Bad behaviour: time for hospitals to walk the cutting edge

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 Training colleges have withdrawn accreditation from specific departments to teach specialist trainees, and yet stories circulate of bullying behaviour from almost every site, over decades.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.