Shared leadership - we're better together
This is article twelve in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).
David was feeling confused. Peanut wasn’t settling under the anaesthetic. He checked her gums – they were a nice bubble gum pink, but her breathing was erratic like she was having a bad dream. One minute fast, and then suddenly slow again. He fiddled with the anaesthetic dial and recorded the latest set of readings.
“Everything alright up there err, erm?” David guessed that the surgeon had forgotten his name...
“Dave.”
“Yes, everything alright there Craig?”
David was tempted to remind him of his name, but decided against it. He wondered about mentioning Peanut’s breathing, but he had conflicting thoughts on whether he should or shouldn’t say something.
On his first day at the practice, other nurses made oblique comments about the way Mr Northway likes things done: ‘don’t disturb him during the operation … he doesn’t like that!’ and ‘he can be a bit grumpy in the mornings’.
“Err, yeh, yes.” David’s throat felt tight.
Mr Northway turned back to the large wound and with his head tilted, started swabbing the area as if he was working on an oil painting.
“Good, we’ll be finished soon enough. I’ve done so many of these ops I shouldn’t wonder if I could do one in my sleep. Isn’t that right Mel?” Mr Northway gave Mel a twitch of a smile at the corner of his eyes.
His young intern stared at the pool of light framed by green drapes and pretended she hadn’t heard him.
The operation continued. Mr Northway occasionally huffing, and speaking in a strange language that David had yet to master:
“Reduction forceps,”
“And now the slocum rotation gauge. No, not that dummy!”
Eventually, with an extravagant ‘THWACK’ of his rubber gloves onto the instrument trolley, the operation was over.
“Well, that’s me done! Untie me please.”
But as Mel reluctantly tugged at the back of Mr Northway’s gown, like she was trying to unwrap a particularly unpleasant cheese David was getting more concerned. Peanut hadn’t improved, in fact things were getting worse. A little later, David was alarmed to find Peanut howling and swimming around her kennel oblivious to anyone. “You alright Dave?”
Joe, the head nurse, had come through to see what all the commotion was about.
“I think she needs more pain meds Joe but to be honest, I didn’t feel like I could tell him what I thought we should do,” David shouted back. “God, now what?”
The effects of hierarchy
Steep hierarchy undoubtedly plays a part in the withholding of important information at work – in the medical sphere this can lead to serious accidents1. Furthermore, care teams communicate better when each team member feels empowered to speak up. A sense that it is OK to say what you see is one definition of psychological safety – an important aspect of safe, high-quality medical care2. Another way of conceptualising this type of ‘high-functioning’ teamwork is to consider all team members as potential leaders, depending on the situation. Different scenarios call for differing skill sets – and when teamwork allows for ‘distributed’ or shared leadership, there is also a higher probability of a positive clinical outcome2. Of course, in common scenarios the knowledge, expertise, and legal status conferred on qualified veterinarians will naturally mean they need to lead. But this doesn’t always have to be the case. Evidence from human health shows that collaborative teams provide better and safer care than groups of individuals operating in narrow, or siloed roles2. Empowering shared leadership allows nurses, for example, to speak up with relevant observations and suggestions, while other team members are focussed on cognitively demanding work. This ‘open’ organisational culture, focussed on ‘what is right, not who is right,’ plays an important part in patient safety1.
A survey-based research project at the Royal Veterinary College suggests that unhealthy hierarchy adversely influences communication in veterinary practice3.
Amongst the questions asked in the questionnaire were,
“In your clinic, do staff feel free to question the decisions of those with more authority?”
And:
“In your clinic, will staff freely speak up if they notice something that may negatively affect patient care?”
To the first question, 51% of all respondents said that they felt the staff could speak up always or most of the time.
To the second question, 69% of all respondents said they would speak up always or most of the time, but the result fell to 59% for staff who weren’t in a managerial role (survey response rate = 335).
How can we improve things?
Of course, there are no quick fixes and culture change is a slow, iterative process. Equally, it’s important not to feel despondent if you unearth communication behaviour in your practice or organisation that could do with improvement (there are now culture surveys available to help you establish if this is the case4.
Amy Edmondson, Novartis Professor of Leadership and Management at The Harvard Business School suggests some techniques to start using on a regular basis5,6:
- Stay vulnerable. Statements like, ‘I’m human too! So do let me know if you notice me making a mistake or doing something that doesn’t seem right’ can be very powerful. They let team members know that it’s OK to verbalise what they see and hear. This can work in a back-office environment as well as in a clinical context.
- Check-in with the team. Questions like: ’Is there anything you don’t feel clear about?’ or, ‘I’m happy to hear your thoughts,’ are verbal cues that give others, including more junior members of the team, the confidence to speak up.
- Embrace messengers. It’s important to overtly praise team members who communicate unsafe acts, or report mistakes. Feedback not only helps organisations to learn – helping to avoid a repetition of the same mistake in the future – but thanking these individuals gives them the confidence to speak up again. In doing so, a safety culture can take root.
- Frame the work. Try using language that explicitly acknowledges the inherent risks involved in our work, like:
- ‘This practice plays a unique role in the lives of our clients – we look after their companions when they are sick, or injured. When this happens, we are called upon to help. But the stakes are sometimes very high and the procedures we perform are complex. Sometimes we will falter – this is inevitable'.
- ‘Veterinary care is a demanding occupation – technically as well as emotionally’ It is vital that we understand why we fail, and equally important that we are kind to ourselves and those around us,’
Descriptions such as these help the team understand the importance of their work, as well as the significance of constantly looking out for the unintended errors that anyone can make.
At a practice level, this is undoubtedly a sensitive topic – by asking teams to provide more feedback, it might feel like we are asking co-workers to highlight shortcomings. The feedback might be regarding inter-personal issues, or operational concerns, and legitimate questions are:
- What if this sort of protocol upsets the team dynamics, and causes conflict?
- What if they say something which is simply wrong?
The risks of asking for more communication may seem at first glance, unwise, and it may occasionally cause ‘challenging’ conversations. But these obstacles are surmountable. Encouraging more collective leadership can have enormous benefits – it contributes to quality of care and allows the team to express anxieties (leading to greater employee engagement6. There are resources available to help you with this goal too).
Mr Northway wasn’t a ‘bad’ vet in the example given earlier, but his clinical efficacy would benefit from a knowledge of the effect hierarchy plays in patient safety and healthy team functioning. Letting others speak up - and occasionally lead where appropriate - is good for them, good for patients, and good for you too.
Checklist: What can you do next?
- Listen to John Williams and Pam Mosedale discuss how systems and meetings can aid communication, and the role that checklists can play in establishing shared leadership in veterinary practice.
- Read our Surgical Safety Checklist Manual to learn more about checklists and how to introduce them to other members of the team. It includes templates specific to veterinary practices.
- Find out what a successful practice feels like for a Practice Standards Assessor, with this blog by Pam Mosedale, QI Clinical Lead at RCVS Knowledge.
- Sign up for the free RCVS Edward Jenner Leadership Development Programme. Suitable for all veterinary professionals, it covers key concepts specific to the veterinary sector. Delegates can work through the course at their own pace, whilst engaging and discussing learning with fellow online learners.
- Listen to Laura Playforth and Pam Mosedale as they discuss how incivility can increase errors and impact patient care and outcomes. You can then check out Civility Saves Lives, a website run by health care professionals aiming to raise awareness of the power of civility in medicine.
- Find out more about the Nottingham Veterinary Patients Safety Culture Survey (NVSCS), a tool for measuring safety culture in veterinary practices (£).
- Watch Martin Bromiley’s 'Just a Routine Operation' and learn that we all have a role to play in creating a culture where everyone feels safe to speak up when something is not right.
References
1. Leonard, M., Grahmam S. and Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. BMJ Quality & Safety, 13 (S1), pp. i85–i90. http://dx.doi.org/10.1136/qshc.2004.010033
2. Curry, L.A. et al. (2018) Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: A mixed-methods intervention study. BMJ Quality & Safety, 27 (3), pp. 207–217. http://dx.doi.org/10.1136/bmjqs-2017-006989
3. Turner M. (2017) The use of a modified medical safety culture assessment tool to investigate veterinary patient safety culture in small animal practice. Master Thesis, University of London.
4. Oxtoby, C. et al. (2017) Safety culture: the Nottingham Veterinary Safety Culture Survey (NVSCS). Veterinary Record, 180 (19), pp. 472. https://doi.org/10.1136/vr.104215
5. Creating psychological safety in the workplace [Harvard Business Review] [online]. Available from: https://hbr.org/podcast/2019/01/creating-psychological-safety-in-the-workplace [accessed 31 August 2021]
6. Nembhard, I.M. and Edmondson, A.C. (2006) Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior, 27 (7), pp. 941–966. https://doi.org/10.1002/job.413
About the author
Mark Turner BVSc MRes MRCVS
Mark graduated from the University of Liverpool in 1996 and in 2017 completed a Masters degree at the RVC investigating patient safety culture in the UK veterinary professions.
The research project investigated contemporary knowledge of patient safety behaviours in practice including significant event reporting and auditing.
He has an interest in the application of patient safety as a tool for improving staff engagement and success. He has written for Vet Times, Companion magazine and appeared as a guest blogger for the BVA/RCVS Vet Futures project.
September 2021