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3.4 How can I develop my positive workplace behaviours?

People do not go to work to upset their colleagues but misunderstandings in the workplace will occur. 

The first step is to understand how our behaviour can negatively affect members of our team.

It is then important to take action to try and change troublesome behaviours.  It is not about punishment.

It is about enabling you to be the best version of yourself and maximising the wellbeing and effectiveness of your team, as described in Question 3 "What are the benefits of improving poor behaviours?".

General steps to address problematic / poor behaviours

  • Be honest but kind to yourself if behaviours were inadvertent
  • Ask for advice when you need it
  • Look after your wellbeing
  • Apologise for hostile/negative behaviours when they occur
  • Educate yourself on the topic by exploring this toolkit and signposted resources, including Module 7 "I want to learn more about workplace behaviour"
  • Ask for honest feedback on your behaviour from a wide range of people
  • Reflect
  • Improve your understanding of ‘human factors’ e.g. RCOG e-learning on human factors in maternity and situational awareness, further resources from Each Baby Counts
  • Try to identify situations where you have been prone to undermining behaviour and think through and discuss strategies to improve those situations for you and the team.
  • Seek a mentor or coach- this may be available via your manager or via HEE for trainees.

2. Advice on common problematic areas

External factors can come from many places.

They include tiredness, hunger, time constraints, feeling under pressure or being in an unfamiliar or new environment to name a few.

External stressors can impact how you interpret the situation around you and influence your reaction to it.

Video case study 1 (7mins) from the RCOG e-learning module on improving workplace behaviour explores this concept.

Practical tips

1. When external factors are influencing you it can help to make your team aware of this so they can support you.

You do not need to share all the details, but an honest “I am experiencing some difficulties, so please forgive me if I am less patient than usual and please do tell me” is hugely helpful and demonstrates good leadership/professionalism.

If factors are significantly affecting your behaviour talk to your supervisor or clinical lead and consider whether you need support or time off

2. If you find you behave in a way that could have been better, apologise and explain

3. Strengthening your ability to manage external influences, your so called ‘resilience’, can help. This should not be a substitute for addressing the external stressor directly but can be of additional help:

4. Ask for support if and when you need it

5. Look after yourself and prioritise your wellbeing

Infographic: Evolution of incivility

See infographics by Civility Saves Lives at www.civilitysaveslives.com/infographics

Kindness and gratitude improve the performance of the people you work with.

Team members want to feel acknowledged, heard and valued.  This is not the same as telling them that they are always right. Video case study 2 (9mins) from the RCOG e-learning module on improving workplace behaviour explores this concept.

Practical tips

Use body language and non-verbal cues which show respect

Show kindness and gratitude

Infographics

See infographics by Civility Saves Lives at www.civilitysaveslives.com/infographics

 

Giving feedback in an effective and productive way is a key aspect of a positive workplace culture.

If done well it allows increased performance, confidence and resilience in the workplace.  If done poorly it can be destructive and have negative outcomes.

Below are two videos from the RCOG e-learning on Improving Workplace Behaviour. You are encouraged to record your thoughts on the positive and negative aspects of each case study.

  • Video clip (15 mins) shows 2 scenarios with example of poor and effective feedback for each.
  • Video clip (15 mins) looks in more detail at performance management and insight.

One of the current challenges in the NHS is a lack of continuity in teams.  This can inhibit the ability to develop positive bonds with your team.  When interactions to deliver feedback occur without an underlying positive foundation the feedback is more likely to be received/perceived poorly. The concept of radical candor is based on this balance.*

 

* https://www.radicalcandor.com/resources/

Feelings of conflict can sometimes be expressed in negative and unhelpful behaviours – defensiveness, anger, or avoidance. 

Conflict often occurs if one group is too assertive in trying to achieve  their own goals whilst not addressing the needs of others. Considering your needs and the needs of others when communicating and making decision can help avoid conflict.

See RCOG eLearning on managing your team and leadership.

Developing your ‘emotional intelligence’ can help you to manage conflict better. Emotional intelligence is about managing oneself effectively. It is a social intelligence that allows one to monitor one’s own and other’s feelings and emotions and use these to guide one’s actions.

The following table is redrawn from "Emotional Intelligence Has 12 Elements. Which Do You Need to Work On?" by Golman et al (2017)

Self-awareness Self-management Social awareness Relationship management
Emotional self-awareness

Emotional self-control

Adaptability

Achievemnt orientation

Positive outlook

Empathy

Organisational awareness

Influence

Coach and mentor

Team work

Inspirational leadership

 

Other resources for avoiding conflict

 

After working in a department for a while, you can begin to take all of the subtle cultural knowledge that you have accumulated for granted.

Remember that when new members join your team from outside of this culture, they are trying to learn these new cultural norms alongside doing their day-job and may fear asking for help.

Video case study 3 (23mins) from the RCOG eLearning module on improving workplace behaviour explores this concept.

The BMA also has an insightful webinar (free for members) which aims to develop sensitivity and skills for cultural communication.

Increasing your own appreciation of this cultural transition will give context to your interaction with staff who are new to a department or new to the NHS.  With this in mind you may interpret their behaviours differently.

Those that have lived and worked outside of the UK have the additional challenge of adjusting to British culture.  They will have additional stressors such a need to arrange housing, bank accounts, healthcare and other practicalities.

Practical tips

  • Get to know your team before challenging interactions occur; where have they come from, what is their background and do they have any specific needs?
  • Learn the names of your team members correctly
  • Try to consider how cultural influences and experience may be impacting behaviours
  • During this period of adjustment acknowledging this and supporting them develops feelings of inclusion and value.
  • Consider supporting new team members with periods of shadowing, mentors and signposting support available.
  • Keep your eye out for the RCOG’s new eLearning module on "Doctors new to the UK".

Case example of the consequence of negative behaviour related to being new to a workplace culture:

‘I am an SHO in O&G and an international medical graduate.  On my second or third day in the speciality a registrar singled me out in the operating room upon seeing me scrub in. They knew it was my first time assisting in this particular procedure. They shouted at me and made me scrub a total of 3 times once even slapping my hands so that I would have to do it again.

It was my first emergency theatre experience and there was no attempt to teach me any specifics or show me where anything was. A scrub nurse showed me where everything was in the end. The midwives and theatre staff were also very kind and reassuring.

It was hard as I was new to the dept and speciality. I didn’t feel that I could report it. I made sure I knew where everything was in any theatre I was in in future as the humiliation was something I wanted to avoid. Professionally I never let someone speak to me that way but I was new and didn’t want to stir up any problems.’

 

Handovers can be busy and dynamic.

Getting this time "right" for all team members can improve productivity and patient outcomes.

The RCOG e-learning module on handover gives some useful advice on how to get this right and provides 2x 5-minute video examples.

Do:

  • Show kindness and gratitude to the team who are finishing their shift.  Appreciate that they may be tired and may have had difficult situations to manage.  You could ask how they are and thank them for their work
  • Generate feelings on inclusivity by encouraging everyone at handover to introduce themselves
  • Check in on the new team before you start.  Do you know them? How are they? What are their learning needs? What are their concerns?
  • Generally avoid giving feedback in a public forum and find an alternative, more appropriate time, to deliver this.  However, there may be times where the departing team have started an unwise or unsafe plan which needs to be changed. Consider ways to address the management safely without undermining them. Phrases such as “Hindsight is a wonderful thing but I wonder if…” or “It sounds like you had an incredibly busy shift. I wonder if you had time to consider this option as an alternative given x…”

Don't:

  • Inadvertently use disrespectful gestures such as eye rolling or exchanging glances with colleagues
  • Avoid provocative expressions like “who on earth made that decision?”. It is OK to disagree with management plans but this can be discussed in a kind and respectful way. Ideally then talk to the individual about the plan after the handover (see how to give feedback).
  • Do not avoid giving feedback to the team as this is a key way for us all to learn.  However, it is important to deliver it in an appropriate and effective manner, which is rarely in the handover environment.

Poster 5: Handover (PDF 260kb)

 

Case example of inadvertent uncivil behaviour in handover:

'In my first year as a registrar in O&G I witnessed an episode of undermining in handover.  As we were running through the board our SHO was presenting a case and the actions he had taken.  Our anaesthetist started questioning the SHO on what he had done and why he had done it and went on to explain why she thought what he had done was wrong.  It was really uncomfortable to see so I chirped up in what I hoped was a friendly and neutral way to explain why the SHO’s thought process could also have made sense and moved the handover on.

'I knew the anaesthetist well enough to know that they probably had not intended on undermining the SHO in that way and just got a bit carried away.  Immediately after handover ended I asked her for a quick word and gently explained that I’m sure she didn’t mean to undermine our SHO but that it did appear that way.  She was really apologetic and quickly scooted off to find the SHO and apologise before he went home.'

Some tips and resources

  • Get to know your team and develop positive foundations.  This will mean that any feedback you deliver is more likely to be effective and be received as constructive.
  • It can be useful to have a strategy for delivering effective feedback.  The following articles are helpful for this: TOG article, BMJ article
  • Consider undertaking formal training in delivering feedback through your employer, affiliated deanery/HEE or university or through an associated organisation e.g. BMA course, BMA webinar
  • The East of England Deanery developed this interactive workshop in conjunction with the University of Bedfordshire, on strategies for difficult conversations and particularly on how to avoid undermining when giving feedback.
  • Promote learning from things that go well: eg. Learning from Excellence: resources, community
  • Use excellence reporting systems: Enable all staff within the organisation to report good and excellent practice that they experience via a quick and simple form. Here is an explanation from Learning from Excellence (link to PDF) and video
  • Introduce appreciative Inquiry: asking positively framed questions (inquiring) about a particular topic, in order to increase the value of that topic (appreciate).  Read more about Appreciative Inquiry (PDF) and watch an introductory video

Case example of poorly delivered feedback and its effect: ‘I was working as an SHO. Following an incredibly busy night shift I went home to rest. I got a call 2 hours later from the consultant who had just seen one of the patients that I had arranged follow up for. She found tubo-ovarian abscesses on ultrasound and asked why I had not taken swabs for pelvic infection. Before I could explain anything, she shouted down the phone at me for doing a bad job, not allowing me to explain that the patient had them with her GP. I couldn't rest after that and ended up coming to work exhausted with another busy night where by the end of the shift I made mistakes twice on labeling blood bottles resulting in having to redo my training. It upset me, made me unsafe. I felt unappreciated, unheard. I was merely doing my job the best I knew how. I felt the feedback could have been delivered in a better way then again, this individual is known to come down hard and has caused other individuals to go on stress leave. I did not feel at the time that I could say anything. I just avoided them like the plague.’

The labour ward is a high pressure environment where a positive workplace culture is paramount.

In maternity care intra- or interprofessional communication have been identified as critical contributory factors to negative outcomes in several official investigations/reports:

General tips

  • Be kind, civil and respectful
  • Use first names only to break down barriers
  • Foster a culture of openness that encourages asking for help
  • Treat all members of the team as equally important and valued
  • Be helpful to each other, no task should be beneath anyone
  • Establish clear escalation policies
  • Adopt structured communication tools such as SBAR

The labour ward presents particular challenges. It can be useful to reflect on your experiences on labour ward to try to determine which factors might be negatively influencing your behaviour in this setting.  Below are some of these challenges and targeted ways you might address them.

External influences such a workload and lack of rest breaks

See "influence of external factors"

Multidisciplinary working

See Module 4 Question 4 "Team and multidisciplinary working"

High intensity clinical situations

RCOG Improving human factors and situational awareness "mini-toolkit"

Human factors on RCOG eLearning

The importance of learning from adverse events.  The following have been reported in maternity:

  • A lack of skill when giving constructive feedback
  • Fear of criticism and causing upset
  • A culture of avoiding receiving feedback

Feedback

Learning from Excellence (PDF)
Use of appreciative inquiry (PDF)

Psychological safety on The King's Fund website

Emotional wellbeing after adverse events

See Module 4, Question 4 Staff wellbeing

Schwartz rounds on Point of Care Foundation

Need for strong and compassionate leadership

See Module 4, Question 4 "Set the tone and lead from the front"

Handover

See Handover above

 

For those looking to affect departmental change we recommend exploring Module 4 "I am responsible for a department that has a problem with bullying or undermining".

Theatre presents a challenge as multiple demands commonly converge, such as patient safety, training of juniors, time pressure, and external demands.

Those new to the team and the environment will find this environment particularly challenging.

In this situation a positive workplace culture in theatre is essential for effective team performance, patient safety and staff wellbeing.

Poster 3: Theatre (PDF 258kb)

 

Practical tips

1. Recognise the influence of external factors on you and your team.

2. Be kind. 

  • If there is a communication breakdown in a stressful situation you should apologise (see Poster 1 "Sorry" below).
  • Support you team members to have breaks and reset.
  • If someone is struggling, ask them if they are OK (see Poster 2 "Tea" below). You don’t know what might be affecting their work. A bit of kindness may go a long way to improving things for them and yourself.
  • Support new team members with scrubbing, preparing patients and familiarise them with both  equipment and processes that are new to them. Remember team members who are new to the department or to the country will have other valuable skills but may not be familiar with local processes and the local team may underestimate their capabilities as a result. This can cause them to feel undervalued, underconfident and potentially less able to perform well.

3. Be assertive without being confrontational:

  • Build positive working relationships with the theatre team at the beginning of the list. Get to know their names, roles and experience
  • Set goals at the start of your theatre list
  • Identify external pressures such as time and divide up your list as appropriate so everyone knows what their role is.
  • Set aside specific time for feedback.  It is important to be able to both give and receive constructive feedback.
  • Keep goals objective and avoid comparison with others.
  • This wikiHow "How to Be Assertive Without Being Aggressive" by relationship expert Maya Diamond has some more tips.

4. Thank your team at the end of the theatre list, conduct an effective team-debrief, take the opportunity to identify and learn from excellence

Case example of the consequence of negative behaviour related to being new to a workplace culture:

‘I am an SHO in O&G and an international medical graduate. On my second or third day in the speciality a registrar singled me out in the operating room upon seeing me scrub in. They knew it was my first time assisting in this particular procedure. They shouted at me and made me scrub a total of 3 times once even slapping my hands so that I would have to do it again.

It was my first emergency theatre experience and there was no attempt to teach me any specifics or show me where anything was. A scrub nurse showed me where everything was in the end. The midwives and theatre staff were also very kind and reassuring.

It was hard as I was new to the dept and speciality.  I didn’t feel that I could report it.  I made sure I knew where everything was in any theatre I was in in future as the humiliation was something I wanted to avoid. Professionally I never let someone speak to me that way but I was new and didn’t want to stir up any problems.’

In healthcare we work closely with a wide range of colleagues, and maintaining professional dialogue is important.

Communication – both verbal and non-verbal – are key to ensuring smooth transactions.

Meetings provide a particular communication challenge as they are essentially public forums and small negative interactions can have a march larger effect on an individual than you might expect.  Some of the challenges include:

  • Ensuring all members have a chance to speak and feel heard
  • Ensuring all attendees feel their input is valuable
  • Preventing dominant characters from being too dominant, without belittling/undermining
  • Receiving and feeding back on inputs that may not be useful, without belittling/undermining
  • The presence of outside influences such as time pressure, not having eaten and multiple demands on your attention at one time

It is always important to acknowledge the contribution and perspectives of others.

Welcoming a range of ideas and opinions fosters diversity and inclusion.

Some tips (particularly for meetings you are chairing):

  • Know who is in your meeting by name, and background if you can
  • Be an active listener and hear what team members are saying.  ‘Thanks for that idea…’, ‘that is an interesting idea…’, ‘by that do you mean…’
  • You can demonstrate you have heard what members of the meeting have contributed by summarising matters back to the group
  • Thank members for their contributions
  • Invite silent participants to comment
  • Use positive body language such as nodding and maintaining eye contact
  • Avoid immediately rejecting an idea e.g. ‘That is an interesting idea. My concern with that approach at the moment would be...Perhaps we can hold onto that as an idea for now and come back to it as it may evolve.’
  • Avoid talking over people
  • Actively avoid inadvertent signs of frustration or disagreement such as sitting back and crossing your arms, sighing and eye rolling
  • Move the meeting forward in a positive way such as ‘thank you for your ideas on this matter. In the interest of time I am going to move us onto the next item for discussion.’
  • Finish by thanking people for their time

If you would like to improve your own conduct in meetings then asking for feedback from your colleagues can be useful.

The right for colleagues to be treated with respect and to be free from bullying, undermining and rudeness, extends across all forms of communication.

The temptation when using ‘depersonalised’ forms of communication is that courtesy and respect can easily be forgotten. In some ways communicating sensitively by email is even more challenging. 

The GMC has guidance on the use of social media which is useful for all healthcare professionals.

Top tips

  • Hold difficult conversations in person
  • Pay particular attention to kindness and appreciation in email correspondence
  • Avoid responding to a difficult situation or provocative email by ‘firing off a quick email’.  Instead consider delaying your reply so you can gain perspective and remove the emotion from your response.

Infographic: Getting your message across: email or phone?

See infographics by Civility Saves Lives at www.civilitysaveslives.com/infographics