Civility as a cornerstone for a positive culture and safe care

The 2025 General Medical Council (GMC) survey1 of 71,000 trainees demonstrated that, within the obstetrics and gynaecology (O&G) specialty, 27% of trainees feel apprehensive about escalation of care and asking for senior advice. Successive maternity reports cited uncivil behaviour as a key barrier to escalation of care, a leading factor in recorded incidents. This article defines how incivility hinders psychological safety, team performance, morale and effective communication by causing cognitive depletion and impacting working memory.2 It can impair capability mindfulness,3 which reduces the ability of clinicians to be alert to unsafe situations as well as anticipate and prevent errors before they occur.4 Incivility: Low-intensity behaviour that is either intended to be or interpreted as being rude or discouraging, often characterised by a lack of regard for others, such as mocking, belittling or withholding information. Psychological safety: A condition wherein you feel included, sense a safe space to learn and contribute and feel safe to challenge the status quo, all without a fear of being judged or marginalised or punished by others.5 Capability mindfulness: This is having a mindset of constant awareness, to manage unexpected situations through anticipating, discovering and correcting before something could go wrong. Safety II: This is an approach to safety management through the analysis of how clinicians enable things to go right, and how systems are designed to create positive outcomes under changeable conditions.6 Failing to meet basic standards of clinical behaviour has obvious effects on colleagues and those receiving care. Unprofessional conduct is disrespectful to colleagues and endangers effective and safe working; it undermines the trust of women. (Kirkup East Kent report4) Despite the real-world consequences, the study and recognition of the effects of incivility remain challenging. A recent scoping review on maternity safety7 identified contributing factors such as hierarchy, team dynamics and fear of speaking up, but did not explore the root causes of these concerns or their role in escalation. Previous research by Riskin,8 Katz9 and Vauk10 found that rudeness can impair diagnostic accuracy, communication and procedural performance. However, such impacts often go unrecognised in after-action reviews, as they challenge cultural norms and can reflect a broader tolerance of incivility and variation in care. One critical consequence is a reduced willingness or ability to seek help. Maben11 found that erosion of interpersonal trust led to a measurable reduction in escalation behaviours, which in turn compromises patient safety. The concept of ‘learned silence’ is considered the antithesis of psychological safety and captures the emotional cost of escalation or speaking out against uncivil behaviour and is increasingly linked to avoidable harm. The safety-II approach to care identifies clinicians as key decision makers at the centre of promoting safer care. By focusing on what goes well, safety-II promotes a proactive culture in which front-line staff are empowered to identify strengths and adapt to challenges.12 This is particularly relevant in clinical environments characterised by dynamic changes in complexity, such as labour wards or operating theatres, where rigid protocols may not account for every scenario. Staff who understand how and why their decision-making and adaptations succeed are better equipped to handle variability and maintain delivery of safe care. This article attempts to demonstrate the challenges in maintaining this mindset. Figure 1 depicts the interconnection of civility, psychological safety, capability mindfulness and safety II and how these four concepts are vital for positive culture and safe care. These processes are disrupted by uncivil behaviours. It suggests that capability mindfulness is required to allow clinicians to quickly interpret dynamic and complex environments such as labour wards or theatres. The ability to adapt decision-making and seek assistance reduces variation in care but only if it feels psychologically safe and trusted to do so. We suggest that civility represents a cornerstone of safe care because it promotes these aspects of care and that seeking help represents an important step in reducing variation of care. The negative impact of incivility on the ability of clinicians to provide care has been highlighted in surveys and national maternity reports. Incivility can have detrimental consequences not only on the person subjected to the poor behaviours but also on witnesses and service users.2 The spectrum of incivility ranges from verbal and nonverbal acts of rudeness, microaggressions, undermining and explicit bullying and includes aspects of discrimination. The influence of incivility, therefore, remains difficult to acknowledge and to study within hierarchical clinical environments. These effects, however, have now been successfully simulated. This has enabled observation of the changes to team performance in uncivil environments (see Case study 1). Studying incivility in this way allows for further exploration of its effects on capacity for learning,3 team communication, escalation and team cohesion. A recent simulation-based study sought to evaluate how incivility impacts team performance in obstetric emergencies and explore how simulation can be leveraged to teach non-technical skills in such contexts. This interventional, crossover simulation study involved 23 obstetrics and gynaecology (O&G) resident doctors from various training levels (ST1–ST7). Participants attended a regional teaching day and took part in two high-fidelity simulated scenarios involving postpartum haemorrhage (PPH). Each scenario was identical in clinical complexity but differed in the behavioural conduct of one key team member: the anaesthetist. In the first scenario, the anaesthetist was civil and supportive; in the second, the same individual was instructed to be overtly uncivil, interrupting colleagues, obstructing requests and displaying dismissive behaviour. Resident doctors, observing via video link, completed the validated Team Emergency Assessment Measure (TEAM) questionnaire after each scenario, evaluating leadership, teamwork, task management and global performance. The study found a significant reduction in overall team performance in the uncivil simulation compared to the civil one (p = 0.006). The most substantial declines were noted in teamwork-related domains, particularly team morale and effective communication—both dropping from perfect scores (4.00/4.00) to markedly lower ratings (2.22/4.00) under uncivil conditions (p < 0.001). The post-simulation debrief allowed resident doctors to process emotional reactions and critically reflect on how incivility disrupted their cognitive processing and team coordination. Many resident doctors were surprised at the extent to which the incivility impaired not only the flow of communication but also their willingness to speak up or intervene. This study highlights the power of simulation as a pedagogical tool to expose and examine the often-underestimated effects of incivility in clinical practice. By creating a controlled, high-fidelity environment, the simulation allowed resident doctors to experience first-hand how disruptive behaviour can derail otherwise competent teams. It also created space for structured reflection, equipping participants with strategies to mitigate such challenges in real clinical settings. Simulation provides a safe, replicable and emotionally engaging method to teach non-technical skills such as communication, emotional regulation and team cohesion. This case study demonstrates that exposure to incivility in simulated obstetric emergencies can significantly impair team performance—particularly team morale and communication—underscoring the need for civility training as a core component of obstetric education. It is imperative to ensure the ‘culture’ within all healthcare settings is one that promotes openness, transparency and the psychological safety to escalate concerns. Yet the review team found evidence of disempowerment, with staff encouraged not to complain or raise awareness of poor practice within both personal and professional capacities. (Ockenden report13) An individuals' and teams' ability to communicate, manage risk, learn both on the job and from mistakes is promoted by psychological safety. It is defined as a shared belief that the team is safe for interpersonal risk-taking.5 Psychological safety is crucial in clinical environments for fostering open communication, reducing errors and improving team performance. Psychological safety also contributes to staff wellbeing and retention. Environments that promote respect and inclusion reduce burnout and foster job satisfaction.14 In healthcare settings, the promotion of psychological safety allows staff to speak up about concerns, authentic investigation of incidents and effective organisational learning. Edmondson et al.15 found that hospitals with higher levels of psychological safety reported more medical errors, not because more errors occurred, but because staff felt safe reporting them. In short, it promotes organisational learning and a safety-II approach to safety management. In the long term, psychological safety promotes learning on an individual and system level, and in the short term, it enables care to be balanced, questioned and respectfully challenged. Capability mindfulness is a key aspect of risk resilience, emphasising situational awareness within organisational structures, human behaviour and values, to manage unexpected events effectively. In clinical environments, this concept extends to understanding team members' roles, skills and boundaries, as well as maintaining respectful interactions and humility in decision-making. It is particularly relevant in high-risk, high-acuity settings like healthcare, where collaboration, adaptability and trust are critical for patient safety and effective care delivery. Exposure to incivility decreases an individual's and team's cognitive function (i.e. bandwidth) and impacts on their working memory.16 When there is an environment of incivility, this leads to a lack of psychological safety and results in team members being unable to raise concerns, give or receive feedback required for learning and willingness to contribute. Incivility and reduced psychological safety impair capability mindfulness17 as many of its components rely on information sharing, awareness and balancing risks and escalation of concerns. The safety-II approach is a modern perspective on patient safety that focuses on understanding why things go right in healthcare, rather than solely investigating what goes wrong. Introduced by Hollnagel,6 safety-II emphasises learning from everyday clinical work and supporting adaptability in complex systems. Unlike the traditional safety-I model that centres on error prevention and root cause analysis, safety-II recognises that individual clinicians and successful teams can adapt their approach to care in order to achieve successful outcomes within dynamic clinical settings. Research from The Health Foundation18 supports this approach, highlighting that successful clinical outcomes often rely on flexibility, teamwork and tacit knowledge rather than strict rule following. Adopting safety-II fosters a culture of continuous improvement, trust and psychological safety, where learning from everyday successes becomes as valuable as learning from failure. Taking these concepts together suggests that behaviour can influence the reason why things go right. It opens a door to examine the effect of working environments on behaviour and by extension safety, particularly in the context of sustained acuity. Finally, it underlines the tension between team cohesion, functional hierarchies and ultimately culture. Civility is therefore the foundation of positive culture and safe patient care through its positive impact on creating psychological safety, enabling capability mindfulness and supporting teams to increase their adaptability in managing complex clinical scenarios. We suggest that safety-II is equally underpinned by civility and psychological safety as variability and adaptability in team performance requires the same creative thinking, feedback loops and team contribution. Organisational culture is set by the top of the organisation … but typically takes a long time to permeate through the rest of the organisation. (Dr Bill Kirkup19) Aunger et al.20 in their realist review acknowledged that the high rates of uncivil behaviours in healthcare are likely to be driven by organisational, situational, team and leadership issues which interact in complex ways. We therefore can consider the following action points to address this complex interaction via the following approaches at an organisational and personal level. Organisational Cultural: Training: Regular simulation training: Recommendations from national maternity reports have outlined the need for regular multidisciplinary training on both human factors and civility to increase healthcare professionals' understanding of what constitutes incivility and the impact this has on a team's management of simulated clinical scenarios (see Case study 1). All trusts must mandate annual human factors training for all staff working in a maternity setting; this should include the principles of psychological safety and upholding civility in the workplace, ensuring staff are enabled to escalate clinical concerns. (Ockenden report13) Support: Personal ‘Culture is everyone's responsibility’ NHS England 22 The Women and Newborn Behaviour Charter was initiated in response to significant changes within the Maternity and Neonatal departments following an external cultural review. The charter supports key organisational goals, including safety, staff well-being and retention. This work aligns with the broader vision of fostering a culture of kindness, respect and civility throughout the department. Reproduced with permission. Created by Nicky Boardman, BSc (HONS) Midwifery, Psychological wellbeing lead Midwife, Salisbury NHS Foundation Trust. A working party was formed by recruiting interested individuals from the ‘Change Maker’ workshops. Volunteers from all staff groups were invited through various channels, including social media, posters and emails. Initial workshops were held to gather input on desired behaviours, which were then grouped and refined into concise, clearly worded principles that retained the spirit of the original ideas. Regular updates were shared at multi-professional meetings and via social media to maintain transparency and engagement. Once a draft was created, it was circulated for feedback, amended accordingly, and finalised with the help of the communications team for design and production. Although originally focused on maternity and neonatal teams, interest grew across the division, leading to broader departmental participation. The Women and Newborn Behaviour Charter represents a grassroots initiative to improve workplace culture through collective action and shared values. It promotes civility, respect and kindness and has been systematically integrated into daily practices, education and communication across the division. The charter's success highlights the power of inclusive, staff-led change in fostering a supportive and respectful working environment. Sustained commitment to communication, inclusion and adaptation will be key to its ongoing impact. Creating a culture of civility is fundamental to delivering safe, high-quality care in clinical environments. This article highlights the interconnectedness of civility, psychological safety, capability mindfulness and the safety-II approach. Sustained culture change requires clear behavioural standards, consistent management of poor conduct, training in communication and conflict resolution and supportive leadership. By embedding civility into daily practice and organisational systems, clinical teams can strengthen psychological safety, enhance adaptability and ultimately improve patient outcomes. Farrah Pradhan: Employed as a staff member at the RCOG. Simon Cunningham: Faculty of RCOG. Ganga Verma: RCOG Workplace Behaviour Advisor, RCOG Council Member Rep for Thames Valley and Wessex. Member of Civility Saves Lives. Hannah Pierce: RCOG Surgical Skills Fellow, Vice Chair Education—National Trainee Committee, SEAC Education Board and TEC. Member of Civility Saves Lives. FP and SC initiated the article and performed the literature search. GV and HP developed the infographic. FP, SC, GV and HP co-wrote the article and finalised the draft. None required.