Civility and why it matters.

As a doctor who has been working in the NHS for just a few months now, I have seen great dedication from staff, who make patient care their ultimate goal. I have experienced and have been humbled by the kindness and whole-hearted trust that patients and their families place in healthcare providers. But as a black doctor working in the NHS, I have also experienced racism and selective incivility at the hand of not only, patients, but also staff.

As of March 2021, the NHS employed 1.3 million people (1), so it is entirely possible that a fair number of them would have racist views and it is practically assured that you may work with one of them in your time working in the NHS. At first it may be subtle differences in the tone they use with you compared to white colleagues, or it could be more overt things such as limiting training opportunities for black trainees or even undermining your decisions. It can take the form of bullying or rude and passive aggressive comments, designed to denigrate you. The first time it happens, it can take a minute or two to realise what has happened, as you’re left struck with a mixture of shock and disbelief. These feelings fester inside and can mature into feelings of low self-worth, doubt and anxiety. That’s where the effects of incivility can permeate your ability to make sound clinical decisions, and therefore affect patient care (2).


At a time when the number of doctors from black and ethnic minority backgrounds work in the NHS is the highest on record, one can feel content with the progress made. But on a closer look, black doctors are under-represented and systemically excluded at senior levels, both in clinical and management positions (3). This has a direct impact on both the clinical care provided to patients from an ethnic minority background as well as the staff who work in these institutions.


In my first few months as a FY1, I have experienced strong feelings of anxiety and worry knowing I’ll be working with certain colleagues. The feeling of dread when you realise who you’ll be working with when you show up to work. The uneasiness when you know you have to talk to said colleague about a certain patient or that you’ll need to ask for their help on a matter. The unhelpful comments of ‘It’s just the way it is,’ or ‘They don’t mean it like that,’ do little to soothe the wounds inflicted by the perpetrators and only maintain the hostile environment that facilitates incivility. The sinking feeling when you realise colleagues that should offer support and reassurance, brush it off because ‘It’s always been like that’, and what exactly can you do in your position as an FY1, and after all, you rotate every 4 months, so why can’t you just put up with it? It is important to realise that my experience isn’t unique and many healthcare workers, especially from a minority background, will identify with my experiences. Not only does incivility have a direct impact on the recipient but also affects the witnesses who are more likely to report a decrease in performance after witnessing incivility towards a colleague and are also more likely to be less willing to help others (2).


There is a lot of resources available that set out how to manage racism from patients – from LearnPro modules in trusts’ inductions to local campaigns. However, as I’ve come to realise, there’s less support on what to do when the perpetrator is a colleague.


The first thing to do would be to confide in someone you trust about what you’re facing at work. This can be your educational supervisor, clinical supervisor or it could be a fellow doctor you work with. Ultimately, your concerns need to be made clear to management and depending on your hospital’s policy, this may involve submitting a formal complaint. It is very important you have the support of a colleague or a mentor that you trust, as it can feel isolating and intimidating to challenge work behaviours, especially in institutions where such incivility has been accepted as the status quo. In addition, it can be helpful to talk through the consequences that incivility has had on you as an individual and seeking professional support if necessary. Organisations such as the BMA offer peer support services or other counselling services and local trusts have staff wellbeing services which can serve as support networks when beginning to address the emotional impact incivility may have on an individual (4,5). In addition, addressing incivility when it happens in clinical areas where we work goes a long way in dismantling the toxic environments where incivility thrives – it is not enough to only offer a sympathetic word or nod when a colleague experiences this. Actively addressing rude and aggressive actions from colleagues sends a clear message of no tolerance to such behaviour and makes the working environment a place where everyone can thrive, and not just survive.


References:

1. NHS workforce - GOV.UK Ethnicity facts and figures [Internet]. [cited 2021 Dec 7]. Available from: https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-business/workforce-diversity/nhs-workforce/latest

2. CSL: The Basics | civilitysaveslives [Internet]. [cite