Civility Saves Lives

If you wanted to completely destroy any psychological safety in the group, what would you do? If you wanted to create a culture of fear, where nobody felt safe to speak up, suggest ideas, highlight concerns, or admit a mistake, how would you do that?

One very effective way to do that is simply being rude. Cut people off mid-sentence, walk away while they’re speaking, shout or snap at them, tell them their ideas or suggestions are stupid or that it isn’t their place to speak up.

Rudeness and incivility takes many forms, and it can be culturally or even situationally contextual as well. But it’s very rarely a good thing. Of course, psychological safety isn’t about being “nice”. But it does require a foundation of civility: if we’re rude, aggressive, or dismissive with our colleagues, it’s not going to foster an environment where we feel safe in taking interpersonal risks. 

The “Civility Saves Lives” Campaign

Healthcare is a high-stakes domain: someone staying silent about a concern or mistake can result in life-changing consequences or death, so the significance of a team culture that enables people to speak up without fear can’t really be overstated. The “Civility Saves Lives” campaign was started by Chris Turner and Joe Farmer in 2016. They met for a coffee and Chris had just read about Christine Porath’s research whilst Joe had just come from an on-call where he’d seen rudeness directly impact patient care. Between them, they felt they had to do something about it, and formed Civility Saves Lives. 

The King’s Fund Survey from 2012 highlighted numerous benefits when healthcare staff perceived themselves to be in a psychologically safe team:

• Reduced Hospital Standardised Mortality Rates
• Reduced patient complaints
• Improved staff satisfaction
• Improved staff performance
• Better reported health of staff

Incivility damages the interpersonal fabric of a team, and can comprise anything from shouting and aggressive speech or body language, to rolling eyes, tutting or even checking emails in a meeting. Importantly, incivility is determined by how behaviour is perceived by the recipient, not necessarily how it was intended. Impact matters more than intent.

Of course, sometimes we need to be abrupt, forceful, or shout. If there’s a fire in a building, the most important thing to do is to tell people what is happening, what to do, and when to do it – we’re not particularly concerned about whether people feel aggrieved, since feeling aggrieved is still better than being dead.

Being perfectly civil all the time can be very difficult, and maybe impossible – I’m sure all of us have been unintentionally uncivil to colleagues at times, but the most important thing is that we create an environment where people can give us feedback, and we can apologise and improve as a result. We won’t get it right every time, but we can be open to learning and improving. 

The aforementioned research by Christine Porath has demonstrated some of the individual direct effects of incivility, including a 61% reduction in cognitive ability, plus: 

• 80% lose time worrying about the rudeness
• 78% reduced their commitment to work
• 63% lose time avoiding the offender
• 48% reduced their time at work
• 38% reduce the quality of their work
• 25% took it out on others, including customers
• 12% leave

We can see that the consequences of rudeness, even if unintentional, extend beyond the individual to the entire team: Performance drops, willingness to assist other people declines, and patient outcomes are negatively affected. Studies by Riskin et al, and Katz et al. demonstrate that rudeness can lead to significant increases in diagnostic and procedural errors, risking patient lives. In our work with healthcare teams, we all too often find incivility to be a significant factor in reducing psychological safety. For context,healthcare workers are frequently under pressure, physically and mentally tired, and often facing challenging, high-consequence situations – which can lead to unintentional incivility. Patients, of course, may also be rude, aggressive or challenging, especially if they are in pain or worried about their health or that of their family.

Being civil saves lives. Recognising and addressing incivility is not just about improving the atmosphere in the workplace so that it’s a nice place to be; it’s about safeguarding patients and enhancing the quality of care. This is how important psychological safety is in healthcare, just as in other domains such as aviation.

Links to Crew Resource Management

I think it’s worth noting the parallel here between this campaign and Crew Resource Management (CRM) in aviation. Both domains recognise the critical role of communication, psychological safety, and team dynamics in preventing disasters and ensuring good outcomes for people in our care.

CRM in aviation emerged from an understanding that the majority of aviation accidents were not due to technical failures, but rather failures in communication, decision-making, and teamwork. Flight crews, cabin crew, ground operations, and air traffic controllers regularly attend CRM training to help create positive interpersonal environments. CRM training involves many aspects including effective communication, leadership, situation awareness, and decision-making skills.

The core essence of CRM — ensuring that all team members feel comfortable speaking up and that their concerns are respected and addressed even in the face of a steep power gradient — mirrors the goals of the “Civility Saves Lives” campaign. In healthcare, like aviation, a lack of psychological safety can have dire consequences. When team members feel undervalued, disrespected, or intimidated, they are less likely to speak up about potential issues or contribute effectively to team decision-making processes. This silence can lead to errors, misdiagnoses, and ultimately, harm to patients.

Similarly, the campaign’s focus on reducing incivility aligns with CRM’s emphasis on avoiding and addressing negative behaviours such as being aggressive, rude or dismissive, which can lead to safety silence. In aviation, this could mean the difference between a safe flight and a disaster. In healthcare, it could mean the difference between life and death of a patient. When teams communicate effectively, candidly and maintain a positive interpersonal environment, they are better equipped to address concerns and handle unexpected, complex, and high-pressure situations successfully.

In environments where the stakes are high and teamwork is essential, psychological safety, open communication, and respect are not just beneficial, they’re critical to success and safety, and a core precursor to psychological safety is being civil to each other.

To find out more about Civility Saves Lives, head to ​​https://www.civilitysaveslives.com/. And if you would like Joe or Chris to come and speak with your organisation (it doesn’t need to be in a healthcare context) or at your event about the Civility Saves Lives project, there’s a form on the website to contact them.

Further Reading

Civility Saves Lives Website

Papers:
The Impact of Rudeness on Medical Team Performance: A Randomized Trial 
The price of incivility
Exposure to incivility hinders clinical performance in a simulated operative crisis
Incivility and the clinical learner.
The Level and Frequency of Faculty Incivility as Perceived by Nursing Students of Lorestan University of Medical Sciences.
Association of the nurse work environment with nurse incivility in hospitals.
Incivility, retention and new graduate nurses: an integrated review of the literature
The Downward Spiral: Incivility in Nursing

Related psychsafety.com articles:

Psychological Safety in Aviation
Psychological Safety #129: Crew Resource Management, Diversity of Thought, PSIRF and more.
Psychological Safety & Bullying
Seven Examples of Damaging Psychological Safety in The Workplace
Psychological Safety in Healthcare
Psychological Safety Practice Playbook: Healthcare

Joe Farmer of Civility Saves Lives was kind enough to contribute the piece below for this issue:

Rudeness directly undermines team performance, which in healthcare teams is critical for effective decision-making and good patient outcomes. Tackling this issue is the first step in a difficult process. It’s essential for team members to recognise that rudeness, whether intentional or not, conflicts with their primary goal: to do their best for their patients.

This rapidly brings with it the need for solutions “what can we do about this?” Therefore the second step that I often suggest is one that relies on each of the conscientious healthcare professionals in the room to go away and reflect on their own actions and behaviours, which in itself can have huge positive impacts. 

But it leaves a big question in a lot of minds, which is “what about other people? What do I do if other people are rude?” This step is complex and relies on two main components; the employer having a system in place to report and handle the incidents sensitively and timely, and the individuals feeling a sufficient level of psychological safety to highlight the issue. If you fear the implications of raising a concern, even though you know that your motivation is wanting the best outcomes for the team, or in healthcare, the patient, then why would you raise it? You have to trust the system will receive this in a blameless manner and handle it in a way that reduces the friction, not increases it. There are so many factors that might hold this part back, and with it, such complexity in how to get it right. But if civility and psychological safety occur together, positive changes can follow for the team and for the team’s outcomes.

Psychological Safety Online Workshops

You can now book on each of the psychological safety online workshops! Options include Intermediate, Advanced, Management, Measurement, Practices, and the new Train-The-Trainer supplementary workshop. 

Psychsafety.com courses all now come with Credly Badges! After completion of the course, you’ll receive an email to claim your badge, which you can use to evidence your CPD and share on your LinkedIn profile.

Note: in addition to affordability based pricing, we now offer one free scholarship place on every workshop we deliver. If you would like to request one of these free spaces, email me (tom@psychsafety.com). The scholarship is intended for those for whom any payment at all is out of reach. Preference is given to people in lower-income countries and from disadvantaged or under-represented groups. 

Psychological Safety at Work

I really enjoyed this episode of The Human Risk podcast, featuring Niall Downey. Niall covers the topics in his excellent book “Oops! Why this go wrong“, and examines how the lessons and principles of CRM can be applied to healthcare contexts. A key point made in this is about regulators – the importance of having a just culture and psychological safety supported by regulators in ensuring that people who speak up are not punished.

Our own Tom Barron has written a great piece on leadership styles and attachment theory, and unpacks the nuances of secure, anxious, avoidant, and disorganised attachment styles in leaders and their ripple effects on team dynamics and overall well-being.

I want to give a massive thank-you to Amy Edmondson, who took time out from a busy schedule of teaching and research so I could drop in for chat while I was in Boston for work with a client. We had a wonderful chat and I’m super grateful to Amy for the opportunity.

Finally, I’d like to welcome Bea to our team! 

Bea is a second year Classical Civilisation student studying at the University of Nottingham and we’re thrilled that she’s joining us for a work placement, helping out with research and content creation. She has experience in PR and is interested in management consultancy and culture in the business world, hence finding her way to our team. Bea is also super-creative – during lockdown, she completed a Diploma in Cryptozoology (the study of mythical animals!) followed by another in cake baking and decorating. She loves to write, spending time on her own novels as well as academic research and articles. We’re looking forward to her creative input over the next few months!

This week’s poem:

Is This Thing Working? By Todd Snider

Is this thing working? Is this thing on?

In the hallway of a high school, anywhere USA
There was a bully that would pick on a different kid,
and it seemed like every day
He had this pack of back slapping buddies,
that would laugh and back him up all the way
And this screaming girlfriend who would make believe in everything he’d say

Is this thing working? Is this thing on?

Because then one day this kid, that he’d beat up a couple time before
Realized, to even his own surprise, that he probably could indeed take more
And with that he hatched an evil plan to make that devil pay
He walked up to him, in the middle of the gym,
and he found the nerve to say
“you gonna hit somebody, today? You gonna hit me too.
In fact, you’re gonna hit me every day, because now I’m picking on you”
And as crazy as it all might sound right now,
I’m not stopping until I’m through
It’s too late to beg for mercy

Is this thing working? Is this thing on?

Because that bully he just laughed and laughed,
of course, and so did all of his friends
And he beat that poor kid unmercifully, for days and days on end
Only slight less impressively each time,
to that pretty girl, and all of his friends
Who would eventually, secretly, start hoping for that kid to win

So, it this thing working? Is this thing on?

You know, you’ll never hear him say this now,
because he thinks we still don’t know
But winning this battle every day cost our bully the war a long time ago
And of all the scars he’s got to show, for every blow that kid sneaks in
The worst one is probably knowing that tomorrow he’s
going to have to get up
And fight that kid again

Is this thing working? Is this thing on?



I love this song by Todd Snider. He plays a few different versions of it (in fact, it’s a different version every time he plays it) but my favourite is this raw one. I really like the narrative in this of the courageous kid who understands that what the bully values most is the admiration of his peers and his girlfriend. The bully can thus be defeated by making him dread these daily hollow victories, gradually losing the admiration of his peers.

The power of the oppressor is undermined not through retaliation but through the persistent moral strength of the oppressed.