Episode 84: Complaints and How to Survive Them Episode 4: Creating a Workplace Where It’s OK to Fail with Prof Susan Fairlie and Dr Jane Sturgess

There are prevailing hierarchy systems in all workplaces, even in healthcare. This can breed fear around failing, admitting mistakes, and speaking up when we have concerns. It can also create unhealthy barriers between colleagues. As a result, we often don’t have the important but difficult conversations that are crucial for good patient outcomes, staff well-being and workplace health.

In this episode, Professor Susan Fairlie and Dr Jane Sturgess join us to discuss how to create a workplace that doesn’t shy away from failure. We talk about how civility can save lives and also touch on the issues around incident reporting in healthcare. Most importantly, we talk about creating a culture where people can have difficult conversations without defensiveness.

If you want to know how to approach failing and speaking up in the workplace, tune in to this episode.

Here are three reasons why you should listen to the full episode:

1. Learn the importance of speaking up in creating a healthy workplace.

2. Discover actionable tips on how to have a difficult conversation at work.
3. Understand the importance of learning from near hits.

Episode Highlights

[07:07] The Interplay Between the Workplace and the Individual

• Failing fast and early can be beneficial if we learn from those mistakes.

• There should be a system at work that allows other people to challenge someone who is not doing the right thing.
• Studies show that chaotic workplaces have higher error rates, burnout level, and staff turnover.
• Workers must reflect on how they perform; organisations must create efficient systems.
• We should look into systems that make it easier for us to do the right thing and harder to do the wrong thing.

[10:08] Improving the System on an Organisational Level

• There needs to be an expectation of making communication easier and more respectful.
• The latest CREW study showed that sustained organisation-level improvements could enhance resilience, staffing levels, and patient safety.
• How people speak to each other in the workplace creates an impact. It isn’t only about what we say; it’s how it’s said.
• More senior doctors must make it easy to have a difficult conversation with them. Junior doctors should be able to challenge them and speak up.
• It’s not only the recipient of incivility that suffers or gets affected.

[14:22] How to Get Juniors to Speak Up

• Calling each other by first names reduces the hierarchy between colleagues.

• It’s easier to have a difficult conversation with leaders if they really listen.
• It’s crucial to keep an open mind and allow people to get involved in decision making to build trust.
• Once your juniors start to trust you, they will feel that they can speak up without consequence.

[19:22] Having Difficult Conversations and Reducing Defensiveness

• Sometimes, the kind thing to do is to have a difficult conversation with a colleague.
• When a leader doesn’t listen up, the members will not be able to speak up.
• When you receive or give painful feedback, it’s essential to remind the other person that you have a positive intention.
• We should work hard not to offend but work even harder not to take offence. To do this, we have to dig deep when having a difficult conversation.

[22:57] How to Face a Difficult Conversation for Leaders

• When having a difficult conversation, remove the emotion and listen to the content. All healthcare professionals have this innate empathetic skill.

• You can also ask the help of a coach. Coaching should be the expectation rather than the exception.
• Psychological supervision also helps you get rid of negative energy rather than carry it around.

[26:47] Helping a Person Receive Feedback

• The H3 model refers to the head, heart, and hand. Listen to the full episode to learn the application of this model!

• The POIPS model refers to permission, observed, impact, pause, and solutions.
• The advocacy-inquiry model refers to understanding the other person’s opinion before intervening with your own perspective.

[32:17] Incident Reporting

• In hospital incident reporting, people only report big, significant incidents. As a result, little things slip by.

• We should turn the phrase ‘near misses’ to ‘near hits.’ When people think of the little things as near hits, they’re more likely to report them.
• Institutions that speak up and have difficult conversations have lower risk and better safety outcomes. That’s because they learn from their mistakes and near hits.
• If management doesn’t receive incident reports, they can’t do anything about a workplace issue.
• We must view incident reporting as powerful information rather than a weapon or pejorative.

[39:27] Good Practices in Speaking Up and Providing Feedback

• Incidents in primary care typically happen behind closed doors. There are also no big governance teams who operate the Datix.

• If we don’t share the outcome of reporting an incident, people won’t see the worth of that action.
• Culture is a social construct. There must be role modelling and a social movement on keeping people engaged.
• Staff that feel valued, engaged, safe, and empowered to speak up and have difficult conversations directly correlates with patient mortality.

[42:24] Addressing Issues around Incident Reporting

• The first issue is not recognising a problem as significant enough to need reporting.
• The second issue is it takes time to write an incident report, and you don’t get feedback.
• Involving staff in the outcome and decisions around an incident report boosts its effectiveness.
• There should be a shift from a compliance mindset to a commitment mindset.

[47:14] Building Trust Within Teams

• Every gesture and action we take speaks volume. Walk the talk.
• Trust will come from people seeing they’re getting taken seriously.
• The actions and behaviours you ignore are the actions and behaviours you accept.
• The way you let people talk and behave with you is the way you set your work life.
• You need to be brave and have a difficult conversation to address the issues you see.

[51:41] How to Start Speaking Up

• Having a coach, clinical supervision, and mentor is powerful.
• There are also available courses and books around having important but difficult conversations.
• Unless you practise something, you won’t get good at it.
• Listen to the full episode to learn Prof Susan and Dr Jane’s top three tips for anyone having difficulty speaking up!

7 Powerful Quotes from This Episode

[09:20, Jane] ‘Interventions that focus merely on the individual gave some benefit. But that benefit could be significantly boosted if you had organisational level intervention.’

[10:41, Jane] ‘From an organisational level, there needs to be an expectation of making it easier and of making communication easier and more respectful.’

[19:51, Susan] ‘It’s actually what Martin Luther King would have said, “A tough mind and a tender heart.” You’ve got to be able to have those difficult conversations.’

[20:52, Jane] ‘Whenever you give feedback, or whenever you have a really important conversation, it’s so important not to ambush people.’

[31:35, Rachel] ‘Failure is the best learning, isn’t it, and mistakes are the best learning.’

[47:26, Susan] ‘Let’s demonstrate that it is okay to speak up. So I think the trust will come from when people see that they’re being taken seriously.’

[47:58, Jane] ‘The way that people talk and behave with you is the way that you will set your future.’

About the Guests

Professor Susan Fairley is a specialist in QI and organisational development with a background in nursing. She is a visiting professor at Western University and also an executive coach. Professor Susan is currently working with the Time for Care Team. There, she is both in the Infection Prevention and Control Safety and Support Unit. She is also part of the Behavioural Insights Unit around courageous conversations in the time of COVID.

You can find out more about Susan through her website.

Dr Jane Sturgess is a consultant anaesthetist and a specialist in risk and communication. She’s an Associate Dean at Health Education England and is currently the Learning from Deaths Lead in her hospital practice. Jane has written various books about medical-legal issues. She educates around risk and protection and difficult conversations in Medical Protection.

Connect with Jane on LinkedIn.

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Episode Transcript

Dr Rachel Morris: Do you live in fear of a complaint? Do you dread making mistakes or getting something wrong? No one goes to work expecting to fail and no one ever likes to be wrong or receive a complaint. But making mistakes is normal. After all, no one has a 100% success rate, and receiving complaints from patients and clients could be seen to be an occupational hazard. We know this. So why do we find it so hard to cope when it happens? And it will.

That’s why we’ve put together a series of You are Not a Frog podcasts on complaints and how to survive them. Going through a complaint or investigation is one of the most stressful things that can happen in your career. And I’ve seen firsthand the anxiety and emotional turmoil it can cause and I know what it’s like to berate myself when I inevitably fail. But it’s because we care that we find these aspects of our professional practice so difficult.

But what if there’s a better way of handling things? What if we could learn to view the whole complaints process as just another part of our professional practice, and learn the skills we need to manage ourselves, our colleagues and our patients in an empathetic and compassionate way throughout? In this fourth episode, in the Complaints and How to Survive Them series, I’m chatting with Professor Susan Fairley, a specialist in organisational developments and an executive coach with a background in nursing. And, Dr Jane Sturgess, who’s a consultant and anaesthetist, and is a specialist in risk and communication.

We’re talking about how to create a workplace where it’s okay to fail. We chat about how incivility at work can cause your performance to plummet even if you’re just an observer. We talk about how you can create a culture where you can admit your near misses or your near hits, and how to have those crucial conversations that can feel so uncomfortable at the time. So listen if you want to work out how to challenge, even if it’s your boss. Find out how good leaders can encourage a culture of learning from mistakes, and find out how you can approach speaking up and discussing issues in exactly the same way as breaking bad news.

Welcome to You Are Not a Frog, life hacks for doctors and other busy professionals who want to beat burnout and work happier. I’m Dr Rachel Morris. I’m a GP turned coach, speaker and specialist in teaching resilience and I’m interested in how we can wake up and be excited about going to work no matter what. I’ve had 20 years of experience working in the NHS and I know what it’s like to feel overwhelmed, worried about making a mistake and one crisis away from not coping.

Even before the coronavirus crisis, we are facing unprecedented levels of burnout. We have been described as frogs in a pan of slowly boiling water, working harder and longer, and the heat has been turned up so slowly that we hardly noticed the extra long days becoming the norm. And I’ve got used to the low grade feelings of stress and exhaustion. Let’s face it, frogs generally only have two options: stay in the pan and be boiled alive, or jump out of the pan and leave. But you are not a frog, and that’s where this podcast comes in.

You have many more options than you think you do. It is possible to be master of your destiny, and to craft your work in life so that you can thrive even in the most difficult of circumstances. And if you’re happier at work, you will simply do a better job. In this podcast, I’ll be inviting you inside the minds of friends, colleagues and experts, all who have an interesting take on this so that together we can take back control and thrive, not just survive in our work and our lives and love what we do again.

Did you know that for every episode of You Are Not a Frog, we produce a CPD worksheet, which you can use to reflect on what you’ve learned and claim additional CPD hours. And if you’re a doctor and you want even more resources about how to thrive at work, and to join our Permission to Thrive CPD membership, giving you webinars and CPD coaching workbooks, which will help transform your working life. Liinks are in the show notes.

Now before we dive into this episode, I’d like to share a word from our partners from this series on complaints. It’s all too easy to feel overwhelmed. And for many healthcare professionals, it’s not only feelings of burnout and stress which can be challenging, there’s also the nagging worry of making a mistake and a patient claim being made against you. It’s enough to give you restless nights and impact your day to day, but you don’t have to go it alone.

If you’re a member of medical protection or dental protection, you can access a range of support from clinical professionals who understand what you face, who are here to help you in not just the legal stuff, but your emotional and mental well being too. From expert medical and dental legal teams to independent counselling through webinars and on demand content, you can access it all as part of your membership so you can focus on loving your job, not fretting about it. Find out more about www.medicalprotection.org and www.dentalprotection.org. And now here’s the episode.

It’s really brilliant to have with me on the podcast today, Susan Fairley, who is a visiting professor at Western University. Now Susan’s got a background in nursing, and she’s a specialist in Q AI, and organisational development. She’s also an executive coach. She’s currently working with the time for care team, and the infection prevention and control safety and support unit. And she’s also working with the behavioural insights unit around courageous conversations, particularly in the time of COVID. So welcome, Susan.

Susan Fairley: Thank you very much. Nice to meet you.

Rachel: And it’s brilliant to have also with me, Dr Jane Sturgess. Now, Jane is a consultant anaesthetist. And she’s currently the Learning from Deaths Lead at the hospital in which she works. She’s also an Associate Dean at Health Education, England, she’s written many books about medico legal issues. And she does lots of educating for medical protection around risk and communication. And she’s also running a lot of sessions about difficult conversations. And so we’ve got two experts in difficult conversations here, which I think is really important. It’s probably one of the things that we need to talk about today.

Because today, what we’re talking about is workplace, and developing a workplace where it’s okay to fail. In the other episodes in the series on surviving complaints, we’ve been very much talking about the individual, what should the individual do? How should the individual cope and respond, but what I’d like to talk about is, how the workplace can interact with it individual, how it can cause complaints or how it can help prevent mistakes. And so Susan, what do you think the interplay is between the workplace and the individual? Is it mostly the individual with a bit of workplace? Or is it sort of 50-50? What would you say?

Susan: I think certainly, most organisations would aspire to be a learning organisation. And I think as a learning organisation, failing fast and failing early can be beneficial as long as we learn from those mistakes. But there’s a huge amount of human factors at play. And I think if we don’t stop and reflect on what was my contribution to something going wrong, how has the system either supported or enabled, or created mistakes to be perpetuated, then I think that we’re going to run us into deep water.

And that for me is the thing is around what is the system that is supporting me to do the right thing? What is the system that’s creating a culture where it’s actually, I can’t not do the right thing, if that makes sense. So it does touch a lot on, how am I showing up at work today? How am I making it okay for people to check and challenge me if I’m about to make some rogue decision? And there’s lots of talk around at the moment around patient safety and human factors, and civility, and compassion. And actually, it’s all of that stuff. It’s all welded together?

Rachel: Yeah, so there’s two things really, there’s the whole prevention thing, and that you really need a system, that’s going to actually make it really hard to make a mistake. But then you also need a system in which you can fail fast, and you can speak up.

Susan: Yeah, absolutely. It’s really interesting.

Jane Sturgess: Actually, there’s a study Hector Perez did a really interesting study in primary care in the States, actually in a city practice in 2017. And what he was looking at was, he was looking at how calm or chaotic was your workplace, and what sort of effect did that have on you and your ability to perform well as an individual. And when he sort of extrapolated the data, and he looked at it, he was finding that chaotic workplaces had far higher error rates, far higher levels of burnout, far higher levels of staff turnover.

And there have been other studies. So people like Panagioti. Again, this one’s a secondary case study. So Panagioti was looking at interventions to try and enhance well-being within the staff. And what they found was, the interventions that focus merely on the individual gave some benefit. But that benefit could be significantly boosted if you had organisational level intervention. So starting to look at the systems, the policies, the practices, as well as just the people.

So I think there is a need for the individuals to think about how how they are when they turn up to work, but I think unless we start to, and the evidence is out there that supports us, encourage our organisations and our workplaces to put in efforts to make it easy to do the right thing and hard to do the wrong thing, then we’re never really going to make the quality improvements in patient safety and the reduction in areas that we’re all desperate to see.

Susan: I think that’s that spot on, Jane. I was just reminded of when the ATM machines were first introduced, and people used to put their card in, and get the cash out, and leave their card behind. And so those forcing functions that, as we call them, have changed the way we do things now so that you can’t get your cash until you’ve removed your card. And I think it’s just learning from those sorts of other industries, what can we gain, that is a forcing function to make it easy to do the right thing and harder to do the wrong thing, I think you’re spot on there.

Jane: And I think there needs, from an organisational level, there needs to be an expectation of making it easier and of making communication easier and more respectful. So there was the lightest study that came out, the crew study, which is civility, respect and engagement in the workplace. And that, again, showed that if you put in sustained organisation-level improvements, you can enhance the resilience, the staffing levels and the safety of patients.

So it’s not just about making individuals feel better, it’s actually about improving the standards of care and the quality of care that we deliver for our patients. And of course, you know, the workplaces where people stay, people are loyal, people want to work, and the places where people leave, and their high staff turnover, the use of locums, it all buys in doesn’t it? To increased error rate, fatigue, burnout, not wanting to work. So if you can maintain and sustain your staff, you’re going to maintain and sustain your levels of safety quality.

Rachel: And that’s good for everyone, isn’t it, because it actually saves you money because you’re not gonna churn and it makes it happier to place the work and then you’re going to be more productive.

Susan: I wonder whether people have heard about or aware of the work of civility and incivility saving lives, Chris Turner’s work and Christine Porath. There’s lots of new evidence now emerging around how we speak to each other. It isn’t just what we say, it’s how it said, and we know that that sort of the frown on the wrong person’s brow can close someone’s thinking down and you think if I’m going to say something, and I’m going to get shut down, I might not say something again, and it might be at the time when I absolutely do need to say something, but I’m a bit fearful of being humiliated or made to look stupid.

And particularly if that person is really senior, you know that that frown on that person’s brow can really have detrimental impact. But when I’m doing training with a lot of the junior doctors and senior consultants, I say to them, how easy do you make it for people to sort of challenge you or to speak up? Do you actually invite them in to say, if you think I’m about to make a rogue decision, I expect you to speak up and tell me what might be my blind spots.

Because if we don’t give permission to senior leaders in their organisation, more junior staff and the junior doctors say to me, I need references and you think I’m really going to challenge the consultant when they don’t wash their hands between patients? Of course I’m not, because I’m going to get shut down.

So I think there’s quite a lot we know around bullying, harassment, which is the one end, but there’s the small subtle stuff around that frown, that touch, that, oh, here they go, again, type thing, it can really have such a detrimental impact.

Jane: I think going back to the Civility Saves Lives campaigns, one of the other thing that they’re really keen to highlight is that it’s not just the recipient of the incivility that suffers or their behaviour that is affected. So, their big poster campaign says that 20% of witnesses suffer a decrease in their performance. And then subsequently 50% are less willing to help others. So when something happens later in that day, they’re less willing to offer things.

And of course, the patients because to me, it’s all about the patients with staff a very close second. But the service users become very unenthusiastic about attending an organisation where they can feel or be aware that there’s an incivil attitude. So it affects absolutely everything, and going back to your point as well, Tait Shanafelt has said just last year, 2020, you’ve got to have good leaders to improve teams.

Rachel: I think leadership is 100% key here because no matter how much you say to people, civility saves lives. And if you’re, say in an A&E department and you’re working on one patient here, and then you’re hearing someone having a bit of an argument or being a bit rude there, your performance, your concentration will go down. And that is based in neurosciences and that you are mentally, your threat detection system is going, what’s going on, do I need to be alert and then you’re in your sympathetic zone and you’re not really getting paying good attention.

I think it’s really hard because it’s one thing saying we need good leaders. And then no one ever sets out not to be a good leader. And then you put them in an environment where it’s not. I mean, I guess we’ve all worked in places where everyone said, yes, of course, you can speak up. We’re open here. But actually, you know, that you can’t. And I remember being a junior doctor, something happened, I was actively encouraged not to speak up, because that would be bad for the hospital.

And we can all think of times like that, but it is so hard to challenge. How, as a leader, can you make it okay to challenge because I think when you’re a leader, you don’t feel the hierarchy? You think you’ll be all friendly and then that everyone can say anything to you, I had a really lovely example for a friend of mine, who’s an A&E consultant, and she said, whenever the juniors come in, and they call her doctor, so and so she says, Oh, please don’t call me Dr Center, call me by my first name, because that makes it easier if you ever need to challenge me about something. That’s great, isn’t it?

Susan: I think that’s spot on. I think that first name, reduce the hierarchy. I think, you know, you’ve probably heard of Martin Bromley and the work he’s been doing around clinical human factors. And the pilots in the airline industry, they actually ask each other, please speak up. If you think I’m perhaps to make some some rogue decision. And I think we need to learn from that. So in terms of the senior leaders, you know, really helping make it clear. We all have blind spots, will you please be my ally, and help me find mine or spot mine? Because I need you to keep us all safe. I can’t necessarily know what I might be about to do, might be wrong. And yes, I might be more senior. Yes, I might have to sort of carry the can on something. But if you think I’m about to make a rogue decision, I really, really implore you speak up? Or what do you need me to do more of, or less of to help you speak up? And I think it’s that sort of language, bringing it into sort of your daily conversations?

Rachel: Is that what you did Jane with your juniors? How did you get them to speak up?

Jane: So it’s interesting. So I was asking my learning from deaths team, and I was asking my hga team, what is it that makes us work in a way where everybody is able to say stuff, and they said, it’s the fact that you listen, that you really listen. You don’t just listen to the words, you listen to the nonverbals. And then you act on what you’ve heard, rather than what you’ve decided, we’ve said. So really listening and being interested.

So especially when that opinion is other than yours, or when the idea is other than your so keeping that open mind. And the minute you start to listen, and then act on it, and then allow people to be involved in the decision making, then they start to trust you. And then once they start to trust you, then they feel that they can speak up without consequence. So that said, my teams have said, yes, you do hold us to account. So I think there’s something about a need for support and tension.

So there’s an educational model about if you want growth in an individual, so it was Dallas back I think in the 80s, I can’t remember. But he talks about a support and attention model. So if you want things to improve or to get better, you can’t just be lovely all of the time. And sometimes we see that don’t we, at work, especially in those organisations where there is a lack of trust, or a lack of psychosocial safety climate where people are superficially nice.

So in the public spaces, oh, yes, here here. I completely agree with that. But when you get to the watercooler in the old days, when we could all talk to each other, but when you’re having the private conversations, you start to get the gossip, you start to get the depersonalisation, the cynicism. So there’s something about having genuine conversations, and the only way to do that is if you know that you can have an alternative opinion. But if there’s an expectation of you, you will be expected to meet it. And if you don’t meet it, there will be a question, why haven’t you met it? So really nice. Actually, when you’ve said you’re going to do something, you kind of have to do it.

Susan: I think that’s really fascinating. I’m a big fan of Nancy Klein, I don’t know whether you’ve come across her and she’s written several books about thinking. But she says basically, to your point around listening, listen with fascination. Don’t listen to respond. And to your point around, I think, courageous conversations or a compassionate culture. It isn’t just the soft and fluffy stuff. And as you say being it’s actually what Martin Luther King would have said, a tough mind and a tender heart.

You’ve got to be able to have those difficult conversations. Sometimes maybe somebody isn’t in the right job for them. And maybe the kindest thing to do would be to have that conversation about how might I help you grow into a role that’s more appropriate for you. But I think it’s that bit about complexity theory again, here that our ability to balance agency and communion.

Jane: And I think your point about being the kindest thing to do, is really well made, because I think many people conflate kindness and niceness. And they’re not the same. So sometimes to do the kind thing feels hard, and feels difficult. But as long as you know what your intention is, and what your purpose is with something, and maybe when we start conversations, we don’t know what our intention or our purposes are with it, maybe we’ve got a hidden agenda.

So I think, you know, whenever you give feedback, or whenever you have a really important conversation, it’s so important not to ambush people. It’s so important to give them the right to reply and it’s so important to respect their opinion. You might completely disagree with it and that’s okay. But it’s just as valid as your opinion.

Rachel: I think as a leader, one of the big challenges is hearing this stuff and not getting defensive. And that’s what happens automatically. Someone speaks up, you take it personally as a personal criticism and immediately you go into defence mode, no matter how much you try and do, you’re ‘tell me more’ through gritted teeth. ‘I don’t really want to hear this, and this is really uncomfortable.’ So I’m interested, first of all, how is a leader? Can you not be defensive? And how is a speaker up? Or can you do it in a way that isn’t going to put people on the defensive.

Susan: So my sense there is that as leaders, we’ve got the Freedom to Speak Up campaign, which everyone is sort of fairly familiar with. But I think unless we have the Listen Up campaign alongside it, where actually, as a leader, I am really trying to listen up. And what you have to say might not be terribly comfortable for me to hear. But if I don’t listen up, you’re not going to feel able to speak up. So I think it’s that it’s that both, and I think if you are the recipient of somebody who’s been giving you some painful feedback, just sort of remind each other, that you’re both there with positive intention.

And often I’ve heard the phrase, work hard not to offend, but work even harder not to take offence. And I think that’s quite a powerful way to think about this. But when we reach some sort of impasse. Don Berwick tells a story about the oops and ouch, where people from different parts of political divides. When you say this, it’s a bit of an oops moment, I didn’t mean didn’t mean to offend you, or it might be a bit of an, ‘ouch that that didn’t land terribly well with me, how might you reframe your language so that I don’t take offence?’ And it’s that sort of thinking, I think that we need to be really embracing

Jane: My personal experience in my roles in leadership is that I suffer plenty of oops, and ouch. But, I think when you’re in a position of leadership, very often, you have whole days where people just want to tell you what a lousy job you’re doing, and how you could be doing it better, and how you’ve got it wrong, and why are you doing it this way. So part of being a leader, my experience has been learning how to absorb all of that commentary that you get from people who haven’t learned the skills to say in a respectful, engaging, impactful manner, but to try and remove the emotion and listen to the content and not be defensive.

And one of the skills that I’ve tried to dig really deep with, because I’ll be honest, it’s a really hard piece of work, sometimes a very difficult and, and the temptation is to snap back or to defend or to become offended, enraged, and to shut down the conversation and start to tell rather than ask. So what I tend to do, is I tend to dig really deep. We know that as nurses, as doctors, as any health care professional, that we have those skills. So if we had a patient in front of us that had cancer, it wouldn’t cross our minds not to break that bad news to them.

And we know when we expect that they are highly likely to have an exaggerated emotional response to us. They might get angry, they might get defensive, they might get upset. And whilst this emotion is pouring on top of us, it wouldn’t cross our mind to meet it with the same level of emotional anger. So we have those skills to just listen and be empathic and be interested in that person and why they’re responding this way to help them come through the emotion before they get to a position where they can become rational and engage in a rational discussion and it’s exactly the same.

The other thing as a leader that I’m an absolute fan of, is coaching. And I think coaching should be the expectation, rather than the exception. So I think coaching is key for all leaders so that when you’ve had an oops, or an ouch moment, you can reach out to your coach and say, gee, I just got it a bit wrong today. And I’m not entirely sure what was going on there. And the brilliant thing about the coaches, they don’t tell, they ask, so they’re role modelling what you have to do every single moment of the day.

So I would suggest that psychological supervision is also really helpful. I’m lead for learning from deaths, and I have some very bruising conversations with consultant colleagues, with all sorts of doctors and nurses, when the standard of care has been less than we would have hoped for, and they get very cross and angry with me. And of course, I have very difficult discussions with families when the standards of care has fallen below that they would have hoped for. So psychological supervision. So a touch base, where I can get rid of all of that negative energy rather than carry it around with me is incredibly helpful.

Rachel: I love that idea, Jane, that when we’re speaking up, we need to see it as a breaking bad news situation, because actually, what we do when we speak up is we’re so concerned about ourselves, like, what’s the effect this is gonna have on me? Am I gonna get we don’t think about you. How am I going to help this person receive it? Yeah. And in the best way possible. And I know, Susan, you’ve got a load of really helpful models that might sort of help with that. I think there’s loads of models around, we could probably share about four or five screens. But what models have been particularly helpful?

Susan: So one of the things that we’ve been working on with behavioural insights unit around, for example, classic is about people not complying with social distancing, or wearing PPE appropriately. This is what was some real stuff that we tried out with folks. And basically, this what I’ve called the H3, but basically, head, heart and hand. So my head, the evidence is telling us that we know we need to keep our space or we know we need to, to use PPE appropriately.

My heart, this matters to me, because and this is why it should also matter to you. So you’re sort of giving them the sort of compelling narrative at that point. And then the hand bit is so together, you know, we can create the required culture to take the necessary action. So it creates a sense of otherness and avoids the victim versus the villain scenario that often sort of creeps in. And so we’re acting, we’re acting with integrity, doing it together. So there’s this sense of we are all here to make the right decisions. We are all here with positive intent.

And so that’s one model I think is very simple to use. The other one, which takes a little bit more practice, is what we call the POIP model. And you can use this either in the moment if you’re used to using it. And we created some little credit cards for people to use and having their lanyards, where if they’re wearing lanyards, actually, POIPS stands for permission. Is this a good time to have a conversation? And if not now, when would be? O is observe, let’s make it specific. This is what I spotted. This is what I noticed. The I for impact. So what is the impact of your behaviour on either yourself or others? And then pause, ask them, okay, what do you think? What thoughts have you got on what I’ve just said?

And then the S comes to solutions. So what suggestions have you got? What can we take forward? how might this work for us in practice, so, you know, thinking along the lines of hands, face space would be a classic example, when you got a little bit too close to me, I felt quite vulnerable, I’ve got somebody home home, who I’m caring for, and it means a lot to me that you still won’t comply with the sort of the guidance that we’re all being asked to live up to.

Jane: It sounds very similar to the advocacy inquiry sort of model that I find really, useful, which means that when you’re asking about an event, or you’re trying to understand something a little bit more, the advocacy is you’re really trying desperately to understand the other person’s perspective before you’re allowed to make a decision or intervene with your obviously better perspective.

But it does say the advocacy, well you said this, I thought that, and the impact with this was this. Can you explain that more to me so that I can understand it? So that’s the advocacy and the inquiry and then just put it back to them. What do you think about it now, with permission for you to add a little bit in but I love that point. So I’ve written it down and taken it away.

Rachel: So there are a lot of models. There are a lot of ways to help us speak up, but so far, we’ve talked quite a lot about the individual and the individual as the leader or the individual as a follower. It’d be really nice now to broaden that out and think about how the workplace interacts with this because you can be as brave as you want as an individual and as amazing a leader as you want, but if you are working in a system that is broken, that is toxic, that it’s just overwhelmed and overworked and let’s face it, who who’s not working the system right now that isn’t a little bit overwhelmed and overworked, it’s good to think about how we can actually make it easier to be a good leader, and a good follower in those in those systems.

And I’d like to talk a little bit about psychological safety. I think this is sort of the basis of everything, isn’t it, and that there’s a fantastic book by Amy Edmondson called, The Fearless Organisation, where she talks about all the evidence behind psychological safety. And the thing that really sort of got me was the fact that she thought her research was wrong, then when she was first looking into it, she was looking at teams in hospitals. And she found that the team that was the highest performing had the best outcomes from patients, whether it was the team that reported the most incidents and failure.

And she thought, well, what’s going on here? Like, is there something wrong with my research, and she then looked into it and found that actually, it was the team that reported the most incidents, it wasn’t necessarily that had the most incidents, but what was happening was they were reporting it, they were learning from it. And, then of course, their performance went really high. Because I’m a big believer in actually failure is the best learning isn’t it, and mistakes are the best learning. I heard them describe the mistakes the other day, like almost-mistakes you must make in order to learn now.

That is really uncomfortable, particularly in healthcare, because we, it’s really hard to learn from mistakes, particularly if somebody has come to harm from those mistakes. So we’d rather learn from the small things that happen before they get to the actual making, causing patients harm. So I mean, Jane, I know that you talk a lot about risk and stuff, how does psychological safety interact with managing risk? And actually, what can increase psychological safety in an organisation?

Jane: So I think it’s really interesting. The first thing I’d like to touch on is, is the fact that learning from errors is important, there’s been this whole move, hasn’t there, in the quality and safety thing that we have safety one and safety to where we should also be learning from excellence. And you also mentioned Rachel, didn’t you, about the fact that it would be better to learn from the little things, so that you catch it before you get to the big thing, and I wonder sometimes with the incident reporting that we have in hospitals is people, it has to be a really big significant incident, sometimes for people to report it. So they let the little things go by. And the terminology is that they’re near misses. So I think we should turn that phrase on its head and call them a near hit, rather than a near miss.

Because that’s what it was, you didn’t nearly miss it, you did miss it, but you nearly hit it. So I think if we, if everybody can start to think of these things as near hits, then they’re going to be much more likely to report them. The other thing with the incident reporting System, is the fact that often these things will be looked at and there’ll be RAG-rated. I’m not very keen on RAG-rating, so red, amber, and green, and the things that you think that you’ve taken a lot of effort to report an incident. And then somebody who doesn’t talk to you who doesn’t know about you, he doesn’t know about the circumstances surrounding that near hit scores it as green, and you feel that it’s a tick box exercise, and it gets washed under the carpet.

So I think you’re right, the work that Edmondson did, and it’s been backed up by lots and lots of people is that actually those institutions that speak up have lower risk overall and better safety outcomes. So I think we should be looking at the little to learn. I saw something when I was on Twitter. I love Twitter. I saw something on Twitter and it said that what we should do is we should think about. Instead of thinking about fail as something that’s awful, we should think about it as your first attempt in learning.

Rachel: There was a vaccine, some vaccine developed, I think, and it took hundreds and hundreds of attempts and someone said to the person, what was it like to fail so many times said, oh, I didn’t fail. I just learned. I learned 100 ways that you don’t develop that vaccine.

Jane: Exactly. Exactly. And if somebody says no, don’t think it is a no but what it offers you is your next opportunity. Yeah.

Susan: Yeah. Light bulb, isn’t it? You know, what was it? How many was it? 20,000 attempts and I think Dyson talked about, he had over 5,000 prototypes before he got the right vacuum.

Rachel: So I mean, thing is Jane, something in me, when you say incident reporting has a really negative reaction. I’m snitching on people. In my day when I was on the wards, people would be like, I’m putting an incident form about that. And it was like, this is my way of getting back at that person. No way was it like a learning thing. And it just felt really pejorative.

Jane: Agree. And I think that’s a problem, it’s a significant problem that Datix or incident reporting, it has been weaponised. So people will use that as a verb, I’m going to Datix you. Which is ridiculous. Which is why we have this mentality of fear and anxiety around incident reporting, rather than a thought process that actually, I didn’t have the right number of staff today, or this piece of equipment wasn’t working properly today.

And actually, if the management because we talk about the workplace and their part in the whole of this, it sounds like a social safety climate. If they don’t know, they can’t do anything about it. They haven’t got a magic crystal ball that will tell them what’s happening on the wards or in your primary care practice. They don’t. So unless we tell them, this has happened over and over again. And actually, you might think, goodness me, this is the sixth time I’ve put in an incident form about this particular piece of equipment.

But that will, that will speak volumes to that manager, gosh, this is six times this has happened in a week, actually, I really do need to address this green incident form. Because it’s giving them intelligence. So rather than thinking of it as a weapon or a pejorative sort of a penalty or a punishment, it’s information and information is power.

I think the other thing, with learning from deaths, for example, what we have is, we’ve been given a nationally recognised structured judgement review tool. And they’ve given us terminology that we have to use. So you can score care as excellent, good, adequate, poor, or very poor. Now, the moment you talk to clinicians or, or healthcare practitioners and say that the care is adequate, you can see the shoulders raising. And if you say that the care is poor, or very poor, it sets up an instant defensive reaction, just the same as I’m going to Datix or incident report for me.

So I think we need to work really hard, again, like that breaking bad news analogy to sort of move away from thinking negatively about these words. They’re just words. The problem is the story we make around that word. And once we’ve made a story around that word, then we have an emotional response to it. And the story is nearly always negative when things are described as adequate, poor, very poor, Datix-instant form. So, but recognise it is a bit like the word resilience that we’ve all got a story around it. Look, I can see you wincing already.

Rachel: I’m a resilience trainer and I hate that word.

Jane: But we’ve all got a story around the word resilience. And that that engenders an emotional response in it doesn’t it, but actually, it’s just a word, it has a definition. Let’s just recognise that.

Rachel: It’s interesting to me, because you’re obviously based in secondary care. And you’ve got this incident or this datec system. I’m interested in your experience in primary care season, because I know you work the time for care team. And my experience as a GP as a primary care is that we hardly report anything because you’ve got these really small teams, like, who do you even report it to? There’s no system. If something really bad happens, you’ll do a significant event audit. But that’s about it. And so, again, we have the too nice problem, like I can’t really ruin the team, whatever. So, Susan, have you seen any examples of really good practice where teams are able to feedback and speak up in a situation?

Susan: Thanks for that lovely question. So a few years ago, I did some work with the National Safety Team, which was looking at why is it that the vast majority of interventions take place in primary care, but less than 1% of reported incidents come from primary care? Is that because primary care is so good that they never make a mistake? No, I don’t think so. So I think there’s a lot of stuff that isn’t, the way things happen in primary care are typically behind closed doors, individuals on their own, so there’s a little bit less of the check in challenge stuff that goes on.

There’s also, they haven’t got that big governance team behind the scenes who are going to operate the Datix. So we did quite a lot of work to try and look at how can we make it easier for primary care staff to report, include as a primary care, so I’m not just talking about conditions. So people doing repeat meds, for example, people don’t always know, to your point, Jane earlier, they don’t always know about what needs to be reported. And I think there’s a love that bit about fail first attempt in learning, I think I’m gonna steal that one.

But if we don’t learn from incidents, I think that also if we don’t start to share what was the outcome of somebody taking the time to report an incident, then people don’t actually see that loop of activities worth my while. Something different is going to happen as a result. So I think we’ve got to actually sort of follow that whole, the old audit cycle, the way we were used to describe it years ago, to sharing with people, this is the outcome of your courage to speak up or your courage to log. It’s going to prevent harm for somebody else.

And I think the point that you were referring to earlier, Jane, about that psychological safety and the culture that we create, well, I think culture is a social construct. And as an individual, it’s very hard to create the culture, but if the role modelling is happening, and that social movement about keeping people close to you, getting that spread, that first follower type movement that we often talk about.

And we know from Michael West’s work, where we’ve got staff who feel valued, where they feel engaged, where they feel empowered, where they feel safe to speak up, there is a direct correlation with patient mortality. It isn’t just the nice soft and fluffy stuff, this is now really got some real bottom line, tangible outcomes now that we can see. I don’t know whether people have come across the work of Shawn Achor. I mean, I think he’s fab, he talks about that brain, the positive brain, or the neutral brain is 31% more effective than the brain when we’re distressed, whether we’ve been working in that sort of toxic environment where we feel I can’t really speak up or I’m feeling feeling fearful. So we’re sort of starting off on the wrong foot to make wise decisions and choices. If we’re not in that sort of positive brain mindset.

Jane: I think we need to recognise that actually, at the moment, we need to make reporting, because it is for safety. And that’s why we want to do it. And it will enhance our psychosocial safety climate, because we will recognise actions will occur when we’ve highlighted a safety issue. But it takes an awful lot of time to write these reports, and I think sometimes, so the first issue might be that we don’t recognise that it’s an issue that needs reporting, because we might think it is insignificant.

The second issue is, it takes time. Let’s be honest, if you’re in primary care, and you’ve spent all day in clinic, doing calls, doing triage, or seeing patients face to face, and then you’ve finished and then you’ve got to look up your your results, and then you finished and then you’ve got to write your referral letters and you’ve got to write all of your follow-up letters. And then suddenly, you’ve got to write this incident report, you are much less likely to do that, especially if you’re not going to get the feedback. There’s nothing that’s going to more quickly turn you off from fitting that in. When we’re thinking about work and our psychosocial safety climate, things that play into that are workload. So incident reporting will increase our workload or what we perceive to be our workload.

Maslach talks about control. So we have no control over the outcome of that incident report. So actually involving us in the decision about what RAG rating it gets, or involving us in the outcome is more likely to be an effective solution, that we think about reward. So the only reward you get is somebody sending it back saying well, why did you bother talking about that. Whereas if somebody celebrated you putting in your incident report, then you would feel rewarded, if you sort of could see the outcome and the improved patient safety? That would feel great, wouldn’t it? And then talking about fairness and values, if you put this incident form in, does it match your values, the response that you’re getting? And what does that tell you about the place within which you’re working, and is it fair and proportionate?

Susan: What I’m reminded of is that shift from a compliance mindset to a commitment mindset. I’m doing this now because I can see that it’s going to be taken seriously, as opposed to I’m going to do it because I need to tick a box. So you’re more likely to be committed to something that you have, as you say, I’ve been part of the decision making about what’s going to happen with this. How this gets escalated. And I think that really, again engender that sense of I really want to make a difference. I really like it’s going to have some impact.

Jane: And it plays into, doesn’t it? So shared decision making, no decision about me without me, but actually, no decision about me without me plays absolutely into this, doesn’t it? So, when you’re trying to sort of like, talk about safety or if, God forbid, something horrible happens, you get a massive complaint, you have a death, you have a missed diagnosis, you get a claim, something awful. Do you leave? Do you survive? Do you thrive? And actually, if there are decisions made about you, without you, you’re going to be on this survive or leave access rather than the thrive access on you? So I think it’s really important.

Rachel: Totally agree. And for me, Jane, that’s all about trust. And it just all boils down to trust, because in order to have a workplace where, where it’s okay to fail, I need to trust that, A, if I mentioned something that I’ve done wrong, and I want to learn from it, etc, that it’s going to be okay. That I’m not going to be judged that I’m not going to be, you know, the first thing you think we’re fitting in incident form is, is this going to reflect really badly on me? Am I going to be in trouble? Bottom line is, am I going to be in trouble for this. But if I knew that, actually, people would celebrate the fact if I did it, they were pleased with me, and it would really make a difference, I’m gonna do it.

And then on the flip side of that is with speaking up piece is, do I trust that if I speak up, my relationship with that person is going to be okay, afterwards, i.e., did they have assumed positive intention from me? Did they think I’m speaking up to them to be difficult? Or do they assume that I’m doing it because I really value the relationship, I really value patient care, etc. And it’s when the trust is not there that this becomes so hard, doesn’t it? So I’m just wondering if you guys have some real tips for both leaders and team members on how to really build that trust within the teams because that’s what I think is often so lacking.

Susan: I think what I’m struck by is that bit about every gesture, every action we take speaks volumes. So I think walking the talk was saying we want people to speak up. But let’s demonstrate that it is okay to speak up. So I think the trust will come from when people see that they’re being taken seriously. So don’t tell us that you want us to speak up and report and we’re going to support you, and then actually throw people in front of the bus when they do. So I think it’s got to be actions speaking louder than words for me.

Jane: And I would say, for me, that the actions and behaviours that you walk past, are the actions and behaviours you accept. And the way that people talk and behave with you, is the way that you will set your future. So if somebody has said something rude, if somebody is doing something wrong, if you say nothing, then they will continue to do that. So that’s the standard that you’ve set for your continuing work life.

And as difficult as it is to call the elephant out, sometimes, it’s better to do it. If you think about personal relationships at home, if you’ve all got the friend that is always taking the mickey, that’s always late, or that’s a bit rude or that treats you badly or that never pays at the restaurant or what have you. If you don’t call that out, they won’t know. So they’ll continue to do it. And the longer you leave it, the harder it is to call it out. So I’m a firm believer in being brave, and having courageous conversations and dying by the death by one blow rather than the death by a thousand blows for me.

Susan: I love that I got a quote here that is from David Morrison, who was the chief of the Australian Army when he was talking about do you challenge or do you come down? And he does say the standards you walk past is the standard you accept. I think absolutely right. You know, am I prepared to speak our truth here?

Jane: Yeah. Is that okay? If this happens again, am I going to be alright with that? Or is that going to be something that’s going to irritate the living daylights out of me or concern me deeply? And if it’s going to irritate you or concern you, then you just have to work out, do I have the words? Do I have the skills? Do I have the courage and then I’m just going to say this my intention and my purpose is good. If they receive it badly, okay, but at least they know how I feel.

Susan: I know we’ve got to finish in a moment, but I think there’s something here about what are the consequences I’m prepared to accept if I do nothing? And am I willing to accept those consequences? I think that probably is part of what we’re talking about.

Rachel: Yeah, I had a really good podcast recently, they were talking about relationships and how to get really deep relationships. And often we leave stuff because we go, it’s not, it’s not worth it, it’s not worth it. They said, some change the word, it’s not worth it to either I’m not worth it, or you’re not worth it, or we’re not worth it. Maybe in healthcare, we could change it to patients aren’t worth it. So if you’re then going, patients aren’t worth it. Oh, well, hang on that that’s not what I believe. Right? I really need to speak up.

I think the other thing to say is, and I do teach this a lot that if you give difficult feedback, and it’s like we were alluding to before, Jane’s talking about breaking bad news, that person is very rare, they just probably will have a bit of a reaction, because it’s really difficult to hear difficult feedback, but that that is okay. And we’re so uncomfortable with people being uncomfortable and having negative reactions, just being able to sit with it and being okay, it’s a difference between, you know, short term hurt and long term harm, isn’t it?

But we, I think that’s why we avoid it is simply because we don’t like that short term hurt that, that it might cause. But in the long term, it’s really important. But it’s getting, you know, and I’m talking to myself, because I’m really bad at giving, having those conversations that I know I need to have, and you guys have really inspired me to go and it’s going to but it’s something I think we need, we need to practise it right because it doesn’t come naturally. If someone was really struggling with this in their workplace, they found that there were things that were going on and said that they felt they needed to challenge but just felt they couldn’t, where would you suggest that people start with this?

Susan: I think this, as we mentioned, there’s lots of frameworks out there. I think having a coach is really powerful. I think that really is great. Clinical supervision, having a conversation with somebody else, a mentor, you know, just talk to somebody. I’m reading a book, Radical Candor. I’m constantly learning and we’ve shared tweeners today, lots of evidence about where we can learn more. I think let’s continue to build this sort of culture of where we can learn from each other.

Jane: I think there’s also plenty of courses that are available. So I live in work in the East of England and I’m running a masterclass next week on feedback and difficult conversations, although I think it’s more important to call it an important conversation rather than a difficult conversation. So you set your mind set off right before you get started, I think coaching, I think if you’re maybe a little bit more introverted and feeling less confident about talking to people, there are some fantastic books that you can read if you want to start things.

So if you’re on Twitter, I would absolutely recommend following Amy Edmondson, she’s brilliant. If you want to read a book, there’s one called Vital Conversations. There’s one called Fierce Conversations. There’s one called Compassionate Conversations, they all talk about the same sort of thing, it’s really breaking bad news on steroids. So there’s plenty of reading material out there, and equally, if you’re somebody who gains a lot when you’re learning by talking to others, a mentor network is invaluable. A coach is fantastic or attending a course.

And of course, if you attend a course, it’s just half a day, it’s just a day. Unless you practise something, you won’t get good at it. So every opportunity you get to practise these conversations, and then it becomes much easier to talk to your teenagers, it becomes much easier to talk to your in-laws, it becomes much easier to talk to your managers, it becomes much easier to talk to that colleague that is always a bit of a bull in a china shop that’s irritating the living daylights out of you. So it’s a life skill.

Rachel: As we finish, can I just get your three top tips for anyone in this situation who is sort of facing having to speak up?

Susan: I think, gosh, the first thing I would say is think about why you want to have the conversation. Be clear about what it is that you want to discuss, and be honest about how the issue is affecting you. So I think that would be what I would go in with.

Rachel: Thank you.

Jane: Know your purpose, know your intention, be prepared to listen without defending.

Rachel: Thank you so much. Thank you, both of you. We can talk about this for another couple of hours. So I’m going to definitely get both of you back on the podcast if that’s okay, another time. We’ll put the ways that people can get in touch with you and websites and things like that in the show notes. But thank you so much for being with us today. Bye then.

Thanks for listening. If you’ve enjoyed this episode, then please share it with your friends and colleagues. Please subscribe to my email list and subscribe to the podcast. And if you have enjoyed it then please leave me a rating wherever you listen to your podcasts. So keep well everyone. You’re doing a great job. You got this.

Podcast links

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Check out the Complaints and How to Survive Them Series!

• E78: Preparing to Fail Well with Drs Sarah Coope, Annalene Weston and Sheila Bloomer
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• E82: Surviving the Process with Drs Jessica Harland, Caroline Walker, and Heidi Mounsey

Chaos in the Clinic by Perez HR, Beyrouty M, Bennett K, Baier Manwell L, Brown RL, Linzer M, Schwartz MD

Civility, Respect, and Engagement in the Workplace (CREW) Study

Civility Saves Lives

Mastering Civility: A Manifest for the Workplace by Christine Porath

Clinical Human Factors Group

Nancy Kline books

Freedom to Speak Up campaign

Learning from Deaths

The Fearless Organization by Amy Edmondson

Developing cultures of high-quality care by Michael West

The Happiness Advantage by Shawn Achor

Radical Candor by Kim Scott

Amy Edmondson’s Twitter

Vital Conversations by Alec Grimsley

Fierce Conversations by Susan Scott

Compassionate Conversations by Diane Musho Hamilton, Gabriel Menegale Wilson, and Kimberly Myosai Loh

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