Long before the COVID-19 pandemic, burnout, work-related stress, psychiatric illness and suicide had been increasingly recognised within the physician workforce. People are tired, our tolerance is reduced, workplaces are short-staffed and busy, learning and training can feel side-lined, and we can't always do the job how we want or need to.
Ethical dilemmas in our decision making have been heightened in the pandemic. There have been real tensions between the deontological concerns about duty to care to the patient, the public health consequentialism argument that healthcare outcomes at a population level are maximised, and our own and our family's safety.
And then the paradox that is social media - extraordinary in its potential for connectedness and accessing learning and networks, but also for its 'fake news' and binary judgements.
There is a sense of anguish and helplessness amongst many; our working lives can feel utterly overwhelming. Against this pressurised backdrop, being able to work side-by-side and be compassionate with colleagues when needed is more important than ever. It is well described how we thrive where there is camaraderie and equity, in being treated justly and being able to accomplish and have a sense of achievement (1).
A four-stage approach is described in how to manage poor behaviours, and how to create a nourishing environment for ourselves and for those we work with.
- The hug is to understand how and why we behave in certain ways.
- The nudge is to hold ourselves and others to account in how we behave.
- The tackle is not to be accepting of poor behaviours and to take action.
- The role model is to be the change we want to see.
A helpful starting point is to have standards to which we can uphold our own behaviours, and others'.
The Royal College of Physicians (RCP) Code of Conduct, published in 2018, reflects the privileged position doctors hold and the responsibility this comes with - not only in our interactions with patients but with colleagues too, mindful of power hierarchies.
This code includes:
- treat others with respect and consideration
- recognise and value diversity and individual differences
- behave with integrity, honesty, kindness and patience
- be a role model for professional behaviours
- foster collaborative and supportive working with others
- promote trust and a just culture
- hold themselves and others accountable for professional and personal behaviours.
The GMC's proposed new 'Good medical practice' is now framed as expected behaviours of a doctor, and to work effectively, describes the need to be civil to each other and treat patients with kindness.
It takes great strength and courage to ask for help when recognising our own behaviours fall short, alert that any shortfall may be a symptom of wider health deterioration.
We need to start with ourselves. The illusion of transparency means we assume others know why we behave the way we do. It is a strength to have self-awareness of our own values, beliefs, personal biases and how they influence our perceptions and how we behave, cognisant of unconscious biases. We need to acknowledge there will always be those moments when our behaviours fall short. We are not perfect, we are all different, and sometimes we do not know how we will respond until we are in that moment.
This can be a welcome or unwelcome surprise. Making time to understand ourselves and anticipate a response, particularly at times of stress, helps direct learning on how to behave with civility and kindness. A quick and genuine apology can make a real difference.
Reflection can be a transformative discipline, and there are various techniques that may help how we manage tension in our own attitudes and behaviours, and how well we actively listen. Writing as a contemplative practice, such as the 55 Word Story, can be a thoughtful and simple reflective exercise to capture the essence of an experience (2).
Framing our focus and energies, using a technique described by Covey in the '7 Habits of Highly Effective People', to distinguish between our Circle of Concern (things we care about but can't control) and our Circle of Influence (things we care about and can impact) can help find a way to manage our work lives and that sense of loss of control that may be driving poor behaviour (3).
It takes great strength and courage to ask for help when recognising our own behaviours fall short, alert that any shortfall may be a symptom of wider health deterioration. Sources of support include the RCP Mental health and Wellbeing and British Medical Association Wellbeing resources.
Treating patients with kindness means thoughtful and compassionate shared decision-making. The popular singer-songwriter Harry Styles sings in 'Treat people with kindness', "And if we’re here long enough, we'll see it's all of us and we'll belong” (4). Using the principle of aggregation of marginal gains - that small improvements to individual components contribute to a wider collective improvement of the whole - if each of us act with the intent of kindness, the culture should change to a more nurturing one.
Photo credit: Shutterstock
Psychological safety, compassionate leadership and inclusivity are crucial in creating a sense of belonging and a better experience working in teams (5). Learning how to nurture each other and be equipped to both challenge and offer allegiance in confronting and preventing chronic interpersonal conflicts is tantamount.
We need to be prepared for when others behave poorly towards us. We have a choice in how we respond, and we should learn how to challenge poor behaviours and rudeness. This can help strengthen our courage to take those daunting first steps in starting to move from being a bystander (whether passive or active) to an upstander, recognising there is a choice in doing something to make things better.
To do this is to be prepared to be made to feel uncomfortable. Having explicit agreed standards (such as the RCP Code of Conduct linked above), does help, as does having tactics in how to respond to microaggressions and bias.
Having a rehearsed quick response ready in the moment can be helpful, such as "'We don't tolerate that kind of talk here," or "Let's keep this professional," or "I'm leaving because I don't feel comfortable".
Examples of other useful phrases, with specific examples, are:
- "I heard you say ___ - could you say more about what you mean by that?"
- "I know you didn't realise this, but when you [comment/behaviour], it was hurtful/offensive because [reason]. Instead, you could [different language or behaviour]."
- "I know you really care about ___. Acting in this way really undermines those intentions."
Note that the focus is on the behaviour, not the person or personality.
There are resources of support here too, such as the RCP mental health and wellbeing resource linked above, which includes how to recognise the warning signs of struggling in others.
The Royal College of Surgeons of Edinburgh has developed a guide for surgical trainers in pressurised situations, amongst other valuable resources, which includes 'How to be Assertive Without Being a Bully'. The Civility Saves Lives campaign signposts helpful resources as well, including Sherwood's Civility Learning and Sharing Toolkit.
Where poor behaviours are unresolved and/or veer into conflict, due process can follow. Institutional policies and processes will be in place where you work, and can help to address and, ideally, resolve the situation, whether between colleagues or with patients. Sometimes these processes become external to our own organisations and may include NHS Resolution and the GMC.
We are part of the system in which we work, and it is important to realise what is within our circle of influence and what we can tackle.
Working in medicine should be about learning and growth. We need a resilient and learning system, where the working environment enables a workforce to thrive. Much about the conditions in which we work can feel out of our own circle of control, and is experienced as frustrating and demoralising.
However, we are part of the system in which we work, and it is important to realise what is within our circle of influence and what we can tackle. We need to be relentless in creating safe learning environments and in humanising processes and assessment. We need to address, foster and commit to tackle discrimination, racism and sexual harassment finding leverage points for change.
In a system, this does not necessarily mean looking to the top of the hierarchy - we should look to what we are able to influence, shape and strengthen. Equity, inclusivity and accessibility of healthy working relationships create a sense of belonging. How we conduct ourselves, and hold others to account to be civil, is a fundamental starting point. We all have something we can tackle.
The role model
We have a huge influence on those around us, and to contribute to a thriving working and learning environment, we need to own our own behaviours and hold others to account for theirs. We should be prepared for poor behaviours, including our own, and be equipped with the skills to anticipate and address them when they occur.
The COVID-19 pandemic has taught us to remember that the individuality and wellbeing of each of us looking after the patient is as important as the individuality of the patient themselves. We can all make a transformative difference for ourselves, our colleagues and for patients by being mindful of how we chose to behave individually and collectively.
The views expressed in this article are those of the author and do not necessarily reflect those of the MDU.
Dr Emma Vaux
Dr Emma Vaux (OBE DPhil FRCP) is a consultant nephrologist and general physician at the Royal Berkshire NHS Foundation Trust, where she is clinical lead, Berkshire Kidney Unit; clinical director, integrated medicine; and medical associate director, patient safety.
She is immediate Royal College of Physicians past vice president (education & training) and chief examiner, and led on the development of the RCP500 Code of Conduct. She is a Health Foundation Generation Q Fellow and founding member of the Q Community. Emma is co-editor of ABC Quality Improvement in Healthcare and associate editor of Future Healthcare Journal. Emma was awarded an OBE for services to medical education in 2021.
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