Civility Saves Lives

June 23, 2021



We are living in interesting and unusual times. People across industries and work sectors are experiencing a high degree of uncertainty and stress in their work and personal lives. In this podcast, Chris Turner, an emergency consultant in medicine and a TEDx speaker, raises the importance of civility and respect amongst team members to achieve a culture of high performance in these uncertain times.

Further information

Nippin Anand [00:00:06] Hello everyone. It’s a beautiful day in Aberdeen today and I am thrilled to have you back.

It’s the time of the year that we in the Northern Hemisphere look to fly away somewhere for a holiday and soak in the sun. And it may still be happening for a few of us. But many of us are still in a state of uncertainty whether to book a holiday or not. Hopefully things will improve and we will get to escape somewhere. Fingers crossed, finally there is some light at the end of the tunnel for some of us.

I’m delighted to bring another close friend and an awesome podcast on Embracing Differences, today and his name is Chris Turner. Chris is an emergency medicine consultant. Chris is also known for his work on civility and his famous TEDx talk Civility saves lives and today on this podcast we talk about many things including leadership, rules, processes, and the need for bending rules and procedures. But most of all, I love Chris’s idea of ‘civility saves lives’. I think you will like it, let’s hear from Chris.

 First of all let us just talk about your story. Who are you and how did you get into this space?

Chris Turner [00:01:36] I’m Chris Turner. I’m an emergency medicine consultant from Coventry in England. I lived in Australia for three years got experience of other cultures, underwent four years of psychiatric training and that was eye opening. The way that we trained psychiatrists involves an awful lot of supervision, an awful lot of sitting down and discussing other people’s perspectives not just slipping into believing that our beliefs are always right and it was a challenging and interesting time I had an absolutely amazing mentor a guy called Allan Beverage and when I worked in Dunfermline and I intermittently send him a message. He was formative and that challenging where he’s going to think about how we interact with the patients and what we can do for them. Then I ended up in England and I ended up doing emergency medicine which is a very different world from psychiatry and has an awful lot more kind of rapid satisfaction psychiatry takes a little bit longer.

[00:03:13] But it was also involved governance and maintenance. In healthcare governance is how we try to create and maintain quality throughout the system, and it felt to me like a really key component of trying to be as safe as we could be and I suppose if you would have spoken to me the beginning of my time and governance which I was doing alongside being an emergency medicine consultant. At the beginning it was all about process. I was all about being able to define how it is that we do what we do and making that as replicatable as possible. But I sort of gradually and came to recognize that we had all these brilliant processes in place and yet things were going wrong and then people were afraid that people weren’t following the processes.

[00:04:12] But then we found if you looked a bit harder that the process is being followed by anybody. they were simply work as imagined and the work as done looked completely different. So, there’s not an awful lot of energy that goes into creating and sustaining the fiction that people do the work as it’s written down on paper within healthcare and I guess with another other worlds as well. That led me into a sort of space going OK so if we’re not doing as, it’s written down on paper what are we doing? and then beginning to understand that you’re bending and flexing. We’re constantly adapting with each other in an attempt to get the best outcomes for patients and that we are cogs in a machine. But we’re more than just the cogs in the machine we’re the lubricant. The human last behavior is either grit or its oil in the coals and each one of those relationships will really matter.

[00:05:19] I did some work with Trevor Dale who runs a company called the Atrainability. Trevor Dale introduced me to the work at Christine Porath and she’s been doing these formal bits of work on the impact of incivility and performance and through that I started reading papers and I had an advantage in reading the papers. The advantages were that I had worked in stock where I have been taught to critically appraise and critical appraisal of papers is hard work. Reading other people’s academic work and trying to understand what they were getting out and where their flaws make it within their logic in their methodology. That’s really hard work but I had done it for many years, so I was able to read quite a lot of papers and get my head around for other people who are doing. Then I discovered that world of behavior is actually is very welcoming and most the people who function within it, if you write to them they will bring back and then they’ll give you a call then I have a chat with you and this is fascinating it was kind of put that academics have been way up there and turns out that academics are extremely happy as to have a chat about their work and their areas of expertise and it got to that had a  good chat to people and very gradually came this recognition that behavior mattered that mattered in a quantifiable way and it matters in a way that we weren’t talking about.

[00:06:43] I had coffee one day with Joe Farmer who was my junior doctor. We were talking about an incident that happened in a theater where he was there along with a registrar, a couple of layers up from him, when he was a very junior doctor and they had looked after Joe when he was on the ‘on-calls’. The consultants just lost it at the registrar who apparently hadn’t done anything significantly bad what Joe described was of them starting with a “but…but..” trying to explain what’s going on. The other person was kind of just on and on and on at them and the registrar kept getting quiter and quieter and quieter till they were just standing there and not doing anything. Joe was telling me this story about what we thought was happening there and when people treat us that way, how we drift just pure threat and our lizard brain might get into a mode to think that – ok this might get really unpleasant now – do I need to be ready to fight? What happens to our working memory and how it gets difficult to function. Joe was really interested in this and he goes like, “Well, people don’t know that!” He’s dead right!

[00:08:49] We grew up in a medical culture where you learn by humiliation where undermining people standard for leadership behaviors while leadership is. Leadership was regarded as the right to behave as you like rather than the responsibility to get the most out of the people around you and Jo said people should know about this. We had to think weather thing create and we thought we would start a campaign, but it wasn’t anywhere near his grandiose list out we felt that we do a couple of talks and see if people were interested.  I’m interested in branding and marketing, and we were thinking about what we’re going to call it so that people might get an idea but what this is about, and we started off with lots and lots of thoughts about that “Don’t be..” so we started out for “don’t be an arse”, don’t be like that doesn’t matter you can choose you know. Don’t be up whatever primary or secondary sexual characteristic – you choose. That’s quite appealing to us until we started thinking about their learning for excellence movement and Plunket start with learning from excellence movement up and when we started that, he didn’t say learn from mistakes they said look at the good stuff. None of us come to work to offend other people. None of us come to have a fight job hard enough as it is he don’t need that we added into the top of it.

[00:10:50] Then we thought well let’s work it out and understand what do people really come to work? Well, they come to work to be excellent. They come to work to do the best job we can and so rather than saying that “Don’t be something…” we went for a pro social message and went for Civility saves lives and I think it turned out to be quite a good move on our part because we weren’t seeing people do be something we’re just we would just say that hey guess what there’s a bunch of new information out there and that perhaps how we’ve the behaviors that we’ve had role model to us how we’ve been expecting to be as leaders and within healthcare perhaps that’s not helpful as we thought it might be and perhaps there’s another set of behaviors that we should be thinking about that might help us to get the best out of situations. But that just seems to be able to traction very quickly which is lovely then things kind of exploded a bit when got chance when I did Ted X NHS and from that go invited to go talking TEDx Exeter,  in the world of Ted talks and Ted X talks it’s the fourth most popular TEDx venue the world which had when you could take part, he realized widening emended effort that those guys go to meet that an outstanding event is incredible. From that just start to get more and more abuse of that all cone life and it’s not stratospheric or anything that you can view it through a couple different channels just over 100,000 times that people have looked at the top talking.  I think civility doesn’t matter, for me the key message is that behavior matters, and we all behave all the time.

[00:13:15] Every time we interact each other we’re behaving and don’t believe that doesn’t have an impact upon the performance of the people arranging and bottom line to this is it when we treat each in ways that feel disrespectful to the recipient. So intent is kind of not important here unfortunately. When they feel disrespectful to the recipient that has a direct negative impact on the ability of the recipient to perform and that’s kind of the key message more significant in two settings. So, the more complicated or complex environment is the border seems to matter because in complicated and complex environments we must be creative, we must think about what the best solution in each situation is. Also, the other thing will stop come in the last year so some work by Gady Gilman and his work shows that what he did was he people where they the empathy spectrum so Simon Baron Cohen has said we have empathy in the normal distribution. What Gady Gilman said what happens to people at the gender spectrum when they are exposed to incivility to somebody else so that just witnessing instability and what he found was that the people with low level of empathy that they weren’t particularly affected by watching incivilities of somebody else. But people who are highly empathic were significantly affected by watching incivility to people and that’s important in all sorts of levels for me but within healthcare specifically important in one and that if we think that the people that we want to be delivering here are people who do care and generally those are the more empathic people.

Nippin Anand [00:15:18] It is a very powerful message. This goes back many years ago I used to sail on a ship, and I was I was a young junior officer on the ship, and we were sailing out from a port in China and there’s a rule on the ships that you must not say loud without the port clearance. You get a clearance document or the certificate handed to you by the Port Authority which then basically means that you have cleared the dues for this port before you enter into the next part of the export of call you will be asked for that paper so I was young and naive at that time and I just received that paper last minute from the port agent put it in my in my office and I thought I will give it to the capital later on once the ship sails out and to date I don’t know what happened to the paper you know whether where it got swallowed or and so I went the ship sailed out I went into my came and I couldn’t find that paper so I innocently went to the captain and said I have misplaced that paper somewhere and I don’t know where it is.

[00:16:28] He got little bit furious with me and that moment but he didn’t say much but that was about time we departed from the board I told him and I thought the situation is over he will send a message to the next boat and will try and sort this out because to me this was not the end of the world, we had facsimile on the ship their word means of communication and something could be done about it but no. It was 8:00 o’clock at night, I took my independent watch, and we were we were going we were coasting along China with so many fishing boats in that area. The horizon was full of fishing boats but this guy comes up on the bridge the captain emails was in his late 50s and he was known to be a very terrible captain actually and so he asked me he said so do you know where you might have misplaced it, I said “I’m trying to think about it I honestly can’t”. So, the conversation started to kind of interrogation you know how you went about placing it where you kept it to the point that it became abusive it became abusive and he started to abuse me.

[00:17:33] He abused me continuously 45 minutes or so to the point that my brain was completely dead. I could not respond to anything, and I think at the end of it when he was stepping down from the bridge, he kind of knew what he had done. So before stepping down he said, “I think you should just forget about it now and keep it in the back of it and concentrate on the traffic and make sure that this ship does not collide”. To date I wonder there’s not been many studies done in this area to see what is the relationship between undermining somebody’s dignity and impacting upon their performance and it just brought back that thing through this example, so I still struggle to understand why? Days went by months went by years went by and I got into this profession. I recognize the relationship on how we demean people, how we dehumanize them in many ways and how that impacts upon the operational safety in that context, but you see something else also from the other end, which is that how instruments of safety for example, things that are supposed to improve safety: just culture rules and regulations hung out how these instruments are used to dehumanize people, so it works both ways. So, you will often come up with a rule or anybody unrealistic regulation or just culture, mechanism or a process or a tree or whatever you want to call it you find ways to dehumanize people through those through those tools and I wonder what your thoughts are on that Chris.

Chris Turner [00:19:27] So many thoughts, Nippin. Suzette Woodward introduced me to the work of Vincent and Amalberti from a number of years ago there were looking at different systems that exist within healthcare and I’m going to relate it back to rules. There’s the ultra-reliable system so that within healthcare that would be the giving of chemotherapy or really the therapy relatively linear this step, then this step, in this step. You can describe that in terms of a process and if the people follow process, you will get in resulting aggression, so the process becomes more important than people in that setting. The second group are the highly reliable systems and an example of that would be an operation where there are many things that you can describe them set out in front and you can you can put this step but within that there has to be enough flexibility for the surgeon to not just do it exactly as it says in the textbook because every human is a little bit different. The problems are really different.

[00:21:02] Sometimes vessels around the wrong way sometimes things are stuck to each other sometimes you have to completely change the sort of operation that doing that means sentence settings processes are important but people are equally important so process and people equal each other in those high reliability systems and then you move into the far end there are slightly more messy systems which are ultra-adaptive and what we’re looking for in those environments are we are looking for people to much in bending plates because we might be able to describe individual process is or which pieces of strings but it’s like somebody then gets those pieces of strings then scrunch them up into a ball and you have mass of people who cannot help but interact with each other in my world in him in emergency department very much falls into that category in it those categories we relied upon our people bending, flexing and having the permission to bend and flex in order to get the right outcomes as much of the time is possible can.

[00:22:34] The problem with the problem with written that process for that is the situation is too complex to write down a protocol that is going to work all the time. Instead when we need our process is saying we want to get to this point you can choose how you’re going to get there because the rest of it’s going to fall apart but you do it in the full recognition to other people are dependent upon you in different ways as well and that you only work together and understand what’s going on as well as you can whilst trying to discharge their responsibilities and it relates that sounds a little bit like going into battle when it started to describe that there are similarities there.

Just give you a tiny example in my world. So, I can be standing in the middle of the emergency department. I might need to walk to our resuscitation bay because somebody has been brought in and people are worried about them, and they are sick and I’m walking that direction. If you’re to write that down as a process I would log out my computer turn right walkthrough and that would be great except for I stand there; I turn around I usually forget to logout my computer but it takes carried out for me which is good. As I take a step forward somebody will stop me and say can you look at the ECG and I’ll look at it quickly. Then I walk down another resus. I will get stopped by another person somebody might just want to say hello.

[00:24:12] Then I’ll see a patient in a room who looks like they’re in distress and it’s sort of batter make sure that somebody is coming to that something will come out of the blood gas analyzer room you have a blood gas new asked me to look at that as I’m going to resus then I’ll get into recues then I have to get changed and having to get changed to full FP3 PPE to bold see patients for that means I’m going to take another minute or two to do those outputs when people will still be coming through the door asking questions and then I will go and get to see that patient. But any one of those things, as I got to see that patient might be somebody who is sicker than the patient that I’m going to and at any point I might need to change my course and go in a different direction whilst making sure that somebody lets the guys in resus move and open be coming. The only thing is predictable about that is that it is unpredictable that’s the only thing I can say about it and trying to describe that becomes quite important. I think it’s easy for people who are sitting few four steps remove to look at somebody else’s job and they think they understand it when the reality of how we discharger jobs in not ultra-adaptive fashion and everybody has times when they’re being ultra-adaptive job that also adaptive environment it just doesn’t lend itself towards processing people are far more important.

One of the things that Suzette Woodward said was it she really regrets that we choose to use the expression “never events” within the NHS and she regrets that because what happens is when something goes wrong it’s a “never event” seems to become a witch hunt and that doesn’t allow us get the learning point seems things become rich on people who will do anything to avoid being hunted and they will hide  things in order that they don’t get sort of treatment answer to be fair sort of treatment you described knew having on the bridge from the captain and one thing to say about that is that he tried to put a line under at the end of it but we know that doesn’t work. He’s trying to put align under he probably recognizes going overboard with you but you are going to have a big chunk of your brain intermittently reliving a set of emotions and then feeling that kind of anger that you didn’t respond in the way that you could have done in the moment if your brain it being functioning but your brain wasn’t functioning because when he was doing that to you but he was talking to you and making you feel like crap you’re working memory was being replaced by your fight response is being replaced by Nippin getting ready to have a fighting and when that happened you weren’t the smart person that I knew you to be you just scared I guess and just particularly people who are empathic everybody just don’t also say that we ruminate try and make sense of it and you can measure the impact it has on cognitive ability you know in the moment. It has about 61% decrease in in our working memory but what you were describing was significantly worse than that you know and we knew that people can be driven in those settings described it into the pre state when no the wave after wave after wave of negative behavior torture hits you start off trying to challenge to make your case.

Nippin Anand [00:28:13] In your world, it’s the emergency services but in my world it’s more like fishing boats. But they don’t have those standard procedures and practices everything is more human centered, but I suppose every job, every industry every work sector has this. There are moments when a very ultra-safe can turn into a human centered system. It happens within the workspace all the time. That workspace which I was in at one moment could be controlled through procedures in another moment it can’t be so that reminds me also of so many accidents and incidents and one of the recent one was when there were two pilots in the plane and the lady pilot was married to the guy. So, they were husband and wife and then one stage of flying the pilot slaps the girl and just walks out of the cockpit and moments later you see that the lady comes out of the cockpit crying. At this point, the passengers are wondering who is inside the flight? So we tend to think about of cockpits as very ultra-safe systems but then again you know when something like this happens it shakes any system, I would say, isn’t it?

It’s so interesting but I’m not doing this conscious that we are coming towards the end of it, and I just wanted to l so enjoy this conversation because there’s many very few people who have explored the relationship between safe performance and giving people the dignity and respect that they deserve. You use the beautiful words civility is there anything in conclusion you want to say Chris before we before we end this, I just found it so fascinating.

Chris Turner [00:30:04] Almost all of us have a leadership role of some form and as well as in civility I ended up doing work in health and well-being. So, I ended up in there the national steering group for health and well-being in the NHS which is a fascinating place and I had to do an awful lot of reading. One of the things that I came across when I was doing that reading was that the single greatest determinant of whether something is going to be engaged at work engagement and well-being are bedfellows and they’re also very closely related to performance. In fact, engagement the number one predictor of key performance indicators across all parts of the NHS. The number one predictor of engagement is whether or not your boss is engaged and that’s interesting because that means that from me the number one predictor whether I’m going to be engaged at work whether all my bosses engaged there it’s a bit weird like that medicine once you get to my level.

[00:31:12] But that could be a bit frustrating that the person above me is determining how well I perform but the really empowering thing here is that the person determining how well I perform is not my boss, it’s me! How I am who I am in the work place really matters when I am engaged the chances are that my direct reports me will be engaged. When they’re engaged that better well-being, they enjoy work their performance is better. When I behave in ways that make them feel valued. their performance improves it is very easy to slip into the state of mind that says who am I don’t matter. Very easy particularly when the organization whatever organization you work for but particularly in the organization makes you feel like you don’t matter but actually the hierarchy goes like this and someone’s at the top of each bit of it and how we behave towards each other matters across all the spectrum of performance.

When we choose to treat each other’s in ways that value and respect us, then we allow a culture which allow people to flourish. You want people to flourish at work and make them feel valued. If they feel valued and have that discretionary effort, then they get better. The performance of our teams and organizations is better. That comes when we choose to treat people in ways that they are respected.

[00:33:09] What did you think?

‘when we choose to treat people with respect they deserve, we improve the performance of our teams and organizations’. A simple thing but how difficult it is to achieve in practice?

Very few studies have explored the relationship between safety performance and treating people with the respect they deserve. How may times I have seen that not only safety tools are used to dehumanize people and demean them, but also how dehumanizing people leads to poor safety and business performance. I can never forget the instance when a Filipino worker walked up to me abd handed a chit that read ‘only officers on this ship are allowed internet and nothing for the crew despite that we spend more time on ships than the officers. Who decides who needs internet more, us or them? And when I ask the captain he turned abusive and told me to shut up and get lost’. Stories of people being abused on ships, being stripped off they dignity and respect and particularly people in lower positions is so common.

And I am wondering these are company with good intentions. They spend thousands of dollars sending their people on training courses to make sure that they don’t have navigation accidents. Imagine creating this divide on ships in deciding who gets access to internet and who doesn’t. It’s almost dehumanizing people and stripping them of their basic rights. How is that ever going to improve safety performance? How do you tell that Filipino seaman that you are empowered to speak up when you see another ship on the horizon? What makes us think that this seaman actually wakes up and brings his whole self to work in a safety critical environment?

Nippin Anand [00:35:29] Thank you for taking the time to listen to this podcast. I hope the time you spent was worthwhile. If you think the podcast has made you think, slow down and reflect, I have achieved my purpose. Please share it with others in your community so that messages reaches far and wide.

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