Sunday, 19 August 2012

Fearless Healthcare is what we want

Recently read a book called 'Driving Fear Out Of The Workplace' by Kathleen D Ryan and Daniel K Oestreich. It was published in 1991 so obviously you can see that my wisdom is only now dawning. It is based on the 8th principle of Deming which is 'Drive fear out: employees must not be afraid to ask questions or take a position'. The book is written in an easy language and narrative style with enormous number of quotes gathered from their work with a variety of organisations but when read reflectively it can have profound impact on us and others.

The book wants us to
- be able to discuss the undiscussables
- realise behaviours that create fear
- understand the cycle of mistrust and break it
- acknowledge the presence of fear
- value criticism & reward the messenger
- reduce ambiguous behaviour
- move from participation to collaboration
- challenge worst-case thinking

The authors believe that driving fear out will overcome the invisible barriers to quality, productivity and innovation. The book is nothing to do directly with healthcare and has no direct examples but at a human level the threads are common. I recommend the book.

Healthcare & Fear

There are many reasons that driving out fear is even more important in healthcare. The very strong hierarchical structures in healthcare is an ideal culture medium for fear to thrive especially amongst the medical and nursing colleagues. The mostly pick and mix nature of evidence in healthcare delivery makes these hierarchical voices even more powerful. The difficulty with evidence generally creates poor systems, people who work within poor systems understandably do not do well and the culture of defensiveness and fear becomes greater.

Establishment is very strong in healthcare, in the UK clinical practice context you must submit to the clinical establishment (royal colleges, specialist bodies, et al) or to the research establishment (universities, funders) or face difficult consequences. Clinicians have a legal obligation to provide care recommended by NICE 'guidelines', there are armies of back office people who audit compliance to NICE guidelines which everyone fears of falling short. Providing the treatment recommended by NICE is a statutory duty i.e. law, I wonder why it is not called law and then define some exclusions. Why the euphemism? Now, would you have a fear of falling foul of a law?

The current economy does not help with many reduction in posts and changes in roles. It is also well known that in the context of the NHS the reorganisations are almost continuous and many non-doctor staff do live in fear of the next change that may adversely affect their role, skill and income.

Generally high anxiety and stress is understandably common for clinical professionals when dealing with patients given the very high emotional component involved in any healthcare advice or treatment especially acute care. The stress levels are even higher for patients and that is projected on to clinicians and reflects. This puts pressure to get it right every time, there is a fear amongst clinicians about getting it wrong; get it wrong in high finance and few points might drop of the footsie index, getting it wrong in healthcare could cost people a hand or a foot literally. But working with fear does not help the cause.

Constant comparisons with other industries (aviation, manufacturing, etc) while is very important for healthcare professionals who can understand the principles behind these comparisons and use them for improvement, is often taken out of context and has created an atmosphere where some of the public begin to have very high expectations that are difficult to service and some of the pubic fears healthcare. When let down, these lead to potential litigation which is a common fear amongst clinicians.

I could go on, but you get the idea. I do believe that fear should be driven out of the work place and especially so in healthcare; it would liberate the true power and potential of clinical professionals.

Fear could result in some of the effects discussed earlier in the blog, such as branding people as bad apples ( or agreeing with persons so as to please them as in the Abilene Paradox and other not so helpful behaviours. In healthcare, these combined with the issues around evidence and process efficiency leads to the phenomenon of Clinical Wrongology.

What are your fears at work? What are its effects? How do you and your workplace deal with it?

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1 comment:

Indian doctor said...

I think the monopoly in healthcare in UK has created a perfect environment for using 'fear' as a way to keep employees from asking too many uncomfortable questions. As a rule in the vast majority of cases the system(NHS trusts) destroy the lives of any employee who sticks his/her head out even it was done for the right reasons.