This is a guest post by Dr Mya Cubitt (@MyaCubitt), an emergency physician in Melbourne, Australia. This post reflects her own opinions, which are unrelated to the organisations she is affiliated with. Mya thanks Michelle Johnston and Shahina Braganza for their help in preparing this post.
One sunny day when my daughter was three years old, after a busy day at kindergarten, we went to the park with some classmates. The parents were on the sidelines chatting while the kids clambered about the climbing frame. At one point, my attention was drawn to a heart-stopping moment as a little boy, desperate to get down the slide, shoved my daughter, standing at the top of the slide preparing to descend, out of the way. Somehow, after being pushed off the top of the climbing frame into the fresh air beside it, my daughter managed to grab the frame above her head and was left swinging over the 3m drop below her. After a flurry of movement from too far away parents, the moment was saved without a broken bone, and my heart started beating again.
Afterwards, with all my protective maternal responses zinging, I had to navigate a tricky moment. I was acutely aware that this little boy had no intention of breaking my daughter, and that he was only three, with his own emotional needs. I was also the first to acknowledge that at three, my daughter had less than average slide navigation skills and required time to build up the necessary courage to descend. I had some empathy for the little boys’ frustration. But I was afraid of letting my daughter continue to clamber about the playground with him when he might put her at risk all over again. He needed to be made aware of the consequences of his actions and helped to see how he might achieve his end goal, without the collateral damage. The audience of other sponge-like three-year-old minds and more scarily, their parents, also required careful navigation. How to make the boy aware of the unintended consequences of his actions, while at the same time making him feel safe? How to teach my sobbing daughter to put her shoulders back and say with skilful assertion – please don’t do that again, it was very scary! With assistance, this little dude could improve my daughter’s confidence in slide navigation and she could help him name the emotion ‘frustration’ and teach him to be less reactive. Oh! The holy grail of parenting, for me not to have to step in at all.
Recently, it dawned on me how similar these playground antics are to the cultural change challenge individuals, professions and organisations are facing in adult life. In healthcare, movements such as civility saves lives, and The College of Surgeons operating with respect initiative have linked poor cultural safety to both patient and healthcare worker harm. Unacceptable incivility, bullying, discrimination and sexual harassment are causing significant mental health and suicide harm in our healthcare communities. Healthcare leaders are appropriately mandating change. People such as Jo Shapiro (https://www.safeandreliablecare.com) have championed movements for an organisational response to cultural challenges. In Australia, The Cognitive Institute champions Promoting Professional Accountability based on a Vanderbilt initiative for individual accountability to behaviours that undermine a culture of safety.
Programmes developed from this work often offer anonymised reporting to encourage individuals who don’t feel safe, to speak up for cultural safety. A third party, a trained champion of cultural change, then approaches the perpetrator for a quiet coffee chat. Unfortunately, some form of anonymised whistleblowing will continue to be required. But my own experiences of this system have left me bewildered and wondering – will it really encourage a cultural shift? Are we responding to poor cultural safety with movements that potentially put that at more jeopardy?
Imagine, if I hadn’t been there to observe the kindergarten playground antics. Imagine my daughter having to pluck up the courage to tell me about it later via email, anonymously. Imagine she gets no response at all, only the validation of hitting ‘send’. She doesn’t get a hug, a sorry, little in the way of empathy, no compassion and definitely no learning in skilfully asserting her point of view either in the moment or in a considered way post the event. No empowerment – except to say that telling people matters – and it does, and that the perpetrator can expect an organisational retribution in kind.
Imagine, that the little boy goes on with life having no awareness of what has just occurred but then out of the blue, a ‘cultural champion’ contacts him. The feedback comes as a surprise to him, as its now a few days down the line and the boy can’t really even recall the event. For him, it was just a moment using the slide. Imagine him being told his behaviour is unacceptable, although the detail on ‘behaviour’ is likely to be sparse. It may even be that he views the request to meet as a summons and isn’t quite sure what this cultural change thing is all about. Imagine all he really hears is ‘your behaviour is losing you friends’, ‘people are unhappy with you’. Imagine him not really understanding why, not being given the opportunity to say sorry, leaving this chat with little more than a nagging anxiety that he’s at risk of this happening again and not really knowing when it might occur or why – or more importantly, how to prevent it happening again.
Cultural change is a gruelling journey for individuals and organisations to embark on. Crucial first steps are recognising the complex and intertwined forces of cultural change, resource limitations, system improvement, patient safety, quality, employee value and respect, governance, stress, wellness and burnout. Movements such as crazy socks for docs, RuOK, WrapEM and feminem are all powerful voices trying to help us refocus healthcare communities in a positive way. Amazing and Awesome movements are the relief we all need from the harsh realities of the harm we sometimes cause. And more universal world-wide emotional intelligence awareness movements such as 6seconds help remind us that we are part of much bigger movements to create positive change.
Modelling civility and respect throughout the process of cultural change is paramount. The cost of assumptions and badly handled feedback may be ripples of yet more incivility through fragile organisations and people. In a recent Harvard Business Review post, Christine Porath said: “the vast majority of disrespect stems from a lack of self-awareness [and that] people just do not realise how they affect others”. A professional coach has suggested to me that perhaps simplifying these complex situations back to the playground, where we’re managing these problems with our three-year-old selves, might help us find a way forward. With this analogy, it becomes easier to see how everyone involved might deserve our compassion, curiosity and resources to improve skilful responses to the challenges we face. It is easier to imagine how a compassionate organisation – for surely this is the aim, might mimic the mum on the playground, fiercely asserting her daughter’s rights, while at the same time navigating the emotional and learning needs of every other three-year-old around them. For the little boy perhaps – what were you trying to achieve, what stopped you and how might you have brought others along on that valiant goal of whizzing down the slide? How can we help you achieve your personal and organisational goals? For my daughter, why were you hesitant, what skills can we help you attain in using the slide, how can we improve your skilful assertion during that learning process? And importantly for the organisation, where were the bystanders, why were they so far away, who else could have helped – and what should be done about that big damn gaping hole beside the slide? Put more simply, Jenny Rudolph’s powerful talk on ‘What’s their frame’ gives a message that it’s often not obvious why others are behaving the way they are – and that it behoves all of us to stop, breathe and think not ‘what the f@#K’ but ‘what’s their frame?’ – to practice compassion that generates curiosity, learning and collaboration.
Hospital systems historically focus on quantitative measurement of patient centred outcomes, with little measurement of qualitative or quantitative metrics that could have a significant impact on workplace culture. For example, is there investment in simple moments in time where stressed staff are encouraged to think, reset and re-centre? This might include;
- normalising regular feedback moments,
- funded clinical support time,
- succession planning from new consultants to retirement,
- team meetings,
- deliberate team practice and stress inoculation,
- collaborative inter-department projects and social functions.
Or it may be much more simple moments, where we acknowledge the multiple balls we’re all somehow keeping in the air in a corridor chat into each other’s well-being, a coffee catch-up, or just a simple meal or toilet break. Increasing resources to allow for these inconsequential, yet oh so powerful positive moments may be crucial to the success of the ripple of cultural change. Without them, are we sabotaging our own cultural success?
Acknowledging the need for cultural change, raising awareness of bad behaviour and normalising regular feedback discussions is a place to start. But healthcare professionals will require the opportunity and the skills to engage, respond and act – to participate in the process. The cultural change movement has brought into focus the importance of skills to engage with and advocate for ourselves and our colleagues. They are not the same as the skills we have learnt in order to communicate with our patients and have arguably been seen as dispensable in the process of advocating on behalf of our patients.
Books such as Thanks for the feedback, Crucial conversations and its associated course and others like it, such as The Process Communication Model, have started to fill this incredible need to educate individuals in their own accountability to this moment. People like Tracy Sanson and Mary Freer are skilled advocates in our journey.
I am a doctor, team member, educator and lifelong learner invested in this movement and to the delivery of quality compassionate care for both my patients and my colleagues. I have read these books. I have listened to experienced people in this field. I have heard stories of horrendous days in peoples lives through the simple act of turning up to work. I have had many moments of praise and positive feedback when feeling strong and able to help others navigate tricky situations. I have also been sitting next to colleagues behaving poorly and felt ashamed for not having the skills to respectfully speak out. I still struggle with the confidence and words to speak up for myself. And more importantly, I have failed, and I will continue to fail at being civil and aware of everybody else around me at all times, while sometimes struggling with the demands of my job and my life. Even with improved skills in meditation, awareness and communication, it is inevitable that I will let myself and others down again. I am grateful to those people in my life able to provide skilled feedback and an opportunity to reflect, learn and grow. We are all human, and in some regard, still learning how to manage the playground antics with our three-year-old selves. We will sometimes fail. We need to share our own vulnerability and failures and still expect to be valued with curious compassion and the assumption that we are all doing our best and want to be better. The ripple of forgiveness and compassion, combined with the investment in resources directed at giving us time to reflect, improve and connect, may be more powerful than any other complex organisational response. It will give us the space to stop, breathe, recenter – and when all else fails, create an environment where we are permitted and equipped to check – and dare I say it – parent each other.
Emergency and Acute Medical Unit Physician and resilient student of life.
Dr Mya Cubitt@myacubitt
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.