Get Some Air Cover to Help You Set Boundaries

[00:00:00] Rachel: I want to talk to you today about air cover, how to get it and why it’s one of the number one things that will help you say no. One of my favorite programs is Only Fools and Horses, which I guess shows my age, but Only Fools and Horses is about these three chaps who are constantly trying to make money. And in one of my favorite episodes, they end up going to a stately home and managed to persuade the owner to pay them a lot of money to clean their chandelier. So they have to get this chandelier down, take it off to clean, and then obviously bring it back and put it back up.

[00:01:04] Rachel: And there’s a very famous scene where two of them are standing below this beautiful crystal chandelier. And the other one is up at the top of the roof, unclipping the chandelier, and he’s about to drop it into this massive blanket that’s going to catch it. And in the most fantastic bit of filmmaking ever, you see them unclipping the chandelier, dropping it down and smashing on the floor because they’re standing under the wrong chandelier.

[00:01:33] Rachel: Now over the last few months, I’ve been going around the country doing a lot of conference talks, evening talks to various healthcare professionals, all about how to say no. And invariably, everywhere I go, they also have other speakers who bring some fantastic examples of how they are doing things in their practice, around how they’ve managed to create some boundaries around their workload, around how they’ve managed to work with other people and make sure that they know exactly what they should be doing and what they shouldn’t be doing. And they always have some absolutely fantastic resources to share with people, which will help them say no and prioritize and work out what they really should be focusing on in their practices.

[00:02:16] Rachel: The problem is that as I’ve been going around talking about how to say no, I’ve realized that just like that blanket underneath the wrong chandelier, we are trying to solve the wrong problem. And we think that if we just give people enough resources, if we just tell them the things that they contractually should say yes to and contractually can say no to, then we’re going to be okay.

[00:02:43] Rachel: But we forget the one big problem. And the one big problem is this: that professionals in health and social care don’t see themselves as businesses who follow strict contracts about what they do and what they don’t do. By and large, they don’t see themselves as only providing one very, very small service.

[00:03:04] Rachel: For example, if I got a heating engineer around to fix my boiler and said to him, well, you know what? There’s a leak on my roof as well, chances are that he will say, no, I do not do that. But in healthcare, it’s very different, isn’t it? And I’m sure in lots of other professions as well, that clients, customers, patients have all these different issues and the lines are a bit blurred about what we contractually obliged to do and what we’re not.

[00:03:28] Rachel: And even if we do have a contract with somebody, we want to do our best to help, because we are not just service providers. We are carers and we are helpers. And certainly, as a doctor, it’s been drilled into me that we must make the care of the patient our primary concern at all times.

[00:03:49] Rachel: Now, that’s all very well and good, and absolutely how it should be. But then the… boundaries get really, really blurred and we end up bending over backwards and not being able to say no, not because we’re not totally clear about our contract, But because we genuinely want to help. And when we have to say no, that goes against some of our internal values of I should always be here helping people. I must always cope with all the work. I’m pretty superhuman. I can get everything done. And if I can’t, then there’s something wrong with me. I’m not good enough. I am not enough. And we’ve spoken in other episodes about all these stories that go through our heads.

[00:04:28] Rachel: So even if we have some very strict guidelines about what we can say yes to and what we have to say no to, we still struggle because we feel guilty and that leads to people pleasing. We really care what people think about us and what they say about us.

[00:04:45] Rachel: We also feel a lot of shame when we can’t live up to our own internal values of being able to be there all the time and give the best service all the time to our clients, our colleagues, and our patients. And we end up living with a lot of fear because there’s uncertainty if we say no. What’s going to happen? Does that mean I’m going to get into trouble? Am I going to get a complaint? Is it all going to go really, really badly wrong?

[00:05:11] Rachel: As we know, something needs to change. And I’ve been banging on about this forever, that our resilience, our wellbeing is never going to improve while we are still slave to these stories in our heads, while we are still not able to prioritize our work or say no, because of our internal beliefs about ourselves.

[00:05:31] Rachel: Now, there’s all sorts of strategies that we need to employ and I’m going to do loads more podcasts about this because it’s something I struggle with and it’s something I’m really, really interested in.

[00:05:40] Rachel: But I remember a few months ago, I was sitting talking to a little group of very valued friends. I value their wisdom and they have a lot of insight into my life, the things I do, and we meet very regularly to support each other. And when we meet, we bring a dilemma that we have at work or at home. It doesn’t really matter. And then the others sort of coach us around our dilemma and then make some suggestions. It’s incredibly helpful.

[00:06:08] Rachel: And I was sharing what my thoughts were around how to say no, why it’s so difficult. And I was saying, well, I think I’ve got these sort of solutions that can help people. And one of my colleagues who’s worked in NHS management for a long time, just sat and thought about it and she said, Rachel, you’re missing one big thing. And that is air cover. It is almost impossible to say no, if you have no air cover from colleagues.

[00:06:36] Rachel: So there’s lots of different types of air cover. And the ones that we’ve been focusing on are the sort of air cover about, you know what, it’s not in your contract, therefore, you don’t have to do it, so legally you’re covered. So that’s a very sort of high level of air cover. And whilst it is really, really helpful, we absolutely need it. I think there’s other things that would help even more.

[00:06:58] Rachel: Another type of air cover is getting together with your direct colleagues in your practice and making an agreement what you will say yes to and what you’ll say no to and keeping each other accountable for that.

[00:07:11] Rachel: I remember one of the most freeing things for me was when I was working in my last practice, they had decided there was a certain service they were going to stop doing. It wasn’t clinically appropriate. They weren’t paid for it. And I remember the partners getting all of us together and saying, we’re stopping doing this. We expect you to say no. And if there are any complaints because of that, we’ve got your back. Bring it on. And that was so liberating. It meant that we were all on the same page and all able to do it. And what’s more, we were kept accountable.

[00:07:41] Rachel: See, so often we worry about people coming to us and say, why didn’t you do this? Why didn’t you do that? We’re so worried about dumping on our colleagues or shirking our duty. Maybe we should put a little bit more time and effort into challenging other people when they said yes to too much. We all know those circumstances where you’ve decided something with your colleagues and one of the other doctors just goes and does it anyway. So maybe prescribes that drug that’s probably not indicated or the drug that we’ve told that patient, actually, that’s not the right thing for you, we’re going to stop doing that now. And then all that good work, all that boundary setting we’ve done just collapses. But how often do we challenge people when they say yes too much? Because after all they’re saying yes, because they want to be a good person, but it creates all sorts of issues. for other people, but we don’t bring this up for them.

[00:08:33] Rachel: On the other hand, we are very good at challenging people when they say no and say, well, why did you say no? You know, that’s caused all sorts of problems for me. I think we should have each other’s backs a lot more and recognize when somebody has said no and applaud and appreciate them for that. And actually challenge people who aren’t saying no enough.

[00:08:52] Rachel: So that’s your direct colleagues. That’s air cover within the department, within the practices in which. you work. We need to look out for each other because we’re really bad at doing this for ourselves.

[00:09:03] Rachel: Now, the third type of air cover that we must utilize a lot more is these informal networks that we have outside of work. And this might be with our peers outside of work. So you might want to get together with GPs from other practices or paramedics or consultants, you know, these networks that we have, but quite frankly, we don’t use enough. And whenever we do our training, um, in particular cohorts of people that they just say how wonderful it is to be able to talk to each other. And the phrase is always the same. It’s knowing that we are in the same boat, that someone is struggling with exactly the same situation as I am. Hey, no shit Sherlock. Of course you are.

[00:09:44] Rachel: Why do we all believe that we are the only people sitting there struggling with saying no, struggling with doing the right thing in that particular circumstance and struggling to look after ourselves. All of us are struggling with the same thing, but the problem is it’s largely behind closed doors in our own little consulting rooms, and we don’t get a chance to go out and debrief and say, Oh, look what I’ve had to deal with today. I’m feeling really rubbish about this decision. And in fact, I think I made the wrong decision because I was in the corner at the time and I was worried about saying no.

[00:10:18] Rachel: And that is where the informal connections come in, both within your practices, coffee breaks, and I bang out on about coffee breaks all the time, it’s so, so important.

[00:10:28] Rachel: But a lot of you are in places where you do feel isolated. You might be the only type of professional in that surgery. You might not have a close network of peers on your doorstep. So what do you do then? Well, the answer is to seek them out. Go to training courses where you can sit and talk to them. Get an informal group together that meets regularly. And the great thing about this day and age is that we can actually meet online very, very effectively. So I am currently in a mastermind group with people that live miles and miles away, but it’s really easy to jump on and chat. It’s even better if you can do it face to face.

[00:11:05] Rachel: So booking yourselves on retreats, training courses, coaching groups, mastermind, or simply just meeting up with a load of mates that you were at university with or on a training course with regularly to discuss these issues. And when you meet up, be intentional. Go around, all share what you’re dealing with, be vulnerable. Get some advice from other people, because you’ll be surprised at how many times someone says I’m in exactly the same boat. And just by sharing that story and knowing that actually you’re not a bad person because you made that decision. is wonderfully reassuring. And that is how you can get some extra air cover.

[00:11:46] Rachel: You see, air cover can help with those feelings of guilt that my actions are wrong and people are thinking badly of me by just checking it out with other people who can say, yeah, well, I can see why that person might not have liked it, but that was okay, that was okay. It can help with a bit of triangulation. You know, am I the only one thinking this? Is this all right? And just getting some opinions from other people. So important.

[00:12:12] Rachel: And air cover can help with that fear and the uncertainty that you have when you think I’m going to get a complaint or something’s going to go really badly wrong if I say no here. Because if it’s been agreed as a practice or a group of professionals, then you’ve got other people that have got your back and you’ve probably even got some stuff in writing.

[00:12:32] Rachel: And by the way, side note about complaints and fear when you say no, I always think to myself, why is it that we worry so much about those complaints that are going to come in when we say no?

[00:12:44] Rachel: Now, the last thing I want to do is underestimate the effect that a complaint has on somebody. My challenge would be, what sort of complaint is going to be worse? Is it going to be that complaint that comes in when you said a well thought out no with air cover? Yes, that will be tricky, but you will deal with it and you’ll have other people to back you up. And it’s very, very unlikely that you will end up in front of the regulator if you can talk about your reasons. And even if you made a mistake, if you can show insight and learning and apologize and put things right, things will generally be okay.

[00:13:23] Rachel: But there’s other sorts of complaints that come in and those are complaints when we are nearing burnout, when we are overwhelmed, when we have not said no, when we’ve not looked after ourselves, when we’ve not set boundaries, and our judgement starts to go because we are operating largely from our threat zones, from our fight, flight or freeze zone. And in that zone Our judgment becomes very clouded. We can only think in very black and white terms, we lose all our empathy. And that is where you become rude. That is where the communication breaks down. That’s where you make silly mistakes. And that is where your judgment gets clouded and you might end up doing something you really, really regret.

[00:14:02] Rachel: Now, those types of complaints are much harder to sort out and defend than the other ones where you’ve made a good, well thought through no. And the thing about complaints is we can never really predict what complaints are going to come in any way, can we? We have no control over that. We only have control over our own mindset and our own behavior.

[00:14:25] Rachel: So in order to solve the right problem, which is how do I get over the shame, the guilt and the fear around saying no and prioritizing, we need air cover, we need backup, we need colleagues in our practices and our organizations to support us.

[00:14:41] Rachel: So the first action point would be to write down what you can do in the next couple of weeks to get your colleagues together into the same room for a conversation about this. And then how are you going to document it and how are you going to hold each other accountable for saying no.

[00:14:56] Rachel: My second suggestion is to work out who your personal air cover is. Who are the people that you can go to and discuss dilemmas with? And sometimes it’s even better if they’re not in your immediate practice because they don’t have the interference of, well, who’s going to cover the road to them and stuff like that. So that you can triangulate, you can check things out, you can hear about what people really think of you. And believe me, it will be much, much better than what the stories that you are saying to yourself.

[00:15:22] Rachel: And then finally, back to those resources that these organizations are putting out about what you need to say yes to, what you can say no to what’s in your contract. I just urge you to use them and look at them and you’ll know that the LMCs produce brilliant stuff around this. The BMA has got stuff. Your Royal College will have stuff, your professional body will have some really good guidelines, which will also provide you some air cover.

[00:15:47] Rachel: So be proactive about this. Get your own air cover. It will make saying no a hell of a lot easier.