Hi, I'm Laura Playforth. I'm a veterinary surgeon and I work in the IVC Evidencia as the group Quality Improvement director looking at improving care across our 20 countries in all different types of practise. My background is small animal first opinion, and then I moved into ECC where I worked for a number of years before moving into this role.
And today I'm going to talk about a stitch in time, how civility prevents teams from unravelling. So I wanted to start off with a story, and this is true events to the best of my recollection from my time when I worked in ECC. So this started out on a relatively busy shift.
We've got quite a lot of patients waiting to be seen in the waiting room. We've got a number of inpatients in the kennels with various different illnesses and ailments requiring treatment. And in the middle of this, we had a dog present that was around 7 years old, it was a Great Dane, and it looked to have a GDV.
So this started off being a little bit of a tricky case because the dog was quite nervous. We had some issues trying to manoeuvre the dog out of the back of a very small hatchback car into the clinic. Clearly it was a very large dog, so all hands on deck.
We needed all the staff present to manoeuvre the dog who was trying to get away from us. Being very nervous and trying to communicate effectively with the clients at the same time. So we managed to get the dog into the building.
And On a very busy shift, managed to get it straight through because it was quite an urgent case. So as we started to work the case up, have conversations with the clients. I was getting increasingly a little bit stressed because there was a lot of clients waiting in the waiting room, some of whom had been waiting for a little while at that point, and a number of impatients that still needed things doing to them as well.
So as I was trying to get things organised to get this dog stabilised and start to prepare for surgery at some point once it was stabilised. I noticed that the nurse kept going off to do things, and whenever I wanted to ask her to do something or get something prepared or help me with something, she didn't seem to be available. She was always doing something else, and I started to get a bit frustrated about this because this dog seemed to be deteriorating quite quickly.
And because of how anxious it was and how large it was, it was very difficult to Deal with the patient and try to get things ready myself. So I really needed her help. And as time went on with the case, she would come and help me, and then she would go off and do something else.
And it felt like every time I went to ask her to get something, she wasn't available or it seemed to take her quite a long time to find things. And I started to get increasingly frustrated of all the backlog of things that were coming through. And I can remember feeling I was getting a little bit agitated and I do know what the signs are, and I start to go a bit red in the face and feel a bit flustered.
And I do remember one time looking up and looking at the nurse and thinking, what is she doing? Like, I couldn't understand why she was doing, preparing some medication for a different patients instead of what I just asked her to do. And I can remember my communication getting shorter and shorter.
And at some point during this, the receptionist came in to ask me a question about a call that they'd got on the line about another patient that seemed to be very ill. And I can remember the answer to them. I gave was much shorter than I ordinarily would do.
And probably the tone of it wasn't that great either. And shortly after that, I looked up to see what the nurse was doing now, for goodness sake. And when I looked at her, I thought, gosh, she looks a bit red in the face and a bit stressed, and I thought, oh that's a part of my brain did actually kick in and said, To me, that's not like her, she's normally quite levelheaded, she works in emergency all the time, she's very experienced, it's not like her to be getting stressed about something.
I wonder what's going on. And at that point, something else kicked into the back of my mind to say, I think it's you. I think you're what's going on with her.
I think you're being quite demanding and quite snappy in how you're speaking to her, and I think it's making her really stressed. So at that point, I apologised and we tried to get things back on track. And once the case had been dealt with after the shift, we had a little discussion about it, and I apologised again and hopefully tried to rectify the situation.
But driving home from the shift, I started to think to myself, actually, the fact that she was getting stressed because of the way that I was communicating with her was then impacting very significantly on how she was able to perform her job. So essentially, my communication was making her. Ability to do her job worse, which in turn was making me more frustrated, and we'd got into this awful, vicious cycle which had impacted both of us and potentially could have really impacted the patient.
I don't think it did in this case, or there was nothing observable, but it definitely could have, because things were taking longer and longer to get organised, and she seemed to be spending more and more time doing other things, presumably avoiding me at that point. So I think that was a, a big wake up call for me personally, in noticing how, when I got stressed and my communication started to deteriorate, it really impacted on the rest of the team. So that was something I have tried to work on since then.
But actually something I've got more and more interested in, particularly as I've got into quality improvement and looked at all the evidence that surrounds, not just the impact on us and our colleagues, which is obviously incredibly important, but also the impact on the actual outcome for our patients as well. So this is one instance, and hopefully I learned from that and really tried to minimise the impact of my instability on other people again. I'm sure I was not and I'm not perfect, as none of us are.
But I, once I started to look into this, and how often it does happen, I found that within the last 10 to 15 years in particular, there is a really increasing body of evidence that tells us about the impact of civility, why it happens, how it happens, what it causes. And looking at a study by Para and Pearson in 2013, they looked at a variety of different. Employees and how often they experienced incivility, and they showed that 98% of people will experience at least one episode in their working lives.
So pretty much everybody will experience some degree of incivility, and actually 50% of people experience it weekly. So this is absolutely huge when we think about the frequency of it. And then particularly now as we move on to look at the impact of it.
So I think it's worth taking a moment for us to look at what we mean by civility or incivility. So. Civility is basically.
Not being rude and the behaviour that we would all want to have speaking to people kindly, nicely, respectfully. So incivility or rudeness can be a whole wide variety of things, some of which seem to come to mind more obviously than others. So, I think when we get to the more extreme end things, shouting, swearing, throwing things, things which are moving into a more serious spectrum, those are quite obviously not a civil thing to do.
The same with being aggressive, but there can be some more lower level behaviours which can be slightly less obvious, and we don't think about them as much in terms of excluding people by gossiping behind people's backs, conversations outside of meetings, talking about people, also being dismissive in conversations, talking over people, for example. And one of the most important bodily indicators when we're looking at body language, of being in civil, it can be things like cutting, crossing our arms, and also eye rolling. And that when I was looking at some of the evidence around this, I found a really interesting report from the Gotman Institute, and they were looking actually at indicators of divorce in married couples, and they Did videoed interviews with the married couples over quite long periods of time, and then they looked at all the various different indicators and to see what correlated with people staying together in a marriage or people getting divorced.
And they found that one of the strongest indicators of divorce was contempt for the other person, so a disregard for their feelings and their opinions. And one of the strongest indicators for that in a body language sense is eye rolling. So, who knew that eye rolling could be such a strong indicator.
So for anyone who has been the recipient of or who has rolled their eyes previously, it can be a really, really strong sign of contempt. And again, what matters with these things is when they are repeated or sustained over periods of time. The odd one, especially if we apologise and try and make amends afterwards.
Doesn't necessarily need to be a deal breaker, but if these things happen continuously and they're not changed, then that can really seriously damage relationships, whether that's a work relationship or whether that's a personal relationship. And a lot of this behaviour is. Unintentional or we don't intend.
To cause harm by doing this behaviour. If we're intending to cause harm, that moves more towards bullying, which is intentionally influencing people by your behaviours. So some incivility issues can be.
Unintentional, but still serious and still something that we need to really consider. And again, when we talk about exclusion or rudeness, some of that can be very subjective. So we have very different social norms, very different cultural norms in some cases of when direct speaking is the norm and socially acceptable or when direct speaking can be interpreted by some people as rude.
So that makes defining instability quite challenging in some cases. But the generally accepted definition is how the action or the words are received by the recipient. So that's how we define it.
So it's not necessarily what you intended to do, but it was how they felt when they saw you having a conversation and they walked into the room and it stopped and they felt excluded and othered and As if that was rude and and uncivil, whether that was what you intended to or not, whether that was a natural pause in the conversation, or whether you actually were talking about them. So that's how we define. Civility is an absence of incivility or rudeness, and that's obviously what we're aiming for, but we can see how easily we can get into the realms of being uncivil to each other.
So what happens when civility is lost? And we talked in the title about the, the unravelling of the team and how that can happen. So, what is the evidence?
And as I said, during the last 10 to 15 years, there's been a real increase in very high quality, often randomised controlled trial evidence of the impacts of civility on us, on our colleagues, on our own. Clients and importantly as well on our patients. So what happens when somebody is the recipient of incivility is on average, they can have a 61% reduction in cognitive capacity.
And we know working in the veterinary clinical setting is incredibly complex. There's lots going on, as you could see by my example. That was one shift in ACC, which is very complex and can have an awful lot going on.
But on a day to day in any practise setting, there are lots and lots of different things to consider. You've got a lot on your mental scratch pad to deal with at any one time, and a lot to remember, and the consequences of not remembering or Taking an action that you didn't intend to take can be incredibly serious, as we know. When we look at patient safety errors and incidents, so reducing that capacity by 61% is incredibly significant and impactful, and we can see how that would lead to.
Us being more likely to make medical errors and things that can impact on us and our patients. Also from the evidence, around 80% of people lose time at work worrying about what happened, going over it in their head, thinking about why did they say that? Why did they act like that?
Have I done something wrong? So, again, a lot of time can be lost, which should be focused on doing the job, and again, doing the job correctly and not making mistakes. And as we saw from my example, a 38% reduction in the quality of people's work for all these reasons, because they've lost the capacity.
To carry out things and to think as well as they should, and they're spending time worrying about it. So, again, 38% is very significant. And that's what we saw.
That was what, The quality of my communication or lack of quality. Led to in one of my colleagues was her losing the quality of her work. And 48% reduce time at work.
And I think we can see that in this example of I was getting frustrated of why is the nurse not here doing things? And she did have other things to do with other inpatients, whereas I've got quite tunnel vision focused onto this one patient. But also, I very strongly suspect that she was intentionally being in a different room to me because she was finding my communication difficult.
And 12% leave. Either the practise or the profession, and that's incredibly significant as well. And when we know we've got some concerns around the number of vets and nurses in particular in the professions, anything we do that can make the environment pleasant to work in and stop people leaving.
Is very important. And again, during the example, so I had a receptionist come in to speak to me at some point, and that person got quite a short answer compared to normal. And we know that there is a domino effect in incivility that bystanders who witness incivility also have a 20% reduction in their cognitive ability, even if the incivility wasn't.
Directed towards them. It can still make them much less likely to be able to do their job. And also, the evidence shows that they're 50% less likely to help the next person.
So, They may have been required to provide some information to clients on the phone, and it will make them withdraw into themselves. It's something that we're not aware of, just a reaction that we have to that instability. They are just people are just less likely to help either the clients or other team members, or me or the nurse.
So it has this very significant domino effect. Patients and relatives in human healthcare studies, so clients in our world. There's also a 75% reduction in net promoter score, which is the likelihood of them to recommend your practise or your team to other people, which is hugely significant.
And that's just if they've witnessed something, not necessarily being the recipient of it. So there's overall impacts on the team because of this domino effect. So there's an overall reduction in the cognitive capacity, innovation, communication, collaboration across the whole team.
And this leads to evidence that there are worse clinical outcomes across all clinically significant measures that have been looked at. So I thought this was a really interesting study to highlight, and it is, it's around surgeons. This is not being critical of surgeons as a group.
Things are just easier to measure when we're looking at surgery than they are in many other areas, but this study, they used a simulated operative crisis in human healthcare, and then they had the surgeons either being polite and civil or being rude. And in civil. And then they looked at the anaesthetist performance and the impact that their surgeon's communication had.
And we can see that there was a really significant difference in their behaviour at the expected level in their roles, which is a key critical role for keeping our patients, or in that case, people alive. But one of the other really interesting findings was that when they asked the anaesthetist if they thought their performance was impacted, they didn't think it was. So I think that shows that we are impacted very significantly by incivility, but that we don't recognise it, and that can be even more dangerous.
And when we're looking at, again, this looks at surgery because it's quite easy to study. But whether there's a relationship between concerns, complaints about the surgeon's behaviour and communication and surgical complication rates, we could see there was a really significant correlation there. That when performing complex surgery in particular, rudder surgeons had significantly higher rates of wound complications.
So I think that's a really good example of the direct impact of how we communicate and how we work as a team on patient outcomes. And there's been as well as colleague to colleague in civility, there has been research on incivility between, in this case, in human healthcare relatives and the caregiving team. And does that in civility influence care?
And yes, absolutely it does. So we've got a study up here they were looking at neonatal ICU teams and whether there was perceived rudeness from relatives or not and whether that had an impact. On the outcomes, and it absolutely did.
So reading this from relatives results in poorer performance from teams under stress. And that also goes both ways. So when they looked at actually the magnitude of the impact, it seemed that there was more impact in many cases of client incivility or patient incivility than colleague incivility, which is interesting.
And I, I think we could speculate as to the reasons behind that, whether it's because we have pre-existing relationships with a lot of our colleagues and whether because there is that opportunity for reparation and apology. And mending relationships, whereas with money. Patients in this case, or clients, there isn't always that opportunity to have the relationship or to make reparation at the end, but it does seem that there is more impact, and I think that would probably fit with how most people feel in practise, certainly lots of the people that I've spoken to, that that rudeness from clients can be hugely impactful.
And also vice versa. So as we said, clients who witnessed incivility were definitely 75% less enthusiastic for the team and for the organisation. But also when clients felt that they'd been.
Witnessing incivility, 66% of them felt very anxious dealing with the staff, which actually can stop them from asking for help or reporting problems, and it can also stop them from, Undertaking things that we recommend in terms of home care, which can have significant effects on the patient outcomes because we might recommend that they do something at home, give medication. Do certain other treatments and the clients lose that trust, that bond of trust, which is so important between the caregiving team and the clients can be ruptured because of this communication issue, which causes upset. So Oh, we've looked at the impact of.
Incivility, and I think it's important to look at what we can do to mitigate some of these issues. And I think it's important to say that. It's easy to look at a lot of this literature and a lot of the evidence and to think incivility is just what rude people do, and that's other people, it's not me.
And I, I think there would have been lots of times in my life when that's how I would have. Framed it to myself and thought, oh well, that's what, you know, people who are rude, that's what they do. That's not what I do because I'm a good, well-intentioned, caring person.
I care about my patients, I care about my colleagues, I care about the clients. I wouldn't do that. And as we've seen, I think when we take the time to reflect, we would find out that most of us do do that intentionally or unintentionally, almost always unintentionally.
These things do happen, and I think a good starting point is to always look at ourselves and our own behaviour and be reflective about that and start to role model the behaviours that we want to see out there in our teams as best we can do. And also to be aware. When things go wrong, of how we can try to put things right.
And also to invite feedback from other people and to encourage people to feel comfortable that you want them to speak up if they notice that you're doing something that isn't great, that's having a negative impact on the rest of the team, that you give them permission to be able to speak up. Without them also being critical and biting their head off when they do that. So I think this is a quite an interesting slide as well, which shows the evolution of incivility and this can happen in all of us at some point in our lives, I'm sure.
So we start off with somebody like you and I. We're all very civil and nice and caring people. Lots of external stresses happen all the time, whether that's things in work, cases, whether it's things also outside of work.
We're all human beings and we've all got these things. Honours these stressors at all times, and they will fluctuate over time and some things will become more prominent and more impactful. And we can get to a point where there are lots of stresses, and it can then lead to.
A stress response, which can lead to us being incivil and rude and doing behaviours that we wouldn't ordinarily. And also don't think are acceptable and wouldn't feel ourselves capable of doing. But what can really exacerbate this is having that permissive environment when it's not addressed.
And then that can learn to lead to people becoming more routinely or more habitually. In civil with each other, which again can, as we've seen, have a big domino effect. So not only are people.
Influenced and impacted in terms of their cognitive capacity and their ability to do the job. But if there is an in civil culture, the tendency is to respond to incivility with more incivility, and that can quickly get into an escalating spiral and an unpleasant culture and an unpleasant place to work in. So we also need to be very cognizant of having That kind of permissive environment which allows that behaviour to multiply and flourish, and what we can all do as individuals, to make sure that we can address that and have a culture where things can get addressed.
And I think, It's very important when you have got either a managerial role or a leadership role, or there is that perception of some sort of power hierarchy. You have to be very careful that. People won't always feel comfortable necessarily to speak up because of a perceived power hierarchy, and that can be because you're their line manager, or you're their leader, or you're a specialist, or an expert, or you're very highly qualified, or you've been in the business a long time.
It can be for all those reasons that other people might, in particular, not feel comfortable to speak up and say something. So creating that permissive. Creating an environment that's not permissive, where you've got psychological safety and people can speak up, is really important and it needs a bit of work to do that.
And again, I think something we can do when we're thinking about ourselves and our own behaviour. I think about how we react in terms of other people as well, to prevent that escalation. And thinking about prosocial behaviours, which can be defined as voluntary behaviours, which is intending to benefit other people.
And you can do that proactively, but you can also do that in response to. Other people's incivility, what you perceive as their incivility. So I think it's fair to say that almost everybody goes to work with good intentions, wanting to be good at the role, particularly for those of us that work in caring professions, you know, we care very much about our patients, our clients, we care about each other, and that's generally how we all set off into the work day.
And I think keeping that in mind about other people, as well as about ourselves, can be really helpful, but people have generally, almost always started out from a position of good intentions. And that can, that change of framing can help us when we're moving into a situation where somebody has been uncivil. It can help us to address that in a, a more compassionate way instead of.
Being in civil back and making the whole thing spiral and making it worse. There is a lot of evidence around the importance of refraining from judgement as well. And I heard a really interesting quote the other day that said, What you judge, you cannot understand because you've already made your mind up.
So at the point you make a judgement of that person is rude, or that person is aggressive, you have closed off your curiosity to what's going on in that situation, because you've already decided there's nothing to be curious about. So if we can refrain from that judgement, and again, linking into the assuming of good intentions, we can then become compassionately curious about what's going on with that person. And why is that person being.
Snappy or rude or direct, particularly if it's something that's out of character, there's almost always something going on. They have got some stressors in their life that are impacting how they're able to communicate. And then we can approach that from a more compassionate position.
And acting with compassion is really interesting. I'll go on to a little bit of the evidence around that later. But the definition of compassion that.
I feel is really helpful, is it's not necessarily the same as empathy, so feeling what other people feel, but compassion is making attempts to understand the way that they feel and then doing something about it and doing something to act. And that can be really powerful in terms of helping people. It's not just, oh, that person's really upset and I'm upset.
Which actually just then leaves everybody very upset and doesn't really help the situation, but being able to act in a way that can help. Is clearly good for that person, it's also incredibly good for you as well. And again, moving to mend relationships because we will almost always be uncivil at some point for a variety of different reasons that are going on with us.
So being able to mend those relationships as best we can do. Is incredibly important and not just thinking, oh well, it's done now, I'll just let it go and carry on as normal, but actually reaching out to the person and apologising and doing your best to, Make amends with them is hugely helpful. And I think it's also important to to mention that being compassionate and having a compassionate approach and assuming good intentions doesn't mean it's a carte blanche, anything goes.
I think we can still have appropriate boundaries, and we can still maintain those boundaries as firmly as we need to, whilst also having a compassionate approach to people. So, no, it's not OK to raise your voice at colleagues. That's a firm boundary that we have in this team.
But at the same time, you can approach that in the sense of What's going on with you? Is everything OK, rather than going in with a hard line, we can't do that or worse still. Going and shouting, raising voices back and making the whole thing.
Escalate There is some really interesting evidence of. Anonymity and the incivility that that leads to. And I think we all have a reasonably good understanding of how that can work in life, particularly on things like social media, of when people don't know each other and don't have a relationship, there can be that real, real incivility and aggression and That tends to be lessened when people know each other and have a relationship with each other.
So even things like making sure we introduce ourselves to other people when we're communicating, but even better, if we can have that relationship ongoing, so that we know that that person is a good person and well intentioned and almost all of the time, not rude. On the odd occasion when they are under pressure and don't communicate in the best way, it is much easier to refrain from judgement and much easier to assume good intentions because we've got previous experience of that person. So I think there's a lot to be said for building these relationships with everybody within the team, but also with people outside of the team, including clients, including.
Practises that might be in your local area, including referral relationships, out of hours relationships, the better we get to know people, the more relationship we have, the easier it is to maintain that civility and also to stop any thing escalating. And there's been a number of movements, I suppose within the human healthcare. Professions to look to address these things.
And one of the big ones, which was developed by a doctor who actually had terminal cancer and was a patient herself, is that, hello, my name is. Project where she felt. Very much that lots of the people who came to take care of her, they didn't introduce themselves.
She wasn't sure whether they were a nurse, a doctor, a specialist, an oncologist, what their role was, and didn't feel like she had as good a relationship with them and understanding of their role as she could do. So she campaigned really hard to have badgers made that introduce people. Hello, my name is Lara.
And the duty vet or whatever people's roles are. So that's incredibly good for clients, in our case, but also incredibly good for us, especially when we're working in big teams or busy teams or people who work across different teams, maybe when we're using locums. Just to make sure everybody knows who everybody else is.
And another similar movement to that is the theatre cap challenge, which again came from human healthcare in surgery, where name badges are obviously not visible for infection prevention control reasons. So they wanted people to write their name and the role on their theatre hats, it's very easily seen. And again, particularly in large team was where some people might have the same name.
Everybody's got masks on and gowns, and it can be difficult to differentiate. Who people are and mistakes have definitely happened because people have not been identified. Correctly, or there's been some assumptions made that they have a certain role and therefore a certain skill set when they don't.
And I've definitely experienced that in practise as well, working in the ECC. With different teams and doing handovers where the conversation has been had, a handover's been done, and maybe you handed over to the nurse instead of the vet or vice versa, and the correct person didn't get the correct information at hand over, and that can definitely have an impact on our patients. So, as well as reducing instability, it helps to reduce these kind of mix up errors as well.
So I wanted to highlight this book because I think this is absolutely fascinating in terms of looking at the evidence that having a compassionate approach and really working hard to. Reduce civility, reduce instability and to stop that escalation has a huge impact on us in our roles and also on our patients. So I thought it was an interesting title when I first saw this book, and for some reason in my mind, Compassionomics kind of linked to economics.
And I thought, oh, this is something about. Making money from compassionate care. But actually, the authors named it that because they felt that compassion, in terms of its impact on clinical outcomes, and also on caregiving teams, is as important as the genomics project, which was very, very prevalent in the media when this book was written and developed.
So it's nothing to do with money, really. It's to do with the importance of the impact of compassion. So, I think this is a fantastic book, and it really goes into the evidence around compassion and as we say, that definition of it's not.
Pity, so it's not feeling sorry for people, and it's not sympathy, it's not sort of feeling for them. And it's not empathy in terms of feeling what people feel, because I think we all recognise. The dangers that there can be, you know, for people who are very empathic, which many of us are, but taking on other people's feelings can be very negatively impactful and very draining.
So this talks much more about trying to move towards understanding what people feel, but not, they don't advocate for feeling what other people feel. And then doing something to help. And the power that that can have, both in terms of our own mental health and well-being.
And also the impact on patient outcomes. And it talks a lot about burnout and how there are aspects of empathy that can exacerbate and lead to burnout. But there's a lot of evidence that compassion, in terms of understanding and then that helping behaviour can be an antidote to burnout, which I thought was really fascinating, and there's actual evidence of that being the case.
So I think we can worry sometimes about whether investing ourselves emotionally. Can have a detrimental impact and this shows that there are different ways of doing it, that means it can have a positive impact. But also the impacts on the clinical outcomes, as we said, across the board, is absolutely staggering.
And if you put all that evidence together, if everybody is competent at their role clinically, how we collaborate and work together is the single biggest determinant of clinical outcomes for our patients. Which I just thought was absolutely incredible. So I would recommend it, can be a little bit hard to get hold of, but I got an audiobook and had a, a listen to it and I would highly recommend it.
It also talks about self-compassion, which I think is incredibly important for us as caregivers of how to treat ourselves compassionately. And again, that understanding how you feel, that reflective piece. But instead of moving on to rumination, which can be really negative and detrimental, moving on to do something to help yourself.
Very impactful. And moving on to that compassionate work, so how do we spread that as an antidote to incivility? And we've mentioned psychological safety a couple of times.
And I think that's a very important concept of people feeling, number one, that they can come to work, be their actual authentic selves, that they don't feel that they have to hide or pretend. And that they can speak up when they have got an idea of how things could be better. They can speak up when they think things are not ideal.
They can speak openly or frankly to people, maybe if they are being in civil. And this is something that we can take positive active steps to create with our teams and Again, it starts off by role modelling that behaviour ourselves, but also talking to our teams, encouraging them, supporting them, making sure that when they do bring ideas, that those ideas are considered and things change if they can change, but that people feel heard because they are heard and you build up that trust with the team. And again, having that appropriate curiosity of why things are as they are, why are things different to how they Normally are, instead of the judgement, which shuts down all that understanding.
And using a different lens to look at things, I think is really important instead of perceiving people as being a rude person, understanding what's going on with them. Or maybe they just. Have a more direct way of speaking, and actually they don't have any intention behind that other than getting their message across.
In a way that's that's understood. So I think once we get to know people and understand people, not only can civility lessen, but that. Perception of incivility can also lessen when we understand that that's not the intention behind the way that people communicate necessarily.
And behaviour change, I think everything starts with us and changing our behaviours. So I think in summary, incivility will happen, but there's lots that we can do to mitigate the effect of it, stop it escalating and role model that behaviour and support each other. So I've got a few suggested resources at the end, if you are interested in reading a little bit more.
Our CVS Knowledge I've got some great resources around this and how that cultural piece influences quality improvement in practise and the quality of care that we deliver and clinical outcomes. The Saves Lives website give them credit for a number of the infographics that I've used in this presentation. They've got a lot of free resources, open access on their website, including TED Talks, lots and lots of infographics that can be really useful if you're wanting to have these conversations and show people the evidence in a very easily digestible format, rather than people having to go and wade through lots of published papers if they're not that way inclined.
Again, the Compassionomics book I feel was very impactful. And Helen Silver McMahon wrote a really excellent article and in practise as well about civility saves lives. So thank you very much for listening.