so difficult just to have– I think you said the word restorative. Restorative, reparative processes around the fact that someone’s being hurt, but the answer isn’t to go on a witch hunt in order to sort that out. There are other–
Chris: It’s easier, isn’t it? We quite like the witch hunt. It’s quite nice when someone’s a bad object and we get rid of them and then we decide that, “Hey, well, that’s a problem solved.”
Paula: I think what it leaves is an anxiety that you could be next.
Chris: Yes. It’s undermining psychological safety.
Paula: It actually doesn’t make people feel safe to have these?
Chris: No, but in the moment, there’s a sense of relief that it’s dealt with it if we can pretend it’s somebody else. One of the things I remember growing up, I never really twigged it, but it’s the whole thing of there but for the grace of God. I think as a junior doctor, I became quite aware of it when I was around folk and something went horribly wrong. I knew it could go horribly wrong for me as well.
We were all in this frightening place together. I think there was a lot of sympathy for each other. Particularly, I graduated at a time when we got paid more, but we did stupid hours. I would do nine o’clock on Friday morning and– no midday on Friday, but I would finish at eight or nine o’clock on Monday morning that whole period of time. I’m not a particularly aggressive individual, I’m not particularly shouty, but I tell you what? You get me on Sunday evening when I’ve been awake for the previous I don’t– 36, 48 hours, or whatever, I hear a trigger by that point.
Also, my decision-making was rubbish. We know that decision-making is crap through just sleep deprivation on its own. Being awake all night’s about equivalent being about twice over the drink-drive limit. Faster, riskier decisions. It’s a crazy place to be and yet we created a system that did that in the name of– Well, in the name of service I suspect, but we wrapped it up and pretended it was about education and other aspects.
Paula: I guess that speaks to why incivility, rudeness is so pervasive in the NHS. Would you agree that it is? I feel like it’s something that everybody can relate to and think of lots of examples.
Chris: I think it’s pervasive in healthcare. Lucy and Lipp said as much, Gary Kaplan said as much. These are people who have looked to this long term and say, “It is normalized in healthcare for people to treat each other in ways which sometimes feel disrespectful.” I don’t think it’s deliberately happening. I think what happens is we try and squeeze more and more and more production out of people.
We do it at the expense sometimes of our humanity. We do it at the expense of having enough bandwidth to actually think about the other human beings in the system, the other people who are trying to deliver care. Instead, we try to keep an eye on our patients, we try to be kind and try to be compassionate to our patients. We know that we don’t manage that all the time as well, but sometimes it feels as though the people around us aren’t as deserving of that kindness, compassion.
It is probably served a little bit by the education that we receive, which– I’m going to be a little bit challenging around medical education specifically here. The education that I’ve received was all about personal mastery. It’s all about, “How good are you, Chris?” Every exam I ever did was, went in, and sat down, there was questions, there was one right answer, a myriad of wrong answers. It was all about me having information in my head that I could regurgitate.
For me, it became this situation where I felt I needed to know the answer to everything, I needed to be in charge of every situation. What that meant was the people around me were my troops. For me to command, for me to tell what to do, and they just had to do what they were told. I think that command and control way of behaving is prevalent through loads of the NHS. Where it falls down is pretty much everywhere.
There are very few situations where command and control is really effective. That includes running trauma teams running cardiac arrest, which I do as one of the core things in my job. People think that trauma teams in cardiac arrests are all commander control. I stand there and it’s, “Boom, boom, boom.” If you actually look at what happens in these situations, the good ones, there’s a lot of command and control at the front end of it as people settle into roles and then it opens out.
It opens out and there’s a dialogue. There’s information sharing that goes on. There’s people sharing that information so that the person who is leading it is getting as many perspectives as possible, and then they’re able to make the best decisions that they can with the group. When we fall into this idea that we have to know the answer to everything, it’s really quite damaging.
It’s damaging to us because we don’t know the answer to everything. Nobody does. At the far end of it, it’s damaging to the sorts of decisions that we make for patients and the way that we treat other members of staff because what happens is that we don’t get the benefit of what they know. We know that if you treat people in a way that feels disrespectful to them– Which is why they need to be able to tell you if something does feel disrespectful. If you treat them in a way that feels disrespectful to them in the moment you get a 61% reduction. This is the errors in Paroth work. You get 61% reduction in cognitive ability in the moment. That is a tail that lasts for varying lengths of time.
Two things are happening when somebody feels offended. The first is that they can’t think so well, but the second thing’s equally important and equally negative. That is that, in good teams, the single most important factor determining the quality of decision you make is information sharing.
40% to 60% of the amount of information that we share within teams is directly a consequence of how we treat each other, civility or incivility. When we treat each other well, people share more information. When we treat each other poorly, they don’t share information. I tend to think of it as the model that Joanne Gurry, a professor of linguistics in Warwick. I have been working on this pool of information and it goes like this.
If you come up to a problem, Paula. It’s a complicated or complex problem. This is not a, there’s one right answer problem, this is multiple perspectives. You come up to it and the pool is like a swimming pool and it’s empty. A little swimming pool. Not a massive one, not an Olympic one. You walk up to it, it’s empty. As you walk up to it, you bring with you your knowledge and it fills up the bottom of the pool. There’s a little bit of water sloshing about in there. That’s what you know.
Now, you can make your decision based on that or you can get other people to contribute. You can have the people standing all around it. Now, sometimes you don’t get a choice of who you get it. My trauma teams, my cardiac arrest teams, I don’t get a choice who’s there. I get who I get. All these people are standing around and every one of them has the potential to add to the pool of information, but they will only add to the pool of information– They all have their own taps. They will only turn that tap on if they feel valued and respected in that group.
If I treat people poorly, what happens is, firstly, they don’t think so well. Their bandwidth is squeezed out. The second thing is they turn off their tap. I don’t get their information. Even if I could get them to turn their tap on, the quality of information I get is not so good. That model is one that we take to people, take to leaders when we’re talking about, “How are we going to get the best information in a given situation.”
When I’m talking about in trauma teams and cardiac arrest teams, of course, you don’t get choice of who’s around them. If you are thinking about something within your organization within your department, then you have a choice as a leader about who you get to stand around this pool. You can get a whole bunch of people look, sound, think, just like have the same values as you, but what you’ll get there is the same information over, and over, and over. You get to saturation very quickly.
Or you can choose a different group of people to stand around who represent different values, different sex, sexuality, race, religion, color, the rest of it. Then you might get a whole bunch of different perspectives on it. Now, that’s clearly an equality and diversity agenda, but I would argue that at this stage it’s not inclusivity. Because every single one of those people around this pool has their own tap, and they will choose to turn it on based on whether or not they feel valued and respected in that group.
Our job as leaders and as team members is to provide environments where other people feel able to contribute, where they feel valued when they do that. The things that turn that off, the things that cause people to turn their taps off are sometimes so shockingly small. The eye roll, eye rolls are stunningly powerful. If you’re in a group, and you start to talk about something and somebody eye rolls, particularly the boss, that’s a massive signal to the team.
What happens is, the person who notices it tends to shut up, and nobody else brings up that topic, because there’s a very clear signal that that’s not acceptable. It’s a relatively small microaggression, isn’t it? I mean it’s hard to even know if it was intended to be offensive, which is one of the things and in civility, is that the intent, although it feels intentional to the recipient, the intent isn’t necessarily there on the part of the person who’s doing it.
Other things that people can do is they can correct your English halfway through a sentence. They can finish your sentence off for you. Both of those things. If you’re correcting somebody’s English halfway through a sentence, you’re not listening to their message. You’re probably listening to their syntax, to their grammar.
If you’re finishing a sentence off for somebody else, you’re saying, “I know what you’re about to say.” No, you don’t. How could you know? You might be right, but you don’t know for sure. It’s an arrogance to do that. People do it because they want to get to the conversation quicker, but, actually, it’s not helpful, and it shuts the team up. Beginning to understand this stuff is quite powerful for a lot of leaders, because they can stop and reflect on their own style.
Paula: Just thinking about some of the things that happen, particularly when we’re working online, people clearly doing some other work over here when you’re talking or clearly doing something else.
Chris: Yes, clearly doing something else.
Paula: [laughs] On their phones. That’s also really shuts it down.
Chris: The other thing about the problem on doing things over the internet, and, actually I just did it right there, is that the natural pause at the end of somebody speaking, you think the natural pause is there, then you jump into speaking. You discover they weren’t finished. That was just a little bit of what they wanted to say, and they’d had this micro pause before the next thing comes along. That can feel like you’ve been a bit closed down. The intention there is, there’s frequently no intention on you.
Sometimes when you get that thing where some of the platforms compress things, and then a few moments later, their face seems to speed up. In other words, come really quickly for few second, and then it slows down again, and you start talking over something. Then, you look complete monkey. You’re like, “What have I done? I can’t believe I’ve done this to somebody. I’ve spoken all over the top of them.” Particularly if there’s somebody that you want to impress, or somebody just that you respect and you’ve sounded like, “Hey, listen to me. It’s all about me.”
Paula: Chris, lots to digest there. I’m wondering if we could distill that into some helpful things that people listening could take away. For example, if you someone who’s working in environment and facing rudeness at work and it’s really affecting you, what advice would you give to someone who’s at the receiving end?
Chris: Yes. The practicalities of what people can, actually, during this are fascinating. For a while I got really bogged down in the idea of what can we do to the individual who won’t change. Actually, I think that’s the wrong place to start to look at this, because there’s some really great work by people like Anna Baverstock in Somerset. Anna is a community pediatrician.
Anna did some work with Caroline Lacey and Caroline Walker, where what they did was basically raise awareness of the impact of incivility on performance. That’s it? There’s a wee bit about how you might start to tackle it, but it was only a one-hour intervention. What they found was that when they started to do this project and they did it in maternity, when they started to do this project about 60% of people believed that behavior mattered in terms of performance in the organization.
By the time they had finished it, they were at 100% within the maternity part of the organization. Now, when they started about 70% of people said they’d seen uncivil behavior in the previous few weeks. By the time they got to the end of the project, that was down to 50%. What this says to me is that there are a bunch of us out there who are emotionally intelligent enough to get how we’re behaving might have this impact on other people and then to moderate it, to choose to behave in a different way in that setting.
I think that has to be the starting place. At least, for me, it has to be a starting place. Other people I know are seduced by the starting place being the big stick, to beat anybody up who behaves in an uncivil fashion. As we’ve already said, I think a lot of people are behaving in uncivil fashions and not recognizing, A, that they’re doing it or, B, that it has a negative impact on the people around them.
Let’s start off with a wee bit of education. Let’s start off by letting people know about this. Then beyond that there’s work towards helping people to understand what is perceived as uncivil within their organizations, within their groups. What are the social norms in their groups, and then allowing people to challenge the norms, because your norm may well not be a good norm. Then, beyond that it’s about putting in place a process that we can respectfully let people know the impact on somebody else of an interaction they were involved in.
I know that the language there is very slightly clunky, but it’s not about saying they made somebody else feel something. It’s just saying there was an interaction at the end of it. This other person felt lousy. Then looking to embed ways of having those conversations within organizations.
Twice people have come and spoken to me about stuff, where I have caused significant offense to other people. On both occasions I had literally no idea. On one occasion, I’d asked a really simple question. My question, literally, was about time. Instead what they heard was me saying “they’re useless at their job, and I don’t respect them”. I genuinely asked a question, the answer to which I expected to be 2:00 AM or 3:00 AM. People hear a different intent behind your question.
On the other occasion, I had an emergency medicine, a very touchy specialty. I’m not somebody likes hugs and stuff like that, but I’ve got a General Belgrano exclusion zone around me given half a chance. I’m very traditional Scottish male, do not touch me. I play music and musicians hug each other left, right and center. I’m like, “I’m deeply uncomfortable with this.” I’ve had to get used to it, but if this was on video, you’d see my face pulling itself into contortion of horror.
Anyway, I had to get used to it, but emergency medicine, we’re all squashed together. I once counted 40 people in a 16 square meter radius in our department. That was in COVID. Holy crap, social distancing. Anyway, the thing that happened was miles before COVID, and a colleague was really upset. I could tell that she was really upset. I did give her a hug, but I gave her the sideways hug that I give to my niece who doesn’t like hugs.
Stood alongside her, shoulder-to-shoulder, not front-to-front, shoulder-shoulder. I put my arm across her other shoulder, gave her this tiny waist squeeze, I said, “It’ll be okay. I hope it’ll be okay.” Then discovered sometime later because somebody came and told me that she was really hurt by that, that she’s somebody who hates people being in her zone. As soon as I knew that, I did what people do. I went, I found her I said, “Sorry, there was no intention of that.” She felt that I had to come into her body space and that I wasn’t invited to be there. I totally understand that, totally respect it. My intention was completely pure in what I did, but her perception was different. My responsibility in that setting is not to prove that I had pure intention. My responsibility is to recognize how it had affected her and to let her know that I wouldn’t do it again. I only wanted, at that moment in time, I was just wanting to be her friend and to let her know that she wasn’t alone. These things happen in her lives.
Paula: Chris, in that situation, someone else gave you that message that she wasn’t able to come directly to you. I guess, that’s I think I’m taking away from this conversation about the role that, you called it a “second messenger” can play in this, and that can so helpfully facilitate that process. Particularly when there is a power issue there where people are feeling really scared or upset about things. I’m feeling like as you described that that’s a role that needs some training and support in order to have those conversations.
Chris: We give people training and support to do it. We do it a wee bit differently to how the guys in Nashville would do it. The training and support that we give to people to do it takes about an hour, and for a variety of reasons, one of which is that the people who are selected to do this, we have a system that allows folk in departments to choose who the right people to have these kind of conversations are. Which means that we’re already pre-selecting people who are perceived as being empathic generally.
We teach them how to have the conversation in a three-part fashion. We don’t expect them to always do like this, but this is how I try to do it and it’s the three parts. The two overarching things are what we said earlier. You’re going to care for the person you’re talking to in the moment and you’re going to try and deliver a piece of information. The three-part conversation goes, one, the check in, “How are you?” “No. Really how are you?” and the pause, and the waiting to hear what comes back.
Now, mostly people are fine. Sometimes they’re a bit hacked off with stuff and that’s, actually, what’s happened, is that they’re hacked off with a whole bunch of other stuff and being short with focus or consequence of it. Occasionally you get told really quite devastating things that are going on in someone’s life. Very, very occasionally, you listen to this and you think, “This isn’t somebody who should really be at work right now.”
Now, when we teach people how to do this there is no therapeutic role for the person who’s doing it. That’s not appropriate, but we teach signposting. If some somebody is in a situation, for whatever reason, where they’re utterly utterly overwhelmed, then we will signpost them in the direction of their line manager, occupational health, GP, whatever, there a whole bunch of other things that are right there, but most people are okay.
The second bit and the second bit is about this specific instance. “Hey, Paula. What happened in the department yesterday?” You might think your day was fine. Most people do. When people came to me about this I thought everything was fine. I didn’t know something had happened, but sometimes you’ll know. You say, “He had a conversation with Charlotte.” In the conversation, I made this joke and I realized afterwards that this could have sounded racist, but the thing it’s okay because nobody heard.
It wasn’t meant to be racist but I don’t think anybody heard. Then I can say, “Well, actually, Charlotte heard and so did Tom and they were a bit taken aback.” What people tend to do at that moment in time is move into what’s called Service Restoration Mode. Service restoration mode is where they go, “Okay, that’s not good.” They might say thanks then they say, “I need to go and speak to those guys,” because nobody wants to be that person. Very few people want to be that person.
Then they go off to try to make retributions. Or you have the conversation and they have no idea what went wrong yesterday at work, which is what happened to me on both occasions when people came and spoke to me. The final bit is, the delivery of a piece of information. It goes like this. It goes, “Paula, after you and Charlotte spoke yesterday, she was really upset. I know you’d like to know, I know you’d want to know,” and that’s it.
It’s, as I said earlier, without judgment. It is the delivery of a piece of information that doesn’t say that you are nasty to Charlotte. It doesn’t say that you’re a nasty person. Doesn’t say that you’re unprofessional. It doesn’t say any of those things. It says you had an interaction, somebody else felt lousy afterwards. Then it becomes yours to deal with. What we know and we cannot tell how many people do this, but what we know is a lot of people at that point will seek out the person that they’ve had the conversation with, and they will go and talk to them about it.
We know that some people don’t, but most of them still take it on board and don’t do the same thing again. Not everybody’s got the emotional intelligence to be able to go and have those conversations, and to be vulnerable, and to admit that or to go and empathize with somebody else feeling lousy in that moment, but we know that that information drives behavioral change.
If you think about the people who do healthcare and you think about those the sorts of people who are quite mechanistic and transactional and how they see the world, it isn’t surprising that a lot of those people perhaps might not see the emotional side of this so obviously. We all need help to see the emotional side of stuff.
I had a lovely conversation with guy called Nigel Acheson the CQC. He was talking about CQC inspections. CQC inspections caused a world of distressed organizations. He was saying, “We don’t expect organizations to be perfect, but we love it when they are sensing. When they’re trying to reflect on themselves, when they’re trying to know where they’re coming from, trying to see how they are seen by other people within the organization.”
I thought that was a really powerful message, and I also thought it would be a bloody powerful message if the CQC were to let people know that they wanted organizations to be sensing rather than being perfect, and to be able to show to show protocols for everything under the sun, because protocols simply don’t work for many situations. That’s a whole other conversation.
Paula: It’s making me think about compassion really. We had Chris Irons on the podcast a little while ago, and he was talking about the definition of compassion being a sensitivity to the suffering of self and others, and a commitment to alleviating that. The first part of that is being able to notice what’s going on. When we are full up and lots of stress, we can’t notice what’s going on for other people and even what’s going on for ourselves. That sounds like a really nice compassionate intervention there, bringing those two parts together.
Chris: Yes, and I think so many people are currently running. They’re either running on empty or running on fuel depending on how you look at it. I met a friend last night. I haven’t seen him for a little while, asked him how he’s doing. He said, “Okay.” He said, “Actually, not so okay. Been off work for the last four weeks. I’m off for another four weeks. I’m completely burned out, and I see this happening around me all the time.”
One of the problems with this is that, as people get burned out and they then have to have some time off, if the system works, they have to have some time off. That then loads more responsibility onto everybody else within the system, and there’s a domino effect that happens. I think it’s really useful to be able to notice that there are people who are bellwethers within groups.
There are people once they start to have a little wobble, that just means that that wobble’s coming to other people within the group eventually, and we need to reflect on that. The whole role of compassion within organizations is fascinating. I heard a reference the other day to somebody who was talking about compassionate ruthlessness, and it filled me with fear. It felt to my mind when I was hearing about it, it felt like a corruption of intention, an excuse for ruthlessness. Yet at the same time I understand within systems, sometimes there are things that need to happen, but the absence of ruthlessness is not something that I think is particularly a good thing in most people’s lives. To wrap up as compassionate ruthlessness, it sounds like quite a damaging perspective to take.
Paula: Probably, I would say, a fundamental misconstruing- [crosstalk]
Chris: Yes, an oxymoron. Isn’t it?
Paula: -compassion is, isn’t it?
Chris: Yes.
Paula: Within the Compassion-focused Therapy Literature, they talk about the qualities of compassion being warmth, wisdom, strength and courage. Really, you don’t need
ruthlessness in order to be effective.
Chris: Yet, we ask the impossible of people on such regular basis. If I’m thinking, I think about how people who lead up departments regularly get asked to produce more
with less. That probably had some validity when there was a lot of low-hanging fruit and people could make things better quickly. We had 11 years of austerity, arguably, we’re still in austerity, and most of the low-hanging fruit’s gone.
I look around and I look at where people are being asked to make savings. There’s just a massive risk when we work in systems that use proxy indicators of quality, like, for example, finance and then they expect people to deliver that, and they are measured on that. I worked in mid staffs, and in mid staff’s the exec team was measured on finance, and pretty much nothing else.
The exec team, this was an existential crisis for them. The exec team in Stock, next hospital up the road, the exec team in Stock failed their financial stress test and got sacked on mass. For the exec team in Stafford, the failing of financial stress tests literally ran the risk of them losing their jobs, and they’re like us. They’ve got houses, homes, cars, families, the rest of all, the rest of it. That was the environment that those guys were working in. They drove their decision making through finance.
If you look at Shrewsbury and Telford just now, and I do a bit of work with the guys in Shrewsbury Telford, and they’re good people. They were measured within maternity, they were largely measured on C-section rates, and they were lauded for their very low C-section rates. We see this happening time and time again where people have proxy indicators for performance within complex systems, and then they get squeezed, and squeeze, and squeeze.
The people who are being measured by that, they’re not allowed to think broader. They’re really not even allowed to be that compassionate a lot of the time. They are just measured on that one thing, and they’re hung, they’re drawn, they’re quartered on their performance around that particular thing. It’s a really messed up way of trying to understand complex systems, but it’s seductive to politicians who want to be able to understand healthcare.
For most of us who’ve worked in healthcare for a long time, and I’ve been in healthcare, I’ve been qualified as a doctor for more than 30 years. I don’t understand it and I don’t know anybody I think really does. We’re all using heuristics to understand other people’s worlds. For me the problem with that is we really don’t and the best way to understand it’s by asking and telling, by having environments where people feel able to talk and to contribute.
All of those conversations are underpinned by how we treat each other and that’s civility. When we treat each other in a civil fashion, we have a chance of getting information. If we treat people in an uncivil fashion, they just turn off the tap. We’re not going to get that information from them.
Somebody once said to me that the civility work– It really stung. They said, “Chris, come on. This is a bit basic. Isn’t it? Internally I was raging and I couldn’t think, which is quite interesting. One of those things when you start to go bit of the rage going on in your head, then you can’t think, and you’re not the smart version of yourself that you want to be, but I went away and I mauled it over. Well, simultaneously, still being a bit stung on a regular basis.
Then I realized that I kind of agreed with them, except for the word was wrong. It’s not that the civility stuff is basic, that it is fundamental. You cannot build these good relationships where we share information if it’s a psychologically unsafe environment where people are too strung out to treat each other well.
There’s a responsibility to create the right environment, but also to provide people with a working environment, where they as individuals are not overloaded. That they can also contribute to this positive environment where, or if not a positive environment, an environment where we can talk to each other, hear each other, give each other space and explore ideas, because without that, we starve ourselves with the oxygen of information, which leads to poor decision making.
Paula: Thank you for listening. If you enjoyed this episode and you’d like to help support the podcast, please do share it with others, post about it on social media, or leave a rating and review. I’d love to connect with you, so do come and find me on LinkedIn or Twitter. You can also sign up to my mailing list to keep up-to-date with future episodes and get useful psychology advice and tips straight to your inbox. All the links are in the show notes. Thanks again, and until next time, take good care.
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