How many times do you hear that colleagues have upset each other by being rude? The NHS Patient Safety Strategy for England (NHS England and NHS Improvement, 2019) has a significant thread highlighting safety culture woven throughout:
‘The mistaken belief persists that patient safety is about individual effort.’
The strategy document claims that getting this right could save almost 1000 extra lives each year. In it, Dr Sonya Wallbank described some of the features of a safety culture, including psychological safety for staff; this includes a need to feel supported within a compassionate and inclusive environment operating at the level of the group, not the individual. Also of importance is that each individual knows that they will be treated fairly and compassionately by the group if things go wrong, or they speak up to stop problems occurring. Psychological safety is also described as meaning that staff do not feel the need to behave defensively to protect themselves, which instead opens the space in which they can learn.
In the same document, Dr Suzette Woodward described the importance of individual behaviours of kindness and civility in supporting patient safety. At its core, she argued, a positive culture requires kindness and civility. ‘Civility is seen as nice, tame and safe, but when it is missing, we start to see its importance,’ she argued (NHS England and NHS Improvement, 2019: 10).
West (2019) explored the difference between a team and a ‘pseudo team’ and concluded that real teams who work together have a shared understanding of what they are trying to deliver together. They share objectives, communicate and work closely. A team also meets regularly and reviews their performance. Real teams flourish, perform well and are more innovative. Conversely, pseudo teams do the opposite, leading to hostility and poor outcomes.
Turner (2019) talked about the impact of civility when patient safety issues occur. He argued that that ‘process’ happens on paper, and ‘practice’ happens between people—although process has its place, people are more important. He cited Riskin et al (2015) who published a study of 24 teams who participated in a training simulation. Teams were randomly exposed to rudeness or the control group of neutral comments. The outcomes were graded on a curve from ‘fantastic care’ to ‘catastrophic avoidable death’.There was one factor that was found to be responsible for 40-60% of that variance: incivility or rudeness. It looks like the single most important factor for competent teams to determine the outcome of the team is how we treat each other.
Porath and Pearson (2013) discussed the costs of incivility. They reflected that although many managers would say that incivility is wrong, not all recognise that it has tangible costs. Those on the receiving end of incivility, they argued, often punish the offenders and the organisation, ‘although most hide or bury their feelings and don't necessarily think of their actions as revenge’. They cited a poll of 800 managers and employees in 17 industries, the results showed the impact among workers who had been subject to incivility:
Incivility has been found to have an impact on team performance. Porath and Pearson (2013) argued that witnessing incivility, not just being the the recipient, has negative consequences. In one experiment of theirs, people who had observed poor behaviour performed 20% worse on word puzzles than others who had not. It was also found that witnesses to incivility were less likely than others to help out, even when the person they would be helping had no apparent connection to the uncivil person. Only a quarter of the subjects who had witnessed incivility volunteered to help, as opposed to half of those who had not witnessed.
The more I looked into this area, the more I wanted to understand and explore it—as did many of the individuals who have published on the subject. There is no doubt that civility can save lives and that putting the currency of patient safety firmly alongside championing this area is critical in setting the safety culture required of us now.