Following her presentation on civility at this year’s AOT Annual Conference, Andrea Burgess speaks to AOT treasurer Callum Findlay about why civility is a surgical skill, not simply a matter of manners.
Andrea Burgess.
Abrasiveness in surgery has long been shrugged off as an occupational hazard, the price of working alongside brilliant, stressed people doing difficult things. A growing evidence base says otherwise. We spoke to Mrs Andrea Burgess, ENT consultant at Hampshire Hospitals and University Hospital Southampton NHS Foundation Trust, about why civility is a clinical skill, not a soft one, and why the way we treat colleagues in and out of theatre may matter as much as anything we do with our hands.
"Incivility measurably reduces cognitive performance"
‘Civility saves lives’ has become a familiar phrase in the NHS. For anyone who has not met it, what does it mean and why does it matter in a surgical specialty like ENT?
It began as a grassroots campaign, set up in 2016 by Chris Turner, an emergency medicine consultant, and colleagues, after they came across research on how rudeness affects workplace performance. At its simplest, civility is how we treat one another: respect, courtesy and valuing the people we work with. The provocative part is the claim that it saves lives, which sounds like a stretch for something we file under manners. But in ENT we operate in teams, usually under time pressure, and the quality of those relationships shapes how safely the team performs.
‘Saves lives’ still sounds like an overstatement. What is the actual evidence that rudeness harms patients, rather than just being unpleasant?
The headline study is a randomised trial by Riskin and colleagues, published in Paediatrics in 2015 [1]. Neonatal teams ran a simulation of a deteriorating baby. Some were exposed to mildly rude comments from an observer, remarks unrelated to their clinical work. The teams who encountered rudeness scored significantly lower on both diagnostic and procedural performance. In surgery, Cooper and colleagues looked at more than 30,000 operations and found that surgeons who attracted more unsolicited patient complaints, a reasonable marker for rudeness, had more postoperative complications [2]. Christine Porath’s work shows incivility measurably reduces cognitive performance [3]. So, this is not just about hurt feelings; it has a measurable impact on patient care.
How does incivility degrade performance in a live theatre situation? What is actually going on?
The Riskin study is helpful because it points to the mechanism. The drop in performance was explained by two things: people shared less information and they asked for help less. Translate that into theatre. The trainee who notices something unexpected and decides not to say it out loud. The anaesthetist who lets a concern slide rather than challenge a surgeon who has been snapping all through the list. There is also a bystander effect: you do not have to be the target to be affected. Simply witnessing rudeness degrades your own performance, because your attention is hijacked by the tension in the room.
You have said this is mainly about staff, not patients. Why put the emphasis there?
Because that is where most of it happens, and it gets the least scrutiny. We rightly focus on how we speak to patients, but the bulk of incivility in a surgical service is staff to staff. Surgical specialities and the theatre environment in particular can have a steep hierarchy. The tone a consultant sets with a trainee or a healthcare assistant ripples through all of it. And it does not stop at the theatre doors: the curt late-night email, the sigh during an MDT meeting, the dismissive message in a team chat. Incivility is contagious and travels well beyond the moment.
Is there something about surgical culture in particular that makes this harder?
There is a long-standing stereotype of the gifted but abrasive surgeon, and for years we tolerated it because we quietly conflated being tough with being good. Recent national reports on bullying, undermining and misconduct in surgery have made that position impossible to defend. Staying calm, courteous and clear when the pressure is highest is a marker of a good operator, not a soft one. The surgeons I most want to work with, and learn from, are the ones who keep the room calm and supportive when things get difficult.
Can you share a moment that shaped how you think about this?
One experience that shaped my belief in ‘civility saves lives’ was a paediatric airway emergency at a district general hospital where I did not know the team, the environment or the equipment. A newborn with an unexpected airway abnormality needed urgent intubation. The situation was highly stressful: staff were unfamiliar with the situation and the ENT equipment, anxiety was rising and frustration was beginning to spread through the team. Before attempting the procedure, I asked everyone to pause. I thanked them for coming to help, acknowledged that this was a frightening situation, and reminded them that our best chance of success was to work together. I gave everyone a clear role, encouraged people to speak up if they had concerns and emphasised that we all had a responsibility to watch for signs that the baby was not improving. The atmosphere changed immediately. People communicated more openly, supported one another and focused on the shared goal rather than individual frustrations. We successfully secured the airway and afterwards held an open debrief to discuss what had gone well and what we could improve next time. For me, this was a powerful example of how civility creates psychological safety. In a crisis, respectful communication is not simply about being nice; it helps teams share information, speak up, make better decisions and ultimately deliver safer care for patients.
"Civility is not a persona you switch on at work; it is easier, and more honest, when it is simply how you treat people"
How do you build the kind of safety where a junior nurse or trainee feels able to speak up?
You have to make it explicit, because hierarchy does the opposite by default. Use people’s names. Tell the team at the start that you want to be challenged: say that if anyone sees something you have missed, you want to hear it. Brief before and debrief after. Thank people for speaking up even when they turn out to be wrong, because that is what keeps them speaking up. The WHO checklist and first-name introductions exist partly to flatten the gradient when it matters most. When someone challenges you, respond with curiosity, not defensiveness. People watch how that goes and calibrate accordingly.
Does this spill over into life outside work? Many of us are juggling significant responsibilities at home.
It runs in both directions, and we underplay that. A difficult list or a curt exchange does not evaporate when you take off your scrubs; it follows you home, and the people who get the worn-out version of you are often the ones you care about most. It works the other way too: when you are short of sleep, worried about a child or carrying a caring responsibility, your reserves are lower before you have even arrived. Recognising that has made me more forgiving of colleagues, because the person who seems abrupt may be holding something you cannot see. The habits are the same in both places: assume good intent, notice your effect on the room and repair quickly when you get it wrong. Civility is not a persona you switch on at work; it is easier, and more honest, when it is simply how you treat people.
Practically, what can a trainee or a consultant do differently?
Mostly small, unglamorous things. Learn the names of everyone in the room, not just the medics. Say thank you and mean it. Assume good intent when something goes wrong. Give difficult feedback privately and offer praise publicly. If you see incivility, name it and challenge it rather than letting it pass. For consultants, there is no getting around it: you set the tone for everyone, whether you intend to or not.
If readers take one thing away, what should it be?
That civility is not niceness for its own sake. It is a clinical skill and a patient safety intervention, and it happens to be one of the few things in a pressured NHS that is almost entirely within our own control. The evidence keeps pointing the same way: teams who respect and value each other share more, help more and perform better, and that produces the best outcomes for patients and staff. That, in the end, is what ‘civility saves lives’ really means.
References
1. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics 2015;136(3):487–95.
2. Cooper WO, Guillamondegui O, Hines OJ, et al. Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications. JAMA Surg 2017;152(6):522–29.
3. Porath CL, Erez A. Does rudeness really matter? The effects of rudeness on task performance and helpfulness. Acad Manage J 2007;50(5):1181–97.
Declaration of competing interests: None declared.
