Translator: Riaki Poništ Reviewer: Ellen Maloney
It was 2 a.m. when the pediatric alert bleep went out.
The intensive care registrar and pediatric registrar
arrived in the emergency department
at the same time as an acutely short of breath, four-year-old girl.
The nurses put on the monitoring,
the doctors examined the child and spoke with the mother.
And after a few moments, they met at the bottom of the bed,
and had a discussion
about what they thought should happen next.
It was passionate; it became heated; voices were raised.
And eventually they decided to go with maximum drug therapy
and that they wouldn't do her breathing for her this moment in time.
The intensive care doctor left.
He went back to his department,
and the pediatric doctor started trying to get intravenous access
in the little girl's arm.
The nurses asked, "What do you want us to give next?"
and he replied, "Aminophylline."
They spoke for a moment or two,
and then they leaned forward and said, "How'd you make it up?"
because they were adult nurses
and there were no paediatric nurses in this department overnight,
and you make it up differently for children and adults.
He said, "Look, just go and look it up, will you? I'm busy."
So they did.
They went away, they looked it up,
and then they came back, maybe ten minutes later.
When they got back,
he was still struggling to get this intravenous line in.
They said to him,
"What rate do you want this to go at?"
And he looked up and said,
"For God's sake, leave me alone! Can't you see I'm busy?"
And they did what we would all do.
They took a step back.
They took a step back, and they waited.
And he got the line in, they wrote the script,
and then connected the drug through the pump,
through the tubing and into her arm.
And over the next half hour,
she received 15 to 20 hours' worth of aminophylline,
a very toxic drug.
So what happened next?
Well, after a rocky few hours, she did just fine.
But there was, of course, an incident form.
There was, of course, an investigation.
What did that find?
It found that the nurses hadn't been competent,
it found that the nurses needed retraining,
in fact, the nurses shouldn't be allowed
to give any drugs till they had retraining,
and there might have been some communication issues.
And I think we missed the point,
and I think we missed the chance to be better.
Many of us work in teams.
Health care is no different.
We deliver it,
in complicated, sometimes complex environments of varying outcomes.
And for last 10 years,
as well as being an emergency medicine consultant,
I've been a safety lead,
investigating and trying to understand situations just like this one.
And if 10 years ago you had come and asked me,
said, "Chris, what do you think the answer is?"
I'd have been totally clear with you.
I'd have said, "It's process.
If only everybody did what they're meant to do."
But there's a problem with that.
You can only investigate so many of these
where you know that the people involved
are knowledgeable, good, diligent professionals
before you realize that you must be missing something.
And I was missing this.
Process is written on paper.
But practice - practice happens between individuals and in environments,
and I simply wasn't respecting the complexity of the situation.
So now, if people come and ask me, "What do you think the answer is?"
I still think process has its place,
but something else is more important.
That's people.
And I think the evidence bears me out on this.
So, if we work in teams,
what makes teams perform better?
Well, in 2015,
Riskin and Erez published the first of their landmark papers.
In it, what they did was something that hadn't been done before.
They took teams
who were matched for expertise,
they put them into a patient simulator,
and they measured the outcomes.
Half of those teams were exposed to mild rudeness.
And what did they find?
They found, unsurprisingly, that we grade on a curve.
We grade from the truly fantastic care
that we all want for ourselves and for our loved ones
all the way around to the catastrophic care
where patients die unnecessarily.
And they found
that one factor was responsible for 40 to 60 percent of that variance,
and that's incivility or rudeness.
In fact, it looks like, for competent teams,
the single most important factor determining the outcome of that team
is how we treat each other.
So, incivility -
if it's such a big deal, how come we don't know about it?
I never got taught about it at medical school
in my membership exams or my fellowship exams.
It's because this is new science.
Between 1996 and 2000, on all of the academic papers,
there were only 23 about incivility, rudeness.
Between 2011 and 2015,
there were 1,700,
and they pretty much all say the same thing:
this stuff counts.
So I should ask,
has anybody here seen rudeness at work?
(Laughter)
Maybe to you, maybe to somebody near you,
or maybe it's been by you,
and certainly been by me.
How did it feel?
Now my guess, is that it is a bunch of people
who, when they're thinking about it, feel angry.
But that's not where we start off.
In the moment when it happens to us,
we feel belittled, ashamed, humiliated.
We feel powerless, like children.
And then slowly, over minutes,
sometimes hours, sometimes days,
we start to make sense of it.
And then, we find ourselves saying, "How dare you!
How dare you treat me like that!"
And that's when we find the anger.
So today, I'd like to talk about two of the groups
that are affected by incivility.
Because now, thanks to the wonderful work of people like Christine Porath,
we're able to put some numbers onto this.
And to do it, I'd like to talk about bandwidth.
Because on a good day with a following wind,
we're pretty smart people,
and we can deal with five to seven things.
But we have lives; we have cars, bills, houses, family.
And it takes up space.
So by the time we get to work,
we're maybe dealing with three or four things.
What happens when somebody is rude to another person?
What happens to the recipient?
And I'm talking here about mild to moderate rudeness;
I'm not talking about screaming and shouting in your face.
That's completely different.
On average,
when somebody is rude to us in a mild to moderate way,
our bandwidth reduces by 61 percent.
And then we cart it with us through the day.
We cart this thought of "What on earth happened?"
and then at the end of the day, we get in the car or on the bus,
we're sitting there and we feel a wee bit safe,
and our bandwidth starts to open out again,
and then we have that moment we go, "(Boom!) That's what I should have said!
That's what I would have said to him."
(Laughter)
And that's because in that moment,
you're back.
You're back to being the wonderful, smart, witty self that you are.
And in the moment, you weren't.
In the moment when it happened, we are quite literally less.
When we do it to somebody else,
we make them quite literally less.
What about staff onlookers?
Well, I'm reminded of an episode in the emergency department.
My colleague tried to refer a patient onto the neurosurgical team,
the neurosurgical registrar had said, "No."
And I know him and he's a good guy.
I didn't know that he was a good guy
having a bad day.
I said, "Well, let me go and chat."
I'm the big man, eh?
So I went along, and I said,
"Got this patient, really like you to see her, neurosurgical problem."
He said no.
Second tactic.
"Listen, you know that patient.
I'm pretty sure it's a neurosurgical problem.
If I'd been smart enough at medical school,
I'd have really liked to be a neurosurgeon."
(Laughter)
"And you're here" -
you think I'm joking; that really works -
(Laughter)
"And you're here."
And he said no.
And I'm maybe beginning to get a wee bit angry.
So I decided to drop the C-bomb
because that's the way I roll.
(Laughter)
And I said to him, "I need you to see this patient.
I am telling you to see this patient because I am the consultant."
Boom.
(Laughter)
And he looked at me.
There's quite a lot of eye looking going on at this point.
And he looked at me and he said -
he did this -
"What do I care?
I'm going to be a consultant someday myself."
(Laughter)
And I had nothing, except this:
I can tell you, in here today, that the red mist can descend
from the Pentland Hills just outside Edinburgh
all the way into an emergency department in Midlands
in under about half a second.
And as I stood there and my voice got louder, deeper and more Scottish,
(Laughter)
and I drew myself up to my full 5'7.5",
(Laughter)
I saw two things happening:
The first was my wonderful, fantastic, amazing colleague,
the nurse in charge did precisely what her title says -
and she belted around her desk, and she charged across to us,
because whatever this crap was,
she wasn't going to let it happen in her department.
And the second thing was this:
I saw the heads starting to go down.
First one - pop, then another - pop, then pop, pop, pop, pop, pop, pop, pop,
all these heads going down all around,
all apart from one guy about 3.5 meters in that direction.
And he's leaning against the desk, and he's watching.
And in my corrupted memory,
he's opening a packet of crisps and getting a can of Coke out
because this is the most fun he's going to have all day.
(Laughter)
I thought those guys were just going back to work,
but they're not.
The first thing they're doing is avoiding the eye of Sauron
because we know
that the way that somebody has just treated the last person
is likely to be the way that they treat the next person.
Something else is happening as well,
because they actually have their bandwidth impacted too.
And on average,
they are 20 percent reduced in their performance.
But there's more.
Because if they get up and they walk around the corner,
and somebody asked them for help,
they're then 50 percent less likely to help that person.
This stuff is simply contagious.
So is change possible?
This is 1959,
Western General Hospital in Edinburgh,
the NHS is 11 years old,
and this is my mum.
And next to my mum, Charlotte and Julie,
they were forged as junior nurses in the NHS.
They still meet, and they still have coffee together.
And on the ward, twice a day,
one of my mum's jobs is to clean the ashtrays,
(Laughter)
because there's an ashtray on every single bedside locker.
(Laughter)
patients are being encouraged to go for a cigarette.
"It's good for the nerves.
(Laughter)
In fact, if you don't smoke,
maybe you'd like to think about taking it up."
(Laughter)
And then we learned the terrible toll the tobacco takes on health.
What did we do?
We stopped smoking.
We stopped advising people to smoke,
and we stopped supporting it.
So now it's 2019.
We're beginning to understand the impact the behavior has on team performance.
That's great.
What a wonderful opportunity.
Because by choosing to behave
in ways that value and respect the people around us,
we help individuals and teams to perform at their peak.
In my world, civility can literally save lives,
but for all of us who work in teams, who work with people,
civility can be the difference between OK and great,
no matter what we do.
Thank you very much.
(Applause)