4.4 What can I do to address a problem with poor workplace behaviour in my department?

What is your department's official stance on workplace culture?

There is a move away from ‘zero-tolerance’ policies and towards creating cultures of civility, respect and kindness.¹  Misunderstandings will occur, but in the right environment these misunderstandings are addressed early, are less likely to escalate or to spread.

Make the department's stance visible

Make sure everyone who works in your department is aware of the departments stance on workplace culture.  Some examples of how you might do this include through departmental activities, induction for those new to the department and posters (RCOG posters below, CSL infographics, gathering of kindness posters)

• Poster 1 "Sorry" (PDF)
• Poster 2 "Tea" (PDF)
• Poster 3: "Theatre" (PDF)
• Poster 4: Workplace Behaviour Champion (PDF)
• Poster 5 "Handover" (PDF)

Lead from the front

Show that you believe in civility, respect and kindness.  This can be easier said than done and takes courage.

• Show that it is ok to speak up by letting your colleagues know if you witness incivility or poor workplace behaviour.  Train in 'calling it out'.
• Show that everyone can be inadvertently rude or misunderstood by thanking those who spot your own inadvertent uncivil behaviours.
• Show that it is ok to say ‘sorry’ when it happens.

Compassionate Leadership

• The King’s Fund have worked well with NHS Improvement to develop compassionate leadership resources. They describe 4 key behaviours: attending, understanding, empathising and helping.
• Practical advice for embedding compassionate leadership can be found in Vogus and McCeleenad’s “Actions, style and practices: how leaders ensure compassionate care delivery” BMJ Leader June 2020
• There is increasing evidence that those working in care- giving organisations which are compassionate are more likely to have the emotional resource needed for caring and are less likely to experience burnout. (Figley 1995, Lilius et al 2011)
• Optimism, cohesiveness, humour, support and a sense of efficacy in work contribute to improved patient care (West 2013). There is an unassailable link between patients who are treated with compassion and employees who are treated with compassion.

1. https://www.socialpartnershipforum.org/media/177307/NHSi-Civility-and-Respect-Toolkit-v9.pdf

Happy and healthy staff are more likely to be kind and civil at work.  Therefore staff wellbeing is always important.  If your department has problems with poor workplace culture or behaviours then your staff may be in particular need of support.

• How do your staff know that you really believe staff wellbeing is important?
• What more could your department do to show support for your staff’s wellbeing? 

The answer to these questions will depend on your own department but could include:

• ensuring that there is an enjoyable rest space with refreshments
• encouraging staff to take breaks
• supporting wellbeing after adverse events such as team debriefs and ensuring tutors/supervisors/mentors are aware of members of staff involved in adverse events so that they can provide ongoing support
• Hosting Schwartz rounds
• Ensure that staff members have appropriate supported “Return to Work” after prolonged absence eg sickness, shielding or parental leave.

See more general resources you can signpost individual staff towards

Strengthening team relationships both within and between disciplines is invaluable.

Below we give some examples of strategies to enhance team working. These are designed as a taster to get your started. The list is by no means exhaustive and there are many other excellent examples.

Multidisciplinary working

• Ensuring emergency skills/drills or simulations and teaching is multidisciplinary
• Ensuring multidisciplinary representation at handovers
• Multidisciplinary debriefing e.g. after stressful events, can help build positive relations between individuals and the team as a whole. You could consider using appreciative. Read more about appreciative inquiry (PDF) or watch an introductory video
• Adopting a multidisciplinary approach to team level interventions in general e.g. if you are introducing workplace behaviour champions then have champions across the disciplines, if you are running a human factors session then open it up to staff across disciplines
• Consider multidisciplinary mentorship eg senior midwifery mentorship of most junior medical team members/those new to the department to help foster understanding of each others’ perspectives and work challenges whilst allowing a “safe space” to ask questions.

Improving understanding of self and of others, particularly under stress:

• Human factors training e.g. RCOG eLearning on human factors in maternity and situational awareness, further resources from Each Baby Counts
• Resilience sessions: ‘the ability to bounce back in the face of adversity, and to develop coping mechanisms and techniques to deal with stressful situations and life challenges’ e.g. RCOG eLearning on resilience. This should never be viewed as moving the responsibility of adverse surrounds onto the individual but as part of the individual’s support mechanisms.
• Exploring individual’s MBTI® Stress Heads
• Schwartz rounds ‘provide a structured forum where all staff, clinical and non-clinical, come together regularly to discuss the emotional and social aspects of working in healthcare.’

Celebrate your team and its diversity

• Share in team members’ personal successes
• Celebrate its multidisciplinary nature such as celebrating international nurses and international midwives day.
• Celebrate its multicultural nature by celebrating the diverse holidays/events and festivals that are important to members of your team
• Sign up to the NHS Rainbow Badge Initiative
• Understand the power that diversity bring to a team – NHS employers resource, King’s Fund resources
• Visit the NHS Employers Equality and Diversity Tools and Resources
• Equality and diversity is a mandatory training requirement in the NHS but we would encourage departments proactively addressing practical ways to embed this into local culture.
• Here are a few resources to strengthen understanding on:
  
  • Race – from Kings fund (1, 2, 3) and NHS employers
  • Sexual orientation – from Stonewall and NHS Employers
  • Disability – from Disability Confident and NHS Employers
  • NHS Employers: Inclusion & diversity policy & guidance
  • Explore this resource on Awareness, respect and knowledge of other cultures and cultural identities (PDF 626kb)

Help new team members integrate

• After working in a department for a while you can begin to take for granted all of the subtle cultural knowledge that you have accumulated, especially around departmental processes and guidelines.
• 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 as they may fear that they will be perceived as not being able to manage if they do so.
• During this period of adjustment acknowledging this and supporting them develops feelings of inclusion and value.
• Get to know those who are new to your team; where have they come from, what is their background and do they have any specific needs? Do they have any support networks locally?
• Doctors (and other healthcare professionals) new to the UK have the additional challenge of adjusting to UK culture and the NHS. They may require support with practical challenges such as registering with a bank and securing housing which need to be addressed within normal working hours and yet they may have started work almost immediately after arriving in the area and may feel worried about asking for time to arrange this. There have been examples of people not being able to be paid as they have not been able to arrange a bank account. Take time - whilst being respectful of their privacy – to ensure they have practicalities such as housing/banking/medical cover arranged. You may be able to support them by facilitating leave to do so.
• Consider supporting new team members with periods of shadowing, mentors, tailored induction and signposting support available.
• An RCOG eLearning module for "Doctors new to the UK" is in development (as of May 2021)
• Engage in supported Return to Work for the returning after a prolonged period of absence from usual clinical duties eg parental leave, return from shielding or sick leave. Acknowledge how people may feel apprehensive returning from prolonged periods of absence.

Team education

You could consider ways to encourage individual team members to gain self-awareness and understanding of how they function within a team.

 These are some examples of methods:

• 360-degree questionnaires/feedback
• The Myers Briggs Type Indicator (MBTI) – often used by external companies
• Belbin

These need to be done with support for the individuals and the ability of skilled team members to provide constructive feedback.

There are many free resources on team performance as well as commercial enterprises.  The RCOG does not endorse any particular provider or method.

• Practice gratitudes: Simply remembering to say please and thank you, in person e.g. at the end of a clinic/list/shift, on the phone and in emails can lift the mood and improve communication within the department.
• Develop a ‘Greatix’ Board: Where positive achievements within the dept are shared e.g. thank you cards, notes on individuals or teams that have performed well e.g. managing a shoulder dystocia
• Promote kindness: The Gathering of Kindness aims to build, nurture and instil a culture of kindness throughout the healthcare system.  They have a useful toolkit and posters.
• A ‘Positive Mindset Board’: A daily or weekly message can be placed in a position of prominence to highlight a positive message for all staff for the following day or week – this could also be discussed at handovers e.g. on Labour Ward
• Promote learning from things that go well e.g. 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 (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 it (PDF) and watch an introductory video
• Awards: Creating departmental awards or proactive use of trust awards can show appreciation of excellence e.g the Going the Extra Mile (GEM) award

Infographic: "Thank you" 2 words, huge impact

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

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

Misunderstandings and poor behaviour, which are managed well and resolved fairly, are part of what makes a supportive and positive department.

There is a move away from ‘zero-tolerance’ policies and towards creating cultures of civility, respect and kindness.¹

Misunderstandings will occur, but in the right environment these misunderstandings are addressed early, are less likely to escalate or to spread.

The aim is to make it routine and safe for staff to talk about issues with workplace behaviour.  This requires psychological safety in the workplace or ‘permission for candour’.

It is helpful to remember that most incidences are unintentional and that speaking up will help your team be the best version of themselves.

Examples of just a few of the ways you can ‘make it OK to call it out’ include:

• Give positive reinforcement to those that speak up and ensure there are no negative repercussions
• Enhance reporting systems/procedures such as introducing Workplace Behaviour Champions and raising awareness of your trust’s Freedom to Speak up Guardian
• Nominate and train key individuals who can deliver feedback on poor behaviours effectively
• Induct those who are new to your team so they understand the departmental stance
• Make your departments stance visible with displays/poster e.g.(posters below, CSL infographics, gathering of kindness posters)
• Share stories of when misunderstandings in your department occurred and when speaking up helped

Posters

• Poster 1 "Sorry" (PDF)
• Poster 2 "Tea" (PDF)
• Poster 3: "Theatre" (PDF)
• Poster 4: Workplace Behaviour Champion (PDF)
• Poster 5 "Handover" (PDF)

1. https://www.socialpartnershipforum.org/media/177307/NHSi-Civility-and-Respect-Toolkit-v9.pdf (PDF)

Some of your team will already be strong believers in the importance of a positive workplace culture.

They can be excellent advocates for the cause and help deliver the departments agenda.

Others may not see the value and may question "why we are thanking people for doing their job?".

Persevere – it will take time to change situations but it can be done, and has been.

Consider recruiting a diverse team including junior doctors (trainees and non-trainees), consultants, midwives, students and supervisors/managers into advocacy roles, e.g.:

• Workplace behaviour champions
• Civility champions
• Anti-bullying team
• Positive Working Group-an impartial group to address departmental issues (not just workplace behaviour issues)

Much of the power of these teams comes from their collaborative nature and it is important to ensure representation across your department.