By Dr Julia Harris.
– Chair, Training Standards Committee, Royal College of Emergency Medicine (RCEM), Consultant in Emergency Medicine (EM) Southampton. Lead for the Wessex Mental Health Taskforce and Wessex Patient Safety First Initiatives. Previously Clinical Tutor, Foundation Programme Director, Head of School, and Chair of the Training Standards Committee
Reviewer – Dafydd Hammond-Jones Speciality Trainee Year 6 Emergency Medicine (EM) Leeds Teaching Hospitals Trust (LTHT)
Understand what we have to do as trainees and educators. Learning culture, role modelling, Team work and tribalism, rudeness and performance, and future challenges.
What Trainees Need
Dr Harris started her talk by explaining that Trainees need to develop a number of things that she listed as:
- Clinical knowledge
- Practical skills
- Team working
- Intellectual flexibility
- Increasing autonomy of practice
To help trainees do this, educators must:
- Create a learning environment
- Role model good practice
- Explain the hidden values
- Delegate appropriately
- Give feedback supportively
- Be an advocate for patients and trainees
Behaviours and Culture
She showed a graphic from the National Clinical Assessment Service (NCAS) that showed that referrals to NCAS early in consultant’s careers are for behavioural concerns, whereas as consultant’s age the main reason for referral is for concerns about their capability. We need to support trainees to develop appropriate professional behaviours to trouble early in their consultant careers. She showed a graphic from John Adair about Learning Culture and with this there being Strategic leadership, Operational leadership, and Operational Leadership within. Strategic leadership includes; vision, purpose, communication, and values. Team leadership includes; task, team, and individuals. Operational leadership includes; energy behaviour, manager as a coach and creating the work climate.
Recipe for Culture
To have a good learning culture you need to have the following resources:
- Case mix
- Training time
- Wider multi-professional team.
You also need to have the right environment which includes:
- Knowing the curriculum and training needs
- Getting to know your trainees and their training needs
- Making every contact count
- Valuing your trainees
- Sharing your decision making
- Explain the hidden values.
In summary you need Emotional Intelligence and Organisational Climate. You also need to consider where learning occurs, who delivers most of the education and training, emotional context, delegation, feedback and the value of trainer/trainee meetings, trainee/trainee meetings and training faculty meetings.
Dr Harris talked about Role Models and explained how they are the most powerful influence on the development of attitudes and behaviours, and they set the emotional context for learning. She quoted Albert Schweitzer “Example is not the main thing in influencing others. It is the only thing.” She picked up on how we need to ask if it is the behaviour we are following from the role model or the purpose. You can copy a behaviour, but unless you copy the purpose there is little benefit.
Management of Doctors
Dr Harris talked about how management of people in hospitals can affect patient mortality and how this can be improved by; better training, better knowledge, willingness to share and use tacit knowledge, empowering to use knowledge, co-ordinating effectively, high staff satisfaction and teamwork. She talked about doctors being ‘clever’ people and therefore harder to manage as they; identify more with their profession than with their organisation, they can be wilfully naughty in team, they have a high degree of self-discipline, but often low levels of social discipline, they seek to avoid feedback, and do not collaborate as see themselves in competition with others.
Dr Harris then went on to talk about Goleman Leadership styles:
- Pacesetting “Do it my way
- Commanding/Coercive “Do it because I say so”
- Visionary/Authoritative “Let us remind ourselves of the larger purpose”
- Affliative “people first, task second”
- Democratic “Let’s work it out together”
- Coaching “Let me help you develop”
Each style has its place and each style has pros and cons. The Francis report criticised NHS for using pacesetting style too much. Commanding style is generally negative but useful in emergencies. Visionary is the most positive
Dr Harris talked about Tribalism and how it has been shown to be harmful. She described it as behaviour and attitudes that stem from loyalty to a tribe with negative stereotyping of others and failing to see others perspectives which gets in the way of patient care. Unfortunately tribes are how humans evolved; as long we understand this we can do it better.
Dr Harris then went on to talk about rudeness and how this can affect the workplace. Studies have shown that rudeness is experienced by 25% of employees on a daily basis. Rudeness effects collegiality, teamwork, aggression, helpfulness, task performance, and creativity. All these things can have delayed consequences for organisations. Rudeness can be fought by having a zero tolerance, customer care attitude, flatten hierarchy, using face to face communication, and good role modelling.
Dr Harris finally went on to talk about future challenges including NHS funding, Quality Improvement Projects, and ageing population, mental health, and burnout. All of these things are challenges but if we are not rude, have good culture and climate it will certainly help.
My take home message from Dr Harris was Be Kind, Listen, Explain, Be Inspirational and give feedback.
I particularly liked the theories on leadership, emotional intelligence and organisational climate. Once you learn about these theories it is amazing to see how well and how badly different people perform them and what a difference that makes. I wonder if we should introduce these theories early in medical careers it may improve effectiveness and decrease harm.