When we’re rude to colleagues, the evidence is overwhelming that we perform worse and this is particularly the case when we’re doing something complex in a team, like dentistry. In medicine this ubiquitous problem is being recognised as a formidable invisible enemy of clinical quality and organisational efficiency. There are obvious implications for private dental practice owners, so we spoke to Dr Chris Turner, a lead on professional interactions at the General Medical Council and co-founder of civilitysaveslives.com, a group of healthcare professionals that shares the evidence base around the cost of rudeness (watch his Ted Talk on the homepage).
Chris, how did you end up educating people about civility?
For competent teams the single most important factor determining outcomes is how we treat each other, but we don’t talk about it. This is new science and it’s powerful. I’m a consultant in emergency medicine, working in a tertiary trauma centre in the West Midlands. The first week of January has been overwhelming, we ran out of beds, then corridor space, but the queues continued to mount and the noise levels with them, along with the human distress. Facing that mounting stress, it would be possible for a senior clinician to let off steam with cutting comments, undermining behaviours or even a tantrum. I’ve both seen and done this in my career. But now we know that this has a quantifiable detrimental effect.
What are the effects of rudeness?
We don’t intend to hurt others in conversations, yet when someone feels hurt they often repond on a spectrum from silence (and the withdrawal of effort) to outright hostility. In stressful fields like healthcare, when there is an emergency situation command and control leadership can be beneficial but the bit afterwards — re-establishing connection and relationship — was traditionally neglected. So people have tended to assume that incivility was simply what leadership looked like. A paper called The Price of Incivility by Christine Porath (Harvard Business Review 2013) found 80% of recipients lose time worrying about it, 38% reduce the quality of their work, 48% reduce their time at work, and 25% take it out on service users; meanwhile 20% of witnesses reduce their performance and 50% are less likely to help others.
Tell us about your journey
I started off looking at what trauma teams do. I, foolishly, had told my wife that I thought I ran a pretty good trauma team. My wife responded with, “How do you know you’re good? You might be crap.” This led me to looking into the factors that contributed to good teams. Yes, they want command and control at first, but afterwards they want a collegiate bond, they want to be valued, to be able to contribute the thing they know that no one else in that team knows. The route to that appears to be how we talk to each other. This helps everyone be the best versions of themselves. That’s how it started.
Civility Saves Lives came about four years ago from a conversation with a colleague, Joe Farmer, who had been my F1. He said he wanted to speak to me after he left, and I thought perhaps I’d caused him offence. He’s a quiet guy, not easy to read. He started talking through stuff about behaviour, stuff at work since he left. I told him about Christine Porath’s research into the impact of negative behaviours. We drew it together. We spent a long time thinking about what we would call this. Initially we were drawn to the negative side and thought about something like “Don’t be a d***”, but the truth is that nobody goes to work to be a bad person, and if we are it is not a conscious decision. So we decided to try to appeal to what we come to work to do — to provide the best healthcare that we can.
How do you get people to change?
At first I thought that if I gave people the information then they would change, because we all want to be the best versions of ourselves. Some people did change, realising the impact they had on those around them. Other people bought into the theory and yet in the workplace still caused stress to those around them. These people get a reputation at work that leads to them having a personal theme tune like the music in Jaws. They walk in and suddenly everyone’s over-aroused, just from their presence in the room. When you become that person with a negative reputation, you get worse outcomes. What I realised is that having accepted the information, very few of these people still cause others distress deliberately. The problem was they didn’t know they were doing it.
How do you let someone know they’re causing distress?
We created a system called Calling It Out With Compassion. It assumes that the person didn’t mean to cause offence. It’s a way to have conversations in the most productive way, removing the distressed person because if you’re distressed then trying to tell the person who has caused it is really difficult. When you’re distressed your working memory bandwidth has gone right down and you’re in fight or flight, so you need to win the argument or get out. We took that conversation and gave it to other people, so the distressed person tells a messenger in the organisation, and they talk to someone of the same rank as the alleged perpetrator, who has the conversation with them. The aim is to give them space to reflect on what they’re involved in and decide what they want to do.
Is your system working?
Yes, there’s now a whole infrastructure to support this. We’ve been working with the Greater Glasgow and Clyde health board and the Lothian health board and we do workshops in Birmingham. What we have found is that the supposed perpetrators are frequently extremely distressed individuals. People who hurt others are often hurt. It’s about holding that conversation with compassion. We advocate holding a three part conversation. The first part is, “How are you; no really, how are you?” Then, “What happened out there?” Then you let them know someone else is distressed. You don’t say they caused it, because maybe they didn’t. You let them know that some people felt uncomfortable about what went on. It’s about how that person feels, and you regard it as your professional responsibility to do something about that. You allow people to make their own minds up about what they want to do. We don’t ask people to change, that’s their choice, but we find that people mostly don’t want to cause others distress.
How much rudeness have you seen in your career?
I’ve had episodes in my life with very difficult people. In the 80s and 90s consultants were effectively allowed to behave any way they like. Most were extremely professional, some were very hostile, living up to the caricature of the scalpel throwing consultant. Those guys are rarer and rarer these days. But any human being can be pushed past their window of tolerance and respond in ways they wouldn’t normally want to. I remember thinking one guy was a complete pillock. If, however, I’d spoken to him and asked “how are you?” I might have heard about the terrible divorce he was going through, the words being used about him in court, I might have understood that actually his world was falling apart, and he had no idea about the distress he was causing. But no one was bringing it to him because he was so senior.
In my workplace yesterday it was incredibly loud, we couldn’t get patients into rooms fast enough, everybody was shouting for something, the cleaners were shouting across everybody else, someone thought it was a good idea to have the radio on, walkie talkies were fizzing with static, and I had a softly spoken junior doctor trying to tell me a patient’s history. It’s not surprising that in that environment people become less than the best versions of themselves. It’s overstimulating.
How does hierarchy affect rudeness?
The further up the tree you are the more you feel you have the right to behave the way you like. If I’d thrown a tantrum yesterday it would have been allowed. If a junior doctor or junior nurse had they wouldn’t have been allowed. The impact of these negative behaviours is measurable: it means the team works less well. We think that by shouting at them people work harder, but people aren’t under-aroused in health care, you’re generally in a complex process with another human being a few feet away, trying to get it right, working together with your colleagues. We simply don’t need further arousal.
Is there a tangible financial cost of rudeness?
People don’t want to come to work, and that plays out in different ways but with the same ultimate result: it’s expensive. A project called Crew (Civility, Respect and Engagement in the Workplace) at the US Department of Veterans Affairs found that the most civil hospitals spend $2.2m less a year on equal opportunities lawsuits than the rudest hospitals, where sickness bills were $26m higher too.
Does your approach work?
The Calling It Out With Compassion system is adapted from a model developed by Gerald Hickson at Vanderbilt University in Nashville, known as a “coffee conversation”. They’ve done 37,000 of these conversations and there have been only 2,000 repeat incidents. People are good, they don’t want to hurt other people, they take it on board and choose to change. When those 2,000 people had a second coffee conversation, still without involving HR, only 267 remained unreconciled. Those hardcore offenders then go into the formal disciplinary process.
Do you have any tips on how to conduct these conversations?
Make it one on one. It’s simply about letting someone know something’s happened, with no expectations, so they can make their own decisions. That flies in face of what we want — an aggrieved person tends to want blood. But this is a process of listening, hearing their story, and it seems to change the desire for revenge. It’s the same as the complaints process. People are bristling, but you sit them down, give them a drink, ask them what happened and just listen. Don’t try and point score. Let them feel heard. Then ask, “What do you want out of this?” If you ask them at the beginning, they want revenge. At the end it’s changed to, “I don’t want anyone else to experience this.” People will choose to change. That sounds soft, but the evidence shows it works. It does take time. Some of these people need an hour to tell you about the distress. Once it’s laid out in front of them they can process it well. Instead of battling to be right it’s about accepting that everyone has a view, and their feelings are valid.
What’s the main challenge?
It’s probably how do we create psychological safety for these conversations to happen? That’s within the gift of senior people, to let other people know that they can talk. In trauma we say, “I’m team leader, if you think I’m wrong or miss something you need to tell me because I probably have.” I talk to chief execs who say, “Yes, I want everyone in this organisation to feel they can come and let me know if I have upset them,” but it’s never going to happen because junior employees don’t feel empowered to speak up. These conversations are difficult to have because of the asymmetry of power and knowledge. That’s why we use a peer to peer system: if I behave badly another consultant will be asked to come and talk to me.
Are some people just “toxic”?
Some people have a reputation, but nobody is just toxic, that implies they can’t change. What we need to appreciate is that when they start talking they have a hell of a journey ahead of them. That’s very uncomfortable. You’re moving from a set of behaviours which you regard as highly professional to something different, and that’s not easy. For some of them there’s probably a need for a coaching relationship to create the space for that change. It’s the toxic ones who are seen as leaders that we can’t avoid, and as Christine Porath has said, just one habitually offensive employee critically positioned in an organisation can cost millions in lost employees, lost customers, and lost productivity.