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NEWS sources and social media have been buzzing with story after story of poor workplace behaviour in public hospitals. Training colleges have withdrawn accreditation from specific departments to teach specialist trainees, and yet stories circulate of bullying behaviour from almost every site, over decades. These experiences seem to be the exception rather than the rule.
What, then, do public hospitals have to show for the multiple inquiries and projects targeted at this behaviour? We have safe hours campaigns, trainee representation on committees, directors of clinical training, a plethora of surveys. So many strategies, but what real improvements? The junior medical workforce – and, arguably, the entire medical workforce in hospitals – seems more dissatisfied than ever before.
It’s not uncommon for targeted inquiries to be able to identify poor behaviour and morale, and to recommend that it be eradicated. What appears to be less common is a complex understanding of what drives that behaviour, and, importantly, strategies that target the root causes. We cannot stop bullying by bullying the bullies. Indeed, the psychological literature tells us that workplaces that provoke frustration and fear are more likely to provoke poor behaviour, irrespective of individual workers’ personal disposition. Fear is a stronger motivator than education.
Mission statements at various levels of health care institutions profess that humans are their most valued resource. And yet, structures, policies, and communication often convey very different messages – that the staff are there to be controlled rather than developed, that the mission is more about compliance than creativity. Paradoxically, medical staff who are chosen for strong cognitive and decision making skills are squeezed into multiple layers of credentialing, audit and review. Despite managing hugely complex and sophisticated clinical systems, many at the cutting edge, the structures that manage risk appear to be stuck in a last-century “command and control” paradigm, much further from the front of the pack.
The point is not to ignore or excuse the behaviour, but to understand it in order to change it. We have known for generations that threats can force compliance, but that, for truly excellent work, clinicians – like all workers – need to be inspired to do their very best. Doing the best does not just mean never committing an error, it means using all our knowledge, skills and empathy for our patients to negotiate the best care for them. No amount of effort, however, can produce perfection. We all need support to do good, not just to avoid doing bad. That support should come from prudence, courage and wisdom, not from fear.
Acute hospitals are high-stakes environments. Every day, some clinicians are forced to make decisions outside their confidence level, and with the threat of the sword of Damocles hanging over them. There are many who hold vicarious responsibility, with little control over either the staff or the resources for which they are held accountable. In the higher layers of management, there are too many people whose fear of disastrous error is expressed in a need to micromanage, rather than to develop, those who provide the clinical service. The result: a paralysing amount of regulation, paperwork, credentialing and auditing, combined with the pressure to do things ever faster, but “safer”.
It’s time for hospital management to approach the cutting edge. Like clinical systems, hospital management needs to move from a patchy structure with occasional brilliance to a well organised system that encourages innovation and calls on best practice evidence.
It’s time for hospitals to develop a “just culture”, as described by Griffith University’s Professor Sidney Dekker, in which trust and accountability within an organisation are paramount.
Dr Sue Ieraci is a specialist emergency physician who has also held roles in departmental management and medical regulation. She is an executive member of Friends of Science in Medicine. She can be found on Twitter @SueIeraci.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.
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Sue you are a gem. There are very few others who so consistently manage to clearly describe the complex issues we continue to face in this modern world, particularly in Medicine but inevitably elsewhere in Business, Education, Policing , Politics and almost any endeavour you may wish to mention. Well done again!
I would love to be involved in the processes involved to overcome these issues but instead I will offer up a few observations/opinions of my own, most of which are echoed in the previous posts.
1. Most modern managers begin (or did begin) young, with minimal clinical experience.
2. Some managers have begun at a more advanced level with respect to clinical experience, but lack basic management training. (Of course there are some glowing exceptions but they are too few and far between to constitute a ‘critical mass’ and probably find it hard to progress to a senior level – see below)
3. Most high-level administrators are NOT highly experience in dealing with the complexity of clinical issues and are therefore poorly equipped to understand how to deal with them – ergo the ‘control’ phenomenon. (“If I find it difficult to understand, how could they possibly do that?”)
4. The resulting threat to managers’ egos when making critical decisions with clinical import renders them fearful, aggressive and intimidating in that order : not a combination designed for high success rates in negotiating change.
5. The resulting (and now chronic) managerial behaviours ‘trickle down’ the system, ensuring a widespread culture of fear-> aggression -> intimidation (‘FAI’) in the system, which continues to ‘trickle down’ to new arrivals.
6. ‘FAI-proficient’ managers find complex change at a clinical level impossible to manage effectively because a) they feel too insecure to approach their ‘frighteningly competent’ clinician managers to request help; b) If help is offered, once again their insecurity does not allow them to accept it or alternately, negotiate in a positive manner with its providers to gain a solution which is both administratively and clinically acceptable.
7. ‘FAI trained and experienced’ clinicians and clinician managers tend, in a similar fashion, to treat management approaches with disrespect and dismissal : as they have learned to from those higher up in the administrative structure, during their training years in particular. The resulting issues are identical – no effective ‘meeting of the minds’.
8. Finally, how to overcome this spiral downwards? The real problem lies in the difficulty inherent in accurately selecting a completely new upper level of management (possibly inclusive of some of the more insightful and less ‘FAI prone’ current membership) in NSW Health. This group, if selected, would be characterised by their willingness to fearlessly and completely commit to the ongoing support and encouragment of a collaborative, non-blameful, open-minded re-engineering of the current structures, processes, responses of and training inputs to, our highly complex health system!
9. Any takers? If so, who are they? Where are they? How will they be paid for their time and input?
10. An almost insoluble problem until such time as the current structure self-destructs and those who feel compelled to, rebuild it ‘better’, if possible. If anyone out there has a better knowledge of how, who and where to coalesce and empower these visionary people, let us in on it will you?
Management: The revenge of the C grade students unfortunately. Not sure how to fix that.
This article finally calls out the main issues behind workplace stress. It’s the best I’ve seen so far, measured, balanced but truthful. Ineffective, misplaced, jingoistic and sometimes malicious health management, a powerful but all concealing paralytic buraecucracy, politically sycophantic board governance, community misrepresentation by those with vested and uneducated interests, watchdogs on the hunt in packs for scapegoats especially vulnerable migrants and women, legislative patient safety reform not forthcoming and incompetent but cunning reviewers who pretend to satisfy but protect their and executive careers are root causes of medical staff fear and anxiety and consequent chaotic sequelae at hospital. Silencing those who speak for staff and patient safety, listening and fostering those who are gender bullies, sexual perverts and powerful men for vested and poor quality, self centred executive gain, misunderstanding genuine workers accidentally on purpose and enabling such decay all around us is blinding us to the everyday hard work, ethos, ability and compassion of our colleagues. Dreadful workplace environs where quality units stalk the medicos, powerful people pretend that human errors can be eliminated and defend the indefensible in resource and staff management and ignore the misbehaviour of other professional groups, where administrators create an atmosphere of predatory fear and control causes so much trauma to medical staff. How are such traumatic environs good for patient care? When will this purgatory be called and reform begun? All of us are patients. Including those who deny and enable such chaos. I trust everybody remembers that axiom.
Before we jump to conclusions and give more opinions rather than scientifically validated advice, can we find out what the bullying situations are that have caused so much concern? Is it bullying of junior doctors by senior doctors, or senior doctors by junior doctors, or junior doctors by peer junior doctors, or senior doctors by management, or junior doctors by management, of doctors by nurses, or nurses by doctors, or some other permutation? Until the situation is clearer it seems rather premature to pontificate unvalidated opinions on these situations. Help please?
Our hospitals have become overburdened with control and constraint, at the expense of both patient centred care, and the care of those that deliver that care. The system positions itself with autocracy and bureaucracy to discourage active informed decision making through the misuse of hindsight biased incident review and investigation tools. There has been no shortage of initiatives, strategies, and programs to improve the cultural construct, yet they seem to fail under the burden of bureaucracy and “Taylorist” mistrust.
Jeff Jarvis wrote “there is an inverse relationship between control and trust” in his book “What would Google Do?” He made observations about Googles approach to its people that health could benefit from: Manage abundance, not scarcity; Make mistakes well; Give up control and Get out of the way. Trust naturally builds accountability and supports better decision making.
Maybe it is time to shift from blame to curiosity, and from constraint to enablement.
It seems to me that DiTs’ increasing dissatisfaction can be easily correlated to elongated training times and increased competition for speciality places. Most DiTs I know are absolutely terrified of what the future holds – many for good reason. If that isn’t fear then I don’t know what is.
Association without causation perhaps, but it is far easier to put up with poor behaviour when you know you will only be a ‘junior’ for 6 years. Far tougher when your training spans 6 unaccredited years before you fall off an employment cliff.
In addition to all the excellent points Sue has mentioned, training reform is sorely needed.
Perhaps it’s time to, you know, do some evidence-based medicine!
I can find ONE paper on bad behaviour that could in any way be called a proper trial (‘The Impact of rudeness on Medical team Performance: a Randomized Trial Riskin et al. Paediatrics 136 3 Sept 2015’).
There is lots of industry work (see Porath and Pascoe for exemplars) the rest is just opinion. And usually not from those who actually are or have been guilty of ‘bad behaviour’.
There is NO work on WHY tempers flair, WHY people are abusive. WHAT precipitates an episode. Just opinion and usually not from those who were there, and least of all from the ‘guilty party’.
I can only speak from my experience and journey from bad to better behaviour. A difficult journey with lots of reflection on my own issues. A difficult journey not without its own form of pain.
What we need is some research and evidence before we try to tell the rest of the profession what they are doing wrong?
I enjoyed a personal “sliding door moment” recently from reading Bolman and Deal’s Four-Frame Model – Reframing Organisations. The premise was that organisations encompass four parts: factory or machine [Structural], family [Human Resources], jungle [Politics] and Theatres, Temples or Carnivals [Symbols]. When all four are balanced the organisation will zing with energy and enthusiasm. Conversely when unbalanced they founder.
My experience has been that health managers like us all, are in constant evolution. The last thirty years has seen Structural Frame as the primary focus. The consequences have been that the other three frames have been allowed to atrophy. Sue, I suspect that the organisation malaise that you describe could well be the consequences of that imbalance. My hope is that next lot of health manager iterations redresses that error and refocusing on the family, the carnival and the jungle.
We all (including managers) owe it to our patients and staff to strive to get that balance are near to “right” as is possible.
Sue —
The good news is validated tools like the NSW Re-design tool exist to measure workflow distribution, re-design clinical care to create innovative models of care , enable equitable worklfow distribution and address concerns about effective JMO supervision
In 2011, subsequent to the Garling Commision Enquiry — NSW Health invested millions of dollars to train highly skilled clinicians called Senior Hospitalists who were equipped with high level clinical skills to enable research based re-design of services to faclitate innovative models of care delivery that would address the concerns about workload distribution and effective JMO supervision. Very few of trainees of the NSW Health Senior Hospitalist Intiative were given opportunites for professional growth. The program now is largely unsustainable
The current ‘epidemic’ of entrenched culture of bullying in health occurs DESPITE the available resources and the investments by NSW Health.
The question then is — is the problem within health a ‘normalisation’ of such behaviours driven by ineffective leadership and management ? Do we need accountability structures that would effectively address such barriers ?
Sue, It is not just Public Hospitals. Very similar behaviour does occur and is common in the Private Sector. The drivers for the behaviour are different and the people harmed by the behaviour are a slightly different group but for some reason it does not get reported as it does when it is exposed in the public sector.
Finally someone has called out the workplace environment as a key contributor to the chaos. Well said.
As we see more and more administrators divorced from clinical care, making decisions that directly impede our ability to practice safely and efficiently, the downward spiral will continue. I have seen so many senior colleagues leaving the Public System, finally worn down by bureaucracy and poor resourcing. But Sue has it in a nutshell – we are asked to assume an enormous responsibility and held accountable for outcomes while being stripped of any control over protocols, resources and workforce. We are being micromanaged into the ground. Leave us alone to do what we do best.