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The ‘Hidden C’


The Importance of Civility in Critical Care Resuscitation

A 3-year-old patient with diabetic ketoacidosis arrives at your ED.

While you are leading the resuscitation, one of your senior colleagues belittles a junior staff member for struggling to site an IV line.

The team sits down for a hot debrief once the patient is stabilised and transferred to the ICU. The junior staff member remains silent throughout the debrief and does not attend their shift the following day.

How do you manage this situation?

Introduction: Civility Matters

Healthcare environments, particularly emergency departments, are characterised by high levels of Volatility, Uncertainty, Complexity, and Ambiguity (VUCA).

In such situations, ‘soft skills’ such as teamwork, compassionate leadership, strong interpersonal communication, and psychological safety are essential. However, education and training for healthcare professionals traditionally prioritise ‘hard skills’, particularly critical care resuscitation. The traditional ABC approach to acute stabilisation exclusively considers technical skills while omitting the hidden ‘C’- Civility. 

Incivility can mean many things. Often, it is used interchangeably with terms such as unprofessional behaviour, bullying, and lateral violence.

Most acts of incivility tend to be verbal, though non-verbal abuse does also take place. The lack of consistent definitions in the literature makes it difficult to report its true prevalence and hampers efforts to combat it. Nonetheless, research has consistently shown that healthcare environments demonstrate higher-than-average levels of workplace incivility. 68-90% of nursing staff have experienced incivility, with over 75% of cases originating from their peers. Nurses in emergency services are more frequently exposed than those elsewhere.

Clinicians have reported similar rates, with non-consultant doctors particularly affected.

Factors contributing to incivility in healthcare

Many complex factors contribute to incivility in healthcare. At an individual level, younger or more junior staff members and ethnic minorities are more at risk. The strong hierarchical nature of healthcare systems and the high frequency of interpersonal interactions likely exacerbate this. Certain personality styles associated with strong, assertive traits, scepticism, and social dominance have also been associated with incivility. These personalities are arguably more prevalent in healthcare professionals, particularly in technique-orientated specialities such as Surgery, Anaesthesiology, and Emergency Medicine. 

At an organisational level, lack of resources, high workloads with heavy responsibility, lack of familiarity among team members, lack of supportive leadership, and a permissive workplace culture increase the risk of incivility. These are often hallmarks of healthcare workplaces. High levels of passive acceptance of incivility have been demonstrated in healthcare workers, with up to 80% of incidents being unreported. Barriers to reporting include a lack of awareness of reporting mechanisms, fear of repercussions on professional reputation, and a lack of proactive leadership support. 

The snowballing effect of incivility exacerbates these factors. Once a sufficiently high level is achieved, modelling of behaviours and episodes of retaliation can perpetuate the behaviours far beyond the initial event. In contrast, transformational or authentic leadership and specific civility training can be protective. Unfortunately, these do not feature consistently in traditional 

education and training programmes for healthcare professionals.

Civility Saves Lives

The impact of incivility in healthcare cannot be understated. High levels of incivility correlate with adverse outcomes for patients, staff, and the organisation. 

Riskin (2015) showed that rudeness accounted for a 12% reduction in diagnostic and procedural performance in a simulated resuscitation.

Another RCT demonstrated that clinicians exposed to incivility performed worse in every assessed domain, including diagnostic accuracy, effective communication, responsiveness, and overall patient management. Interestingly, those exposed to incivility in the latter trial were unaware of a drop in performance. They underestimated the impact of this exposure.

A third RCT demonstrated that even brief low-level incivility could increase the risk of major error during CPR by up to 66%

Incivility affects more than just the direct recipient. Exposure impairs information sharing and overall team collaboration. These elements are essential for delivering the multiple parallel processes required during acute resuscitation. Though traditionally considered the lynchpin of emergency care, technical competency alone cannot meet these complex demands. 

The lasting effects of incivility cannot be understated. Loss of psychological safety and mental well-being persist long after the episode and can impact future episodes of care. We also see detrimental effects on staff retention and damage to organisational reputation. Incivility leads to significant economic costs, estimated at £2.28 billion per annum, when considering absenteeism, staff turnover, productivity loss, compensation, and litigation.

You reach out to the junior staff member to check-in.

They admit that they felt undermined and embarrassed, affecting the remainder of their shift. They’ve taken some time off to process the experience. 

With their permission, you speak with your senior colleague to address the situation. They admit that the stress of the situation affected their communication, and they apologise to the junior staff member.

With support from their line manager, the junior staff member returns to work.

How can you prevent this from happening in the future?

Strategies to Promote Civility in Critical Care

Historically, most interventions aim to reduce incivility at an individual level. These interventions are cheaper and quicker to initiate, but their impact is limited unless underlying organisational factors are addressed. Focusing on individual-level interventions exclusively can lead to disillusionment among staff who see these efforts as ‘tick-box exercises’. 

Here are ten things to think about: 

1. Complex Issues demand Complex Solutions 

  • Avoid single-session ‘One-and-Done’ interventions. Instead, target multi-session interventions, preferably involving facilitated role-playing (e.g. cognitive rehearsal techniques). 

2. Lead with Compassion 

  • Interventions that isolate or marginalise perpetrators are less likely to succeed. 

3. Spend time in the Problem Space 

  • By identifying factors contributing to incivility in your workplace, you will be better able to tailor your interventions. 

4. Empower and Inspire 

  • Allowing staff at all levels to contribute to the strategy will ensure relevance and optimise engagement. Identify and train Civility Champions within each staff grade (e.g. BE NICE Champion Programme). 

5. Look at the Big Picture 

  • Organisations tend to over-emphasise individual-level interventions while neglecting systemic factors contributing to incivility. These include understaffing, resource allocation, and psychological safety. 

6. Target Cultural Change

  • Cultural Change programmes (e.g. the CREW Model) can yield long-term results but require adequate funding and protected time to ensure implementation. 

7. Focus on the End Goal 

  • Emphasising the strategy’s distal targets (e.g., staff wellbeing/turnover and patient safety) can boost engagement. 

8. Avoid Passive Management

  • Pro-active monitoring processes (e.g. Ethos) can circumvent a culture of permissive acceptance. 

9. Learn from Excellence 

  • A strengths-based approach (recognising and rewarding good practice) complements a deficit-based approach (reprimanding and correcting bad practice). 

10. Be The Change That You Want To See 

  • Authenticity is lost if managers are themselves engaged in incivility or if trust in management is low.


Critical care resuscitation is stressful. At its heart lies an unpleasant reality- a critically unwell child with an anxious carer hoping for a positive outcome. It is impossible to entirely negate that experience, though we can mitigate its impact through resuscitative measures. 

The ABC approach has historically emphasised technical skills while neglecting the ‘Hidden C’—Civility. By formally incorporating interpersonal elements such as respectful communication, psychological safety, and respect, we can improve outcomes for our patients, colleagues, and the healthcare system.

Civility is more than just a ‘nice-to-have’; it’s a fundamental human right and a priority for patient safety.

Scenario End:

You secure funding from management to introduce a cultural change programme.

This includes interactive training sessions, appointing Civility Champions, and modernising reporting systems.

During one interactive session, a staff member suggests incorporating Civility into the ABC approach for resuscitation. As part of this, the team lead will formally announce a commitment to civility and psychological safety during the pre-brief. The word ‘Civility’ will be written in bold at the top of the WETFLAG board during every resuscitation.

You plan a pre- and post-implementation study to measure the impact of this intervention.

Take-Home Messages:

Civility is not just a ‘nice-to-have’, it improves outcomes for our patients, colleagues, and organisation. 

Interventions at individual and at organisational levels have been shown to improve workplace civility. 

The ‘Hidden C’ of Civility should be formally considered within the ABC framework for resuscitation.

Further Resources:

  1. Civility Saves Lives
  2. NHS England Civility & Respect Toolkit
  3. RCS Edinburgh Anti-Bullying Campaign
  4. Learning from Excellence


Baran BE, Woznyj HM. Managing VUCA: The human dynamics of agility. Organizational dynamics. 2020 Aug 20. 

Churruca K, Pavithra A, McMullan R, Urwin R, Tippett S, Cunningham N, Loh E, Westbrook J. Creating a culture of safety and respect through professional accountability: case study of the Ethos program across eight Australian hospitals. Australian Health Review. 2022 May 12;46(3):319-24. 

Edmondson, Amy C. The Fearless Organization. John Wiley & Sons, 2018 

Edward KL, Ousey K, Warelow P, Lui S. Nursing and aggression in the workplace: a systematic review. British journal of nursing. 2014 Jun 26;23(12):653-9. 

Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership development programs for physicians: a systematic review. Journal of General Internal Medicine. 2015 May;30:656-74. 

Johnson SL, Haerling KA, Yuwen W, Huynh V, Le C. Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial. Journal of nursing care quality. 2020 Jan 1;35(1):70-6. 

Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, Fastman J, Marsh B, DeMaria S. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety. 2019 May 31:bmjqs-2019. 

Keller R, Allie T, Levine R. An evaluation of the “BE NICE Champion” programme: A bullying intervention programme for registered nurses. Journal of nursing management. 2019 May;27(4):758-64. 

Keller S, Yule S, Zagarese V, Parker SH. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ open. 2020;10(6). 

Lewis C. The impact of interprofessional incivility on medical performance, service and patient care: a systematic review. Future Healthc J. 2023 Mar 13. 

Luca CE, Sartorio A, Bonetti L, Bianchi M. Interventions for preventing and resolving bullying in nursing: a scoping review. InHealthcare 2024 Jan 22 (Vol. 12, No. 2, p. 280). MDPI. 

Maben J, Aunger JA, Abrams R, Wright JM, Pearson M, Westbrook JI, Jones A, Mannion R. Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review. BMC medicine. 2023 Oct 31;21(1):403. 

Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskin KS, Bamberger PA. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015 Sep 1;136(3):487-95. 

Roche E, Jones A, Plunkett A. What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? An exploration of antimicrobial stewardship excellence through thematic analysis of appreciative inquiry interviews with healthcare staff. BMJ open. 2024;14(2).

Shoorideh FA, Moosavi S, Balouchi A. Incivility toward nurses: a systematic review and meta-analysis. Journal of medical ethics and history of medicine. 2021;14. 

Taber BJ, Hartung PJ, Borges NJ. Personality and values as predictors of medical specialty choice. Journal of Vocational Behavior. 2011 Apr 1;78(2):202-9. 


  • Seán is an Irish paediatrician with a special interest in PEM, clinician wellbeing, and healthcare leadership. He commenced his PEM MSc. at QMUL in 2022. He established the National Committee for Doctors’ Wellbeing in Ireland in 2021. He has undertaken two Fellowships in Clinical Leadership (RCPI PwC Fellow 2022-2023 and HSE National Lead NCHD 2023-2024).

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