Respect where it's due

by Keith Cooper

Although regarded a ‘soft skill’ by some, respect and courtesy can mean the difference between life and death, says the Civility Saves Lives campaign.

Location: UK
Published: Thursday 18 January 2018
Contract and pen article illustration

'You OK with me swearing?’ asks Chris Turner, an emergency medicine consultant for a Coventry hospital.

He doesn’t; he disappoints. But this polite plea for permission makes sense.

It fits with an unofficial role he has adopted, as a champion of ‘civility’ in the NHS, a subject about which he is ‘passionate’, according to its website Civility Saves Lives. It’s the public face of a campaign he leads alongside West Midlands senior house officers Penny Hurst and Joe Farmer.

‘We are a collective voice for the importance of respect, professional courtesy and valuing each other,’ says the site.

‘We aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare.’

But what is the point of politeness to the medical profession? Oh, come on. What is wrong with rudeness? Can the NHS really expect service, with no angry words, through a busy 13-hour shift?


Mr Nice

Dr Turner knows that warm words won’t win devotees for civility from the medical profession.

‘I don’t expect people to trust me on this stuff. Me just telling people, “you know: be nice to each other”,’ he adds.

‘My instant response, when someone tells me something like that, is: “Go boil your head,” as my father would have said.’

No, he wants doctors to do what doctors do when anything new and unfamiliar comes along: to look at the evidence, as he’s done.

‘Like every other bit of evidence-based medicine, you look at it and you make a decision,’ he says. ‘I am a dyed-in-the-wool, evidence-based practitioner,’ Dr Turner adds. ‘And every bit of evidence that we have at this moment says the same thing: it says the way we behave towards each other counts.’

Some of the arguments for more courtesy in the NHS can be found on the campaign website. It has TED Talks and video clips from business gurus, such as ‘How incivility shuts our brains down’ or ‘Incivility: the silent epidemic’.

There are medical texts too. One randomised control trial assumes ‘rudeness is routinely experienced by hospital-based medical teams’ (Dr Turner agrees). It found rudeness risked iatrogenesis, ‘devastating outcomes’ for patients, and harmed healthcare workers’ performance and teamwork.


Rude health

Another paper in JAMA Surgery found more medical and surgical complications for surgeons with more complaints against them than colleagues (complaints were found to be a ‘marker of rudeness’).

‘More and more, the evidence swings in the direction of favouring civil, respectful behaviours over those which distress people,’ Dr Turner adds.

‘People who have more markers of rudeness have worse outcome for patients.’

There’s now enough evidence to ‘make the argument for civility in the NHS’, he says. He doesn’t want to be judgy. ‘I’m not telling anyone what to do.’ He’s relying on the medical profession to follow the evidence as usual and offers this anecdote: ‘My mum, a student nurse, used to give cigarettes to patients because some doctors recommended them in 1959. Then we found out what tobacco does to the body. And we change. We stop. And we changed our practice.’

But much more seems to motivate this man than the cold hard facts of an evidence base. It obviously animates him. ‘I’m walking in the kitchen, doing laps, gesticulating with my hands, as I’m chatting,’ he says over the phone. His arguments are well-rehearsed. ‘I’ve got an answer for that,’ is his preface for several defences.

This interest in the psycho-dynamics of medical teams, the impact of rudeness and emotional stress on staff and patient care, might be traced to an early interest in psychiatry.

He says it began when his wife challenged his leadership skills at breakfast, shortly after his appointment in Coventry. ‘I thought I was getting on reasonably well. She fixed me with her steely gaze and said: “How do you know? You might
be crap.”’

But also significant are two difficult times in his earlier career. One, revealing of the need to stand up to rudeness and bullying. Another, a realisation of his own emotional frailty under pressure, a susceptibility to the impact of others, that took him somewhat by surprise.

He is reluctant to link his civility campaign to his time as a trainee at the now-notorious Mid Staffordshire hospital. It’s understandable, but difficult not to. The ‘terrible and unnecessary’ suffering of hundreds of patients, uncovered by the public inquiry into care there, has become as much a poisonous political football as its real intention: a means to improve care.

Dr Turner appeared as a witness at that inquiry. He described a ‘culture of bullying and harassment’ in its emergency department, which he joined as a junior in 2007, according to a transcript.

Medical and nursing staff were ‘utterly demoralised’ there, he told the inquiry.

Nurses were threatened ‘on a near daily basis’ with losing their jobs. There was a ‘blame culture … no significant medical leadership. Fundamentally no vision of what good looked like’.

Their working environment had got ‘harder and harder and harder’, incrementally, imperceptibly. The ‘gradual, corrosive effect’ of working there left staff unaware ‘just how much of a disaster it was’, the transcript says.


Downward spiral

The Mid Staffordshire experience ‘broke’ him, Dr Turner admits. ‘First I stopped sleeping and eventually eating,’ he says. He shed two-and-a-half stone in nine weeks and slept only three hours a night. ‘After two years I broke under the pressure and resigned.’

After a brief spell at a hospital in Wolverhampton he got the Coventry job.

Much of his thesis on incivility connects with his experience at Mid Staffordshire, a painful reminder, perhaps, of what happens when bad behaviour is passed over and allowed to take hold.

When investigating incidents, he takes care to examine the working environment, where an error is made, before looking for ‘root causes’.

‘When you look at an incident and you find that somebody didn’t follow the standard operating procedure, it’s easy to say: “Ah! Ha!” that is the root cause of this incident. But what else has happened?’ he says.



The evidence (again) shows that drug errors are more likely missed when there’s rudeness around, he says.

‘Once you’ve distressed people, their cognitive function is impaired. And it’s very easy to turn round and go: Oh God, the nurse missed the drug-calculation error. But that is not to understand that we are human, and impacted by what goes on around us.’

That a culture of rudeness doesn’t appear suddenly is another lesson he has learned outside the literature. It creeps up, gets stronger with practice. ‘It’s like an emotional muscle,’ he says. ‘Once we start to display rudeness, incivility, it gets easier and easier to accept. It’s like doing a little emotional bench press. It becomes normalised.’

So, he takes care to apologise when he’s uncivil himself. But has he been rude recently?

‘Yeah, I’ve been rude many times,’ he says. ‘I would love to get this right all the time, but I get it wrong. I got it wrong last week at work and I’ve had to go and apologise to somebody. She was really hurt and I feel absolutely terrible about it.’

Rudeness should be ‘excusable’ in an NHS under pressure but seen as ‘unacceptable’, Dr Turner says.

‘I accept that people are under intolerable pressure. Nobody should get shot down for being rude on the odd occasion – as long as they acknowledge it. Nobody gets it right all the time.’

Keeping it together under pressure is a challenge he can empathise with.

The first major incident he managed was the worst peacetime military disaster in Australia, in Townsville, Queensland in 1996, which killed 18. It taught him much about ‘team spirit’ but was also personally damaging, he says.

‘Two Blackhawk helicopters collided. There were 20 to 21 young men. They all got brought to us. We only had two resus bays and we ended up with an awful lot of,’ he pauses, ‘dead bodies.’

‘Emotions were sky high. People were exhausted. You were being exposed to dead young person after dead young person, after dead young person.’ It’s the only time, in an hour-long interview, that he punctuates his words.

Months later, in an ‘elaborate joke’ by a colleague, he was called at a party and told another major incident was coming in.

‘It was designed, I know, to be a joke. There was absolutely nothing malicious in it. But I was,’ he pauses, ‘when I heard there was another major incident coming, I felt internally, like I couldn’t cope.’

Incivility is in the eyes and ears of the receiver, he says. ‘It isn’t always intended. Emergency departments are high-pressure situations, like operating theatres, or outpatients or GP surgeries when there are loads and loads of patients. Under those circumstances people get compressed. They say and do things …’

He pauses.

‘I have stood in the middle of an emergency department and asserted myself vigorously with somebody. Afterwards, I realised how that might come across, not only to the other person but to those around us and any patients. Sometimes this realisation has not come until years later, when I’ve been sitting down and reading about incivility.’


Team effort

Medicine is complicated, a team business to Dr Turner with doctors often leading in an increasingly pressurised NHS.

‘Our job is to try to get people to perform at their peak,’ he says. ‘You want to have a team around you which is functioning as well as it possibly can. How we create as good an environment as possible, is one of the key factors, and civility is starting to look like a key underpinning behaviour.’

The weight of the evidence, he says, is in favour of ‘behaving in a way that respects and values people and civility is the root to that’.

‘Some of that evidence might be wrong,’ he admits. ‘If it turns out that I need to be screaming and bawling to get the best for my patients, I guess I’ll end up doing that.’

‘It wouldn’t fit comfortably,’ he adds. He’s speaking from experience, it seems.