1. Changing Behaviours in the Workplace Liz Spencer Consultant Anaesthetist Clinical Tutor Glos Education Adviser NACT UK Bullying is everyone’s problem, not an individualised issue. The organisation is partly responsible for the presence or absence of bullying. Organisations should expect bullying, look for it, and deal with it All staff need to understand the boundaries of what is offensive

2. Objectives Clarify definitions of bullying, harassment & undermining behaviours Develop communication strategies to raise the issues

3. Introduction National issue Team issue – not just doctors About patient safety Not looking back – looking forward We are all involved New behaviours

4. GMP March 2013 you must work collaboratively with colleagues, respecting their skills and contributions you must treat colleagues fairly and with respect you must be aware of how your behaviour may influence others within and outside the team.

5. National Training Survey 2013 13% experienced bullying & harassment Females and non-UK grads more common 19.5% witnessed someone else being bullied 26.5% experienced undermining behaviour from a senior Trainees in O&G had highest incidence ST4-7 more likely to report Those who reported being biullied were less satisfied with their training

6. Definitions Bullying - persistent behaviour that is intimidating, degrading, offensive or malicious and undermines the self-esteem of the recipient Harassment - unwanted behaviour that may be related to age, sex, race, disability, religion, sexuality or any personal characteristic of the individual. It may be persistent or an isolated incident

8. Grade of perpetrator n 44.3%650Consultant / GP trainer 25.2%370blank 12.7%186Nurse / midwife 8%117Other doctor 6%88Other trainee 5.9%87Manager

9. 5 minutes What is going on in your patch? In groups around a flipchart list the issues What are the behaviours? From whom?

10. London Deanery Persistent and deliberate belittling or humiliation Shouting, threatening or insulting behaviour Persistently and unfairly singling out an individual for unreasonable duties Persistently and unfairly preventing access to educational events / opportunities Marginalising doctors without good reason, so that they are unable to carry out their jobs and make progress in their professional development

11. Examples of Behaviours Giving feedback that is poorly matched to the level, resilience or vulnerability of individual Giving feedback that is persistently negative, harsh or without opportunity for dialogue Paternalistic and overbearing attitudes Criticism in front of others Shouting “storing up problems” so criticism is expressed too late Lack of interest in individual’s need for support and development Being unavailable and leaving junior without adequate cover Bullying of juniors by managers in pursuit of targets Institutional bullying with aggressive and intimidating behaviours modelled by Trust leadership

12. What is the effect of these behaviours on the person Loss of self esteem Sleeplessness Not wanting to come to work Not wanting to learn Feeling insecure Fear Decreased motivation Avoidance DOES THIS MAKE FOR A SAFE ENVIRONMENT ?

13. The Workplace Environment “..the community within which students and novice staff engage in the clinical setting directly influences how students and novices perform their practice, make sense of their knowledge, and contribute to safe and contemporary care.” (Egan & Jaye 2009).

14. 2013 Francis Report – Feb 2013 Keogh Report – July 2013 Berwick Report – Aug 2013

15. Place the quality of patient care, especially patient safety, above all other aims, Foster whole-heartedly the growth and development of staff, including their ability and support to improve the processes in which they work Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge

16. Candour the quality of being open and honest; frankness. honesty, candidness, truthfulness, sincerity, forthrightness, directness, lack of restraint, straightforwardness, plain- spokenness, plain dealing, plainness, calling a spade a spade, unreservedness, bluffness, bluntness, outspokenness; telling it like it is "he spoke with a degree of candour unusual in political life" antonyms:guardedness, evasiveness, insincerity

17. Shifting Workplace Behavior to Inspire Learning A Journey to Building a Learning Culture Sue Schoonbeek, RN, BN, and Amanda Henderson, RN, PhD J Contin Educ Nurs 2011;42(1):43-48. Clarify relationships & open communication Recognise & counteract bullying behaviour Role modelling – feedback Shared learning

18. Bullying is a systems problem Joanna Veazey Brooks & Charles L. Bosk Social Science & Medicine 77 (2013) 11-12 There is a surgical personality - disruptive behaviour more prevalent in surgeons - Intimidatory behaviour affects communication Functional leadership demands ownership and command of OR & patient Time pressured decisions under conditions of irresolvable uncertainty Not confuse decisiveness required of surgeons with bullying

19. Surgeons’ professional identity and patient safety: Time for change Stella Stevens Social Science & Medicine 77 (2013) 9-10 Culture of surgery – endurance, decisiveness, courage, risk taking, arrogance & “masculinity”(Cassell, 1987) Disruptive behaviour is a patient safety issue Shared leadership - leadership shifts from one person to another in the team depending on what is happening at that moment in time. Bullying is often “normalized” by a process of “group think” where no-one challenges it Those of us involved in medical education need to confront the occupational culture of surgery

20. Evidence synthesis on the occurrence, causes, consequences, prevention and management of bullying and harassing behaviours to inform decision making in the NHS J.C. Illing, M. Carter, N.J. Thompson, P.E.S. Crampton, G.M. Morrow, J.H. Howse, A. Cooke, and B.C. Burford Prevalence o 11.3 – 18.1%, Males > Females o Particular leadership styles Antecedents – Organisational change, Hierarchical systems – Presence of destructive leadership styles & lack of disciplinary action Consequences – Individual impact – Recruitment & retention – Impact on patient care Interpersonal & Social dynamics, culture & rolemodelling

21. Recommendations Illing etc al (cont) Training delivered to all staff – Shared understanding of acceptable behaviour – Developing communication & conflict management skills – Systems to identify & manage local problems – Develop insight into their own behaviour Tackling bullying starts at organisational level with focus on leadership Culture established – Leaders need to be supportive and committed to change – Prevent, manage & support

22. Normalised Deviancy The normalization of deviance in healthcare delivery John Banja Center for Ethics, Emory University, 1531 Dickey Drive, Atlanta, GA 30322 U.S.A Bus Horiz. 2010 ; 53(2): 139

23. Workers are afraid to speak up.. The likelihood that rule violations will become normalized obviously increases if persons who witness them refuse to intervene. A 2005 study of more than 1,700 healthcare professionals found that “it was between difficult and impossible to confront people” (Maxfield, Grenny, Patterson, McMillan, & Switzler) who manifested problematic work behaviors, especially rule-breaking, incompetence, and showing disrespect. Fear of retaliation, lack of ability to confront, belief that it is “not my job,” and low confidence that speaking up will do any good were the chief reasons given for not calling attention to deviant behaviors. As the study reported, “People don’t want to make others angry or undercut their working relationship, so they leave difficult discussions to others or to another time, and never get back to the person”. Obviously, human beings underlie every rule violation or system failure (Reason, 1999). If personnel feel intimidated or frightened to call attention to the deviance, it is more likely to persist and to interact with other system failures, inviting disaster.

24. Place the quality of patient care, especially patient safety, above all other aims..

25. Table discussion What does this mean to you? As Tutor what can you do differently Do you have any SAS doctors with undesirable behaviours – what should you do?

26. Suggestions ??