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Known Certainty
Recently, I met a coaching client for her second session. As we greeted each other it was immediately apparent that her energy and mood had shifted from the first session. She seemed lighter, her shoulders were higher and posture straighter. There were smiles instead of tears.
In the initial session, we had talked about pressures and expectations. It became clear that these were largely internally generated. Like many doctors, this person had uncompromising expectations of herself.
Perfectionism involves an underlying anxiety tendency, as well as a need to be certain – to be right.
As we had completed the first session, we had discussed taking a different approach. Looking at things from another perspective and deriving self-worth from internal measures as opposed to perceived external feedback. In addition, we commenced a gratitude practice and a type of breathwork.
At the second session the doctor announced that the first meeting had “changed her life!” While this was a wonderful affirmation, I wondered if it could be true. Could a single session really change someone’s life? Would that change be maintained, and did it need to be? Or had the slight nudge in trajectory already set her on a different and more fulfilling path?
In medicine and health, we implicitly learn that it is important to be, and appear, certain when dealing with patients and others. We therefore consciously and unconsciously cultivate an image of being all-knowing. Not encompassing doubt.
Accuracy and confidence is, of course, critical in so much of healthcare. But could an over-reliance on certainty sometimes lead to negative consequences for ourselves and our patients?Excessive over-certainty could lead to embedded inflexible attitudes and a type of naive realism – where our own view of the world is believed to be the only reality.
When these rigid attitudes and beliefs become pervasive, often at the stage of being a junior doctor, they may allow for a degree of comfort with less self-doubt and fear. Indeed, adopting this mindset may be adaptive, as it reduces the need for cognitive resources to be diverted to consideration of unpredictability or uncertainty.
But does this benefit patients? Does it limit our own positive emotion and creativity, and does it reduce our ability to visualise alternate possibilities and different futures? Does it mean that we overcommit to a particular diagnosis and treatment?
This fixed mindset, perfectionism, and need to be right could lead to less empathy for our patients. It could result in giving a ‘factual’ and harsh prognosis without allowing for the unknown, or indeed the unknown unknowns. It may lead to less hope for the patient and family – and we know that once hope is lost, clinical outcomes deteriorate.
As the parent of a now-adult child with a significant life-long diagnosis, I have met with multiple specialists. Some have given the the bleak textbook outlook, devoid of any positives. This has left me feeling deflated, defeated, and helpless. What is the point of going on? I have also dealt with doctors who have acknowledged that even in a difficult situation, none of us can truly know the future. Even in an awful situation, we don’t know exactly what can happen.
These doctors manage to retain their authenticity and recognise the challenges, but still allow for a degree of hope. I know which of the above doctor’s attitudes that I prefer. Hope is energising – it enables you to take forward steps and continue to battle.
So, could this image that we cling to – of being right, certain, perfect, all-knowing – the attitudes that we unconsciously associate with a ‘superior’ doctor, also lead to a single viewpoint and an inflexible attitude?
A circumscribed way of being, and a limited range of allowable emotion with over-reliance on suppression as a form of emotional regulation, may not be in the clinician’s best interests either. A rigid thinking pattern, need for certainty, and emotional suppression, are implicated in burnout. Especially when we reach the point where there is no joy in our work.
What would be the effect of adopting a different lens, seeing alternative viewpoints, acknowledging other perspectives? Would it lead to less individual certainty in one’s own world? Would it lead to loss of credibility as a clinician?
Or would the reverse occur? Would you generate positive emotions, feel happiness, allow your patients to have increased hope, and become a better doctor with a broader scope and increased ability to connect?
These seemingly-simple attitudinal changes may be able to create powerful positive outcomes. Perhaps discussion of, and thinking about, how one thinks, really is important and necessary for us all.
Maybe facilitating broader perspectives and enabling a wider range of attitudes really can change a life.
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Leadership in Healthcare
All people will experience leadership or being led at times during their life. Whether this be in the school yard or in a board room, we have all had leaders in our groups and teams. Many of us have been the designated leader. Given that leadership is so ubiquitous, seemingly we’d all have a clear understanding of what makes a good leader. However, like many of the most important elements in organisations and society, leadership is poorly understood.
Leadership is felt at the unconscious and emotional level rather than evaluated cognitively. We ‘know’ when we are being led well or badly. Good leadership needs to include technical competence and proficiency with the prevalent systems but must also encompass factors that are only experienced intuitively.
The emotional measures of leadership, such as how much trust the group places in the leader, have become neglected and undervalued. Perhaps these elements are diminished because they are less visible and harder to evaluate and comprehend. However, the emotional aspects of leadership are some of the most critical. These factors must come to the fore and be examined and developed if our systems are to change for the better.
What is Leadership?
When I was first starting to be appointed to leadership positions within medical teams and hospital departments, I felt some anxiety. Who was I to direct and control these groups of educated and high-performing individuals? I started to research leadership theories and practices to improve my capabilities and alleviate my anxieties.
From the multiple shelves of books on leadership in any bookstore, it became apparent to me that leadership is a highly valued but poorly understood topic. I also found that there were many different approaches and answers to the question about what leadership consists of. Many of these bookstore texts, often written by an individual who had followed an unconventional path to success (which often also included becoming outrageously wealthy), asserted that their method was the only recipe to achieve your goals. However, none of them seemed to hold the secret to my leadership challenges. While all of the books contained insights and interesting anecdotes, it appeared that each organisational or group context would be different and require its own approach.
As well as edicts from billionaires, many of these leadership books were written by military leaders, detailing actions in battles and wars that were then somehow extrapolated to peacetime business situations, or leadership in other fields. This felt disingenuous when thinking of organisational leadership. A business or hospital is not at war with its competitors. Most of the messages didn’t seem to apply. I wasn’t at war, beginning a start-up, or concentrating on amassing a fortune. Despite the multitude of conflicting ideas, I didn’t really apply any of the lessons learned from the leadership texts.
Oddly, I found that some of the best outcomes that I had with my team would be when I used techniques or styles of behaviour that were similar to those used when playing or coaching sports. The groups responded to being cared for in similar ways. It wasn’t so much control or detailed direction that was required, more so care and respect.
The medical teams needed to connect with each other just as much as a group of teenage athletes playing a sport did. The kids played better when they were treated with affection and allowed to have a sense of fun. The doctors performed for higher stakes, but also worked more effectively when they had a caring and enjoyable environment. It wasn’t about controlling them – it was about relationships and guidance.
The realisation (which perhaps should have been obvious) was that there isn’t a secret way to lead specific teams. All teams are the same, in many ways. The first factor to create a great team and culture is as simple as being nice to people and treating them fairly and respectfully with clear communication. The doctors didn’t want me to tell them how to do their job, they just needed a supportive framework around them where they could develop trust and feel part of a team in which there was regard for all members.
The Desire For Leadership
It is obvious that leadership roles are desired and prized by many in our society. People gain power with leadership roles in any setting and associate such roles with enhanced status and often increased remuneration. As humans, we have an unconscious mental shortcut that assigns other abilities to those in powerful positions, frequently assuming that due to their high status in one field, their opinions about unrelated topics also somehow have extra authority. Therefore, there are many reasons and attractions to leadership. People with certain personality characteristics – including narcissism – will be drawn strongly to leadership roles, even when they are poorly suited.
Each of us has an image or construct of the ‘ideal’ leader, ranging from an authoritarian figure who can bravely lead us forward through solo action and decision making, determination, and self-will, to the democratic leader who involves and consults many people before making each decision.
Leadership is a complex concept that encompasses many facets. It may sometimes be easier to consider what it is that leadership is not than to define what leadership actually is. Leadership is not just the job title, the position, a particular set of attributes, or an ability to organise and manage. Some of the areas encompassed by leadership include: setting cultural expectations, communicating, motivating, collaborating, directing, delegating, taking ownership of difficult situations, taking responsibility for poor outcomes, inspiring others, dispensing consequences, recognising noteworthy efforts, giving directions, making sense of uncertainty, strategising, collaborating, expressing gratitude, forgiving, counselling, and supporting.
Further, leadership is about directing focus onto areas that need or deserve attention. These may be organisational goals, improvements, corrections, or modifications required, as well as areas that warrant praise due to unusual or unprecedented success, exemplary effort, and behaviours valued by the organisation. The leader must have the requisite skills for the position within the appropriate industry and must have clearly held personal values which are congruent with the desired culture of the organisation. The leader must also have an ability to create and share goals with other members.
When I think of the consultants, directors, or heads of units who influenced me most during my training, I must wrack my brain to discern who gave the best advice on surgical technique, or who I obtained certain theoretical knowledge from. However, I have immediate recall of how I felt with each of my ‘bosses’, and what emotions they stirred in me. Some of the lessons I learned were from those I didn’t want to emulate. The best learning was from those whose behaviour I admired. These people were kind, not only to patients but to juniors, nurses, and all staff. I felt great affection for these leaders, and I worked harder for them as I was determined not to let them down. When around good people, we behave more virtuously, with the opposite also applying. The best leaders – those I wanted to be like – were honest, kind, and fair.
As leadership research increases, it is more frequently recognised that emotional intelligence correlates with leadership effectiveness. This does not just imply nicety, but also kindness, empathy, an ability to register the emotional states and needs of other people, and a willingness to try to assist. These qualities are part of the rich mix that constitutes wisdom. Wisdom implies a level of intelligence, both cognitive and emotional. It also requires self-regulation of emotions, which allows the use of different and appropriate styles of interaction according to circumstances and the people involved.
Wisdom has long been recognised as an important virtue in a leader, with both ancient Greek and Chinese philosophers having similar sayings along the lines of, ‘With power must come wisdom’.
The current challenges to hospitals are causing many organisations to consider their culture and try to increase organisational pride, foster staff well-being, and produce a flourishing environment. This is more than merely trying to continue with a current strategy, or business as usual, which only requires technical management or transactional leadership. These hospitals are also examining their leadership structures.
Evolving into a thriving organisation requires a more inspired transformational leadership style that engages the emotions and imagination of staff. This is where curious, appreciative leadership prioritises development of people over development of building or organisational processes. In this environment egos can be controlled in order to collaboratively create the desired vision. With this style, the leader does not need to control everything. They are more responsible for helping to unify, envision, and facilitate. The leader does not have, or need to have, all the answers. The leader encourages a vision and invites others to collaborate with the detail. In this structure, a leader will be content helping to trace an outline and stepping back to allow others to add the colour.
The Secret to Becoming a Leader
When many of us rise in seniority and start to assume leadership roles, we follow the same path. We read leadership guides and manuals, we watch TED Talks, we explore the importance of performing a daily ‘twenty-mile march’,[i] try to become more effective by establishing ‘seven habits’,[ii] and suppress hunger while we are ensuring that we ‘eat last’.[iii] We try to begin with understanding our ‘why’[iv] and attempt to ‘lean in’.[v]
These are all inspiring messages with outstanding lessons. But reading a book or having a position title does not make one a true leader. We may consider ourselves the leader, but can someone really be described as a leader if they don’t have committed followers? Without followers, or at least colleagues who are collaborated with and consulted, perhaps the real position description is organiser or manager. Staff do not choose to be led or become followers because of which books someone has read. They listen to and line up with those they trust and feel affection and respect for.
Perhaps we don’t need the books. It may be better to just reflect on how our own memorable and treasured leaders have treated us in the past. In some ways, we already instinctively know what is required, if we are brave enough to admit it. Deep down, we all know how to look after others, build mutual positive regard, and help create happy and functional teams.
The mentors and very best leaders that each of us has been associated with created a feeling of nurturing, and a sense of being understood. There were, of course, non-negotiable areas relating to performance standards and behavioural guidelines, but even these were learnt in an overarching framework of kindness. To give these gifts to others will be to get them back. The leader in title, who treats others with affection and care, will become the leader with devoted followers.
Excerpt of From Hurting to Healing – Delivering Love to Medicine and Healthcare
Author: Simon Craig; Hambone Press, 2023.
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The Economics of Burnout in Healthcare
Care for our fellow humans cannot, of course, be reduced solely to figures or numbers. However, we are in the midst of a burnout epidemic in healthcare across the world and it may help us to acknowledge the seriousness of this point in time with the aid of an economic analysis.
We all hear daily of the delays in being able to see a GP, the shortage of GP’s, excessive waiting times in ED, elective surgery blowouts, record rates of nurses leaving their profession, shortages of staff – the list goes on. But often the stories seem to come so incessantly that they blur into one and go unheard.
And what of burnout? The occupational affliction that contributes, at least in part, to all of the problems above and also is related to poorer physical and psychological health (including increased suicide rates) in the person suffering. Can we assign a dollar cost to this condition?
For the sake of these calculations I have used data from the US and extrapolated some to an Australian context. Please remember that the numbers may not always be accurate in any transfer, but the themes will be similar and, of course, the exact figures are not the most most important takeaway – more that we have an urgent call to action and an opportunity to improve healthcare systems for the benefit of us all.
- There are 340,000,000 people in the USA
- It is estimated that 100,000 people in the US die each year from medical errors (Rodziewicz, Houseman, Hipskind, 2023) and that these errors occur in both inpatient and outpatient settings (Rodziewicz and Hipskind, 2018)
- It is known that doctors suffering from burnout make twice the rate of serious medical errors compared with non burnt out doctors (Shanafelt, Balch, Bechamps et al, 2010).
- Assume approximately 50% of doctors in US affected by burnout (conservative estimate – most studies indicate higher rate of burnout)
- Therefore, of the 100,000 deaths we can assume that 66,000 are made by doctors suffering with burnout, and 33,000 by doctors unaffected by burnout.
- Every US citizen has a 0.029% (roughly 3 in 10,000) chance of dying each year from a medical error, however that goes up to 0.039% (around 1 in 2500) if treated by a doctor suffering with burnout, and down to 0.018% (less than 1:5000) if you are treated by a non burnt out doctor. I guess we all want to get the doctor unaffected by burnout, huh?
Annual expenditure related to medical errors in the US is approximately $20 billion (Ahsani-Estahbanali, Doshmangir, Najafi et al, 2021) – which equates to $59/person/year just to pay for medical errors.
In Australia, if the same cost applied to medical errors/person applied, this would equate to $91 AUD, with a nationwide bill of $2.37 billion AUD for our 26 million populace.
Imagine that we could eradicate burnout in the, let’s say, 50% of Australian doctors affected. This group would make half the errors and save $788 million each year.
That’s a lot of money. Of course, it is somewhat abhorrent to think that saving money could be more motivating than reducing human suffering and death. And these calculations do not take into account the poorer teams that result from doctors with burnout, the overall reduced standard of care, nor the costs on the doctor’s own health and that of their families.
Make no mistake – we know some of the causes of burnout, and we know that certain demographics such as young doctors are more affected. It is clear that burnout can have its genesis in medical school or early career years. We know some of the organisation-level changes that can help – such as reduction of unnecessary or duplicated clerical and bureaucratic load. We know that improving teams and culture reduces burnout. We have wellbeing science that informs many of our individual interventions.
So, with all of this information at our disposal – and with significant potential fiscal saving as well as reduction of human suffering – why is it that we are not doing more to prevent, combat, and treat burnout? Why aren’t our organisations and institutions engaging with the science to reduce the precipitants of burnout? Why aren’t we prioritising how our teams function and optimising organisational culture? Why aren’t we engaging with evidence-based interventions and measurement? Does there have to be an even greater cost exacted before we address this problem?
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How Olympic Cycling Can Save Healthcare Organizations
It’s no secret, is it? Healthcare organizations and institutions are struggling – some more than others. However, all are faced with seemingly insurmountable challenges. Demand outstripping resources, failing cultures and disengaged staff, everywhere blockages and lack of flow. These are but a few of the common themes.
Big money, large initiatives, great minds – all have been thrown at the problem. The result? Well, if there was an answer we would all have adopted it long ago.
So what can help? Clearly, doing more of the same, or following the same formula that we always have (but trying harder!) isn’t going to work. What’s that famous Einstein quote about madness again?
In this context of highly trained, talented, and committed people following the same established patterns and schedules but without success or ability to change the paradigm, let’s consider the British Cycling team. In 2003, they had been, to put it mildly, seriously unsuccessful for over a century. In the prior 100 years, they had won only one Olympic gold medal and no British cyclist had ever won the 110 year-old Tour de France.
At this point Dave Brailsford, a former professional cyclist and MBA, was put in charge of this mediocre team. However, Brailsford had a different plan to that of his predecessors. His strategy was not to come in with a grand ‘solution’ or to implement bold and revolutionary changes. Instead, Brailsford wanted to concentrate on small change in every facet of team operations in order to “aggregate marginal gains”.
In every aspect of cycling, and the cyclists’ lives, he tried to identify where he could improve things by 1%. When added together, he felt that all these incremental improvements would lead to a substantial elevation of performance.
Some of the areas of attention were obvious – tires, gears and other mechanical equipment, more aerodynamic suits – however others included nutrition, sleep quality, even the handwashing techniques of the cyclists to reduce the common cold. Every aspect of preparation, training, and performance was examined without an expectation that there would be an astonishing breakthrough or solution, but that there would be a possibility to improve by 1%.
The results from this approach spoke for themselves. At the 2008 Olympic Games in Beijing, the British Team won 60% of all gold medals in cycling. In 2012, they went even better, setting 9 Olympic records and 7 world records. In the decade from 2007, a British cyclist won the Tour de France 5 times.
Is there any relevance of this story to our current Healthcare challenges? Could organizations change from focusing on ‘fixing’ big problems (or even worse, failing to act due to overwhelm) to instead focusing on every aspect of Healthcare and trying to improve by 1%?v Would this be useful? I think it would.
When considering what the areas of attention would be, there seem to be obvious elements such as optimizing operating theatre time and technical procedures, reducing infection rates, and speeding up the delays in patients being seen in ED. Of course, all of these are already areas of focus in hospitals.
However, there are innumerable other factors in care that are overlooked, unrecognized, or disregarded – which also affect performance. These things can include efficient movement of patients, reducing unnecessary bureaucracy, effective IT systems. Indeed any aspect of the organization. Further elements that may be considered esoteric by some but which in my experience are essential for a high functioning organization are communication styles, intra- and inter-team harmony, support of staff, inclusion, creation of belongingness and organizational pride…the list goes on.
Can each of the above be improved by 1%? Of course they can. And will the gains add up to create a better organization with improved clinical outcomes and healthier staff? I think the answer is obvious.
It is important to note Brailsford’s – now Sir David Brailsford – prior interest in the Japanese practice of Kaizen or continuous improvement, “Forget about perfection; focus on progression, and compound the improvements.” (Harvard Business Review, 31st Oct 2015).
Brailsford also noted that when this process was embraced, with a united desire to find continuous small improvements there was a contagious lift in spirits, enthusiasm, and culture within the team.
Perhaps there are lessons here for Healthcare.
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What is Organisational Wellbeing?
In an organisation that I have been working with recently, we have been paying attention to wellbeing – and creating a ‘wellbeing plan’.
Clearly an important aim, even if the term wellbeing is beginning to feel overused and at risk of inducing cynicism in those who are hoped to be the recipients of the well-intentioned plan.
In our organisation, like many others, perhaps the most critical steps is to work out what the term wellbeing relates to exactly. How do we define it? Is it the same thing for every individual? Is there a difference between individual wellbeing and that of the team, or whole organisation? Certainly, anything that is hard to define will be difficult to measure and thus judge the effect of any actions.
It can feel as though estimating wellbeing in organisations is a little similar to judging happiness – a notoriously tricky entity to define. But is wellbeing the same as happiness? And what is happiness?
The essence of happiness has been discussed for thousands of years, since the time of the ancient Greek philosophers. Aristotle defined happiness as eudaimonia – a state of flourishing through living virtuously with meaning and purpose. In more recent times we also consider ‘hedonic happiness’ or the state that comes from pleasurable experiences and sensations while avoiding unpleasant ones.
However, despite the work of thinkers over many centuries we still don’t have an agreed-upon definition of happiness, one of the most important things in life. The modern entity of Positive Psychology, the scientific study of wellbeing, also struggles a little with this concept and instead substitutes the term ‘subjective wellbeing’ (wellbeing – there it is again!) as an alternative for happiness. A person’s level of SWB relates to how often one feels positive emotions and moods, how infrequently one experiences negative states, and a general sense of life satisfaction.
Again, SWB applies to individuals. Can it be extrapolated to organisations?
Returning to modern day organisations – where we universally want to increase wellbeing – we also struggle with the definition and measurement of wellbeing in our people as well as at a broader organisational level. Many staff surveys essentially attempt to assess some measures of SWB and then use this as a measure of the whole organisation and indicate where action needs to occur. Is organisational wellbeing simply a total of all the individual SWB measures divided by the staff number? Does the wellbeing of some in the organisation matter more than others and contribute more to the total score? Are leaders weighted differently to new signings?
Going back to the original question of how to produce a wellbeing plan that helps the organisation as well as those working within, what should we do? Can we use measured levels of SWB across all staff as a de facto measure of organisational wellbeing? Would this equate to that equally slippery concept of organisational culture? I think not, because organisational culture is an even broader concept that includes multiple other factors such as performance and ways of undertaking tasks.
Perhaps the answer is that individual wellbeing amongst all staff is not only a critical contributor to their health and the way each person experiences their life – it is also an important foundation of organisational culture. Of course, not all things can be fixed overnight and as a complex entity our organisational culture will develop in emergent unexpected ways. The efforts that the team make to improve individual wellbeing practices and work conditions may create ripples that help others even when not able to be measured.
In the end, the care that we give to ourselves and others, how we interact and communicate, will help wellbeing and aid in creation of a generative and successful organisational culture
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Forced Change in Healthcare
Healthcare is a pillar of every society. It is universally hoped that the existing healthcare system works optimally in that community. Everyone shares these ideals.
However, many of the strengths of embedded healthcare systems can hinder progress in the face of changed circumstances and new challenges. It appears that we are in the midst of this situation currently. Our system still works in terms of clinical outcomes, but the ongoing demands including shortage of resources can make us feel that we are in a leaky boat and baling out water as fast as we can. Will we go under?
In the entrenched and relatively static environment that is healthcare, systems change, and respond to change, very slowly. This is due to the culture being long-standing, hierarchical, conservative, and expert-based.
These are not negatives – these features provide advantages in consistency and reliability. They allow known work practices and learning platforms, and facilitate patient care outcomes that are desirable and comparable across all of a nation’s healthcare system. However, they do slow the recognition of challenges requiring bold thinking.
While we in Australia, and much of the world, are still achieving excellent clinical outcomes our organisations and workers within them are struggling. Our people are disengaged and leaving. It seems that in the face of these increasing challenges it is becoming more urgent to re-examine ourselves. Even with our inherent resistance, we must address a need for change.
What do we make of this? Do we have the courage and ability to re-imagine our systems?
Is it possible to continue to achieve excellent clinical results while also improving organisational systems to a place where they actually benefit those working within them? Surely this goal would be worth pursuing?
It seems that while we have overarching all-of-healthcare processes that are important in clinical care (and which each organisation shares in some way), the solution to plummeting worker wellbeing and poor culture must occur at the level of each individual organisation. Each workplace can produce its own organisational style and bureacratic processes that will be part of the change required to address these challenges.
Organisations should not be carbon-copies of each other and can identify and enact the processes required for their workers, in their context. More of the same will not suffice. Hoping for organisational culture improvement in exactly the same setting, without new ways, will not occur. What got us here will not be sufficient to get us where we want to go.
This is the time for attention to these issues – while we are still afloat. I believe we have an amazing opportunity to reinvent ourselves. We can continue to provide excellent patient care while also altering organisational structures in a way that cares for our own people.
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10 Immediate Actions that Improve Organisational Culture (and don’t cost a thing)
1. Use People’s Names
Not only is the use of names a safety feature in high-risk endeavours such as healthcare, it also creates tighter teams and facilitates performance. Hearing your name spoken by another person causes a surge of oxytocin release that leads to stronger interpersonal bonding and better relationships.
2. Leaders Walking Around
How can a leader understand their organisation if they only see the inside of the executive suite or their own office? How can they feel belongingness, and be seen to belong, if they are never seen? Workers trust and respect a visible leader – it is critical to organisational success.
3. Ask Questions
While walking around and becoming a more trusted leader, the best way to learn is by asking questions. In this way you will immediately gain access to multiple viewpoints, unappreciated facts, and understanding gained through time in the workplace. Benefit from the experience of others. Not only will you hear multiple perspectives, you will also start to engage your workers and team. If you don’t know what to ask, try these:
- What do you need right now to help with your job?
- What advice do you have for management?
- What are you seeing that we could be doing better
4. Model the Values and Behaviours you want to see
For workers to have trust and affection for leaders, they must be shown trust and affection. The elements that you identify as lacking in your team or organisation are what you must deliver to others.
5. Encourage Human Interaction
Being with others has many benefits in addition to mere exchange of information. Relationships build culture. For example, if a meeting can be carried out in person rather than virtually – insist on an in-person meeting.
6. Foster a Culture of Learning and Forgiveness
While we all strive for excellence it is possible that this sentiment can become warped into a suboptimal culture where mistakes are treated with censure and focused on who is at fault rather than how the system did not enable the best outcomes. Negative outcomes are feared, suppressed, and ultimately hidden.
Many major errors result from multiple smaller incidences of poor communication. Negative relationship styles, siloes, and silence can lead to disaster. Honesty and openness facilitate communication that leads to learning, innovation, and improved performance.
7. Be a Beginner
Understand that while you may have an opinion or sense of a problem, others will see things with different viewpoints. Be humble. Encourage ‘Beginner’s mind’. Hear from all voices. Diversity of opinion is critical to nuanced understanding and better definition of problems.
8. Understand Problems at a Granular Level
Get information from as close to the source as possible. Involve those who do the work, rather than merely their superiors. Talk to those involved in delivery of the processes under review. Allow the ‘coal-face’ workers to help craft the solutions. Become an inclusive rather than extractive organisation.
9. Build Positive Emotion and Momentum
Comment on things done well. Express gratitude. Not only is this scientifically proven to enhance one’s own wellbeing, it will also lead to improved organisational culture.
10. Promote an Enjoyable Workplace
Humans like to do more of what they enjoy. People operate more efficiently where they are relaxed and feel supported. Improving workplace conditions will lead to improved staff commitment and reduced disengagement and attrition – this will retain corporate knowledge with multiple downstream benefits. Make the workplace kinder and more fun.
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Recently, I met a coaching client for her second session. As we greeted each other it was immediately apparent that her energy and mood had shifted from the first session. She seemed lighter, her shoulders were higher and posture straighter. There were smiles instead of tears.
In the initial session, we had talked about pressures and expectations. It became clear that these were largely internally generated. Like many doctors, this person had uncompromising expectations of herself.
Perfectionism involves an underlying anxiety tendency, as well as a need to be certain – to be right.
As we had completed the first session, we had discussed taking a different approach. Looking at things from another perspective and deriving self-worth from internal measures as opposed to perceived external feedback. In addition, we commenced a gratitude practice and a type of breathwork.
At the second session the doctor announced that the first meeting had “changed her life!” While this was a wonderful affirmation, I wondered if it could be true. Could a single session really change someone’s life? Would that change be maintained, and did it need to be? Or had the slight nudge in trajectory already set her on a different and more fulfilling path?
In medicine and health, we implicitly learn that it is important to be, and appear, certain when dealing with patients and others. We therefore consciously and unconsciously cultivate an image of being all-knowing. Not encompassing doubt.
Accuracy and confidence is, of course, critical in so much of healthcare. But could an over-reliance on certainty sometimes lead to negative consequences for ourselves and our patients?Excessive over-certainty could lead to embedded inflexible attitudes and a type of naive realism – where our own view of the world is believed to be the only reality.
When these rigid attitudes and beliefs become pervasive, often at the stage of being a junior doctor, they may allow for a degree of comfort with less self-doubt and fear. Indeed, adopting this mindset may be adaptive, as it reduces the need for cognitive resources to be diverted to consideration of unpredictability or uncertainty.
But does this benefit patients? Does it limit our own positive emotion and creativity, and does it reduce our ability to visualise alternate possibilities and different futures? Does it mean that we overcommit to a particular diagnosis and treatment?
This fixed mindset, perfectionism, and need to be right could lead to less empathy for our patients. It could result in giving a ‘factual’ and harsh prognosis without allowing for the unknown, or indeed the unknown unknowns. It may lead to less hope for the patient and family – and we know that once hope is lost, clinical outcomes deteriorate.
As the parent of a now-adult child with a significant life-long diagnosis, I have met with multiple specialists. Some have given the the bleak textbook outlook, devoid of any positives. This has left me feeling deflated, defeated, and helpless. What is the point of going on? I have also dealt with doctors who have acknowledged that even in a difficult situation, none of us can truly know the future. Even in an awful situation, we don’t know exactly what can happen.
These doctors manage to retain their authenticity and recognise the challenges, but still allow for a degree of hope. I know which of the above doctor’s attitudes that I prefer. Hope is energising – it enables you to take forward steps and continue to battle.
So, could this image that we cling to – of being right, certain, perfect, all-knowing – the attitudes that we unconsciously associate with a ‘superior’ doctor, also lead to a single viewpoint and an inflexible attitude?
A circumscribed way of being, and a limited range of allowable emotion with over-reliance on suppression as a form of emotional regulation, may not be in the clinician’s best interests either. A rigid thinking pattern, need for certainty, and emotional suppression, are implicated in burnout. Especially when we reach the point where there is no joy in our work.
What would be the effect of adopting a different lens, seeing alternative viewpoints, acknowledging other perspectives? Would it lead to less individual certainty in one’s own world? Would it lead to loss of credibility as a clinician?
Or would the reverse occur? Would you generate positive emotions, feel happiness, allow your patients to have increased hope, and become a better doctor with a broader scope and increased ability to connect?
These seemingly-simple attitudinal changes may be able to create powerful positive outcomes. Perhaps discussion of, and thinking about, how one thinks, really is important and necessary for us all.
Maybe facilitating broader perspectives and enabling a wider range of attitudes really can change a life.
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Could your team be languishing rather than burnt out?
In the early 2000’s sociologist Core Keyes coined the term languishing. Keyes described languishing as the region between poor psychological health and complete psychological health (or “flourishing”). Importantly for an individual, flourishing was not simply an absence of mental illness – but more a state filled with positive emotion and functioning well psychologically and socially.
Languishing, however, was a state of not feeling good and not functioning well. Perhaps the midpoint of a continuum between psychological ill-health and complete psychological wellbeing or flourishing.
In 2021, organisational psychologist Adam Grant popularised the term with an article in the New York Times There’s a Name for the Blah You’re Feeling: It’s called Languishing
The sentiment of languishing resonated with many people at that time. As Grant described,
“It wasn’t burnout – we still had energy. It wasn’t depression – we didn’t feel hopeless. We just felt somewhat joyless and aimless.”
Can Teams Languish?
We are all aware of the significant effects of burnout on healthcare workers individually, but we emerge from Covid it also feels as though many of our teams and organisations may be languishing – not obviously failing, but definitely not thriving.
Is that possible or is languishing only an individual phenomenon, rather than something that can affect a group? In my view languishing in a whole team is possible, and that transmission of a shared affective experience is more common than we currently recognise. Indeed, the overall emotional state of any group is of vital importance in the way it operates and the results that are produced.
A languishing team could be one that is still functioning, but not anywhere near it’s potential, and a team that still has energy to do the work, but is not energised by the work. Sound familiar?
A languishing organisation may not feel helpless and depressed – but there may be a collective lack of happiness and joy. Is this your institution? Does it feel like the days are just being endured one-by-one, without any highlights or passion?\
What To Do About It?
Often, acknowledging the truth of any situation can be the first step towards resolution. In a group that is worn out and listless – or going through the motions – by becoming aware of the state of languishing, recovery to a more enjoyable state can occur. The saying says that ‘naming leads to taming’ – implying that recognition of feelings and emotions leads to better control of them rather than being controlled by them.
Any team which has the self-awareness to address a difficult recent past that has resulted in the current lack of excitement and motivation is beginning the journey to restore collective flourishing. The leadership to ask “where are we at?” and the courage to jointly self-reflect are behaviours of a high functioning team that has temporarily taken a hit.
Overcoming Group Languishing
The group that collectively addresses the challenges of team languishing will return to flourishing most quickly.
For individuals who are languishing, the advice of Grant and others is to recognise small wins and moments of joy in a bleak time. It is suggested to look for activities that promote flow – where you can be immersed in activities that consume your attention and that are rewarding, challenging, and enjoyable. Uninterrupted time without distraction has also been proposed as important in recovering from individual languishing.
Teams that are languishing may have advantages over individuals. A shared problem that is discussed and addressed is easier to handle when one realises that you aren’t on your own. The joint plan to overcome languishing will most likely have been conceived with multiple opinions and views – optimal team behaviours that create inclusion and better bonds. The communication that is provoked may, of itself, help with the aimlessness and silence that can accompany languishing.
Indeed, periods of team languishing may be essential in making advances as a group. Deciding together how to deal with the problem, and find more joy in work could be the spark that is required for creative leaps. The feeling of joint discomfort and relying on team members to overcome the situation together, may be a step in producing a high-functioning team.
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Repairing Healthcare Systems
The First Step
There are frequent statements from hospital leaders that ‘people are our greatest asset’ or such-like. But these pronouncements can feel insincere, as the actions do not always match the words. However, with the crisis of mounting burnout and decreasing availability of staff, administrators are now starting to believe their own words. Therefore, this is an opportune time to examine and adjust our systems in ways that help people and enable them to be more productive, engaged, and happy.
All clinicians’ time needs to be valued, not wasted. Time that staff spend making bonds with each other must be treasured, rather than treated as frivolous time-wasting. Only now are we starting to realise the value of brief interpersonal interactions.
Of course, every hospital aims for excellence. Within this framework, a more balanced and wise approach is possible. Communication dictates the strength of relationships. Relationship quality influences the performance of teams. Team performance affects patient care, and indeed every other facet of the hospital. Therefore, communication and human interaction become the currency that dictates the quality and success of any organisation.
Traditional business management theory has come to dominate all organisations, including hospitals, and with this approach our systems have become mechanistic and ‘hard’. It’s time to change. Hospital systems should be dynamic, organic, adaptive, and emergent. We must embrace the notion of soft-system thinking to improve our failing health services. We need to care for ourselves before we can look after others.
Excerpt: From Hurting to Healing – Delivering Love to Medicine and Healthcare Hambone Publishing 2023
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