VenetiaYoung, Safeguarding adults lead GP, Cumbria CCG

Published in JHH13.3 – Saving the NHS

I have worked in many settings in the NHS over 35 years as a GP and as a systemic therapist in adult mental health. My therapy training taught me to look for the places where there was manoeuvrability in families and systems. My GP self always looked for simple tools for 10-minute consultations. I have found so many ideas, tools and skills that work and produce lasting change.This is the passion that drives me – that remarkable change is possible even in the most complex of systems and the most dreadful of circumstances. in my new role as safeguarding adults lead GP I hope to enable organisations to become more curious and compassionate in the ways they care for vulnerable adults, including their staff.

Background

This article rose out of a conversation I had at a symposium for medical school teachers (held at the University of Westminster’s Centre for Resilience – Peters 2016) with a senior clinical manager of a London teaching hospital. She listened to the narrative of two ‘case’ examples where change had happened in simple ways and then began to expand the thoughts and ideas, evoked into thinking about her own hospital. The article is under[1]pinned by the work of Michael West (2012) and his research into effective teamwork and the work of Frederic Laloux (2014) and his examples of self-motivating organisations.

The advent of the critical culture full of regulators, rules and imposed organisational recipes for change, has left many workforces in the caring professions demoralised, demotivated and distressed. Negative beliefs about the length of time it takes to ‘turn around the ocean liner’ and the impossibility of implementing real change and compassion in complex systems, do not help. Suppose that these limiting thoughts are removed and a thought emerges that change is simple. What will happen next? Where do you start to think about this?

One sense is to start with the principles of the Care Act 2014, which deals with vulnerable adults. Maybe the NHS and care homes could be seen as ‘vulnerable adult organisations’. This means that applying the thinking of the six principles of the Care Act would involve thinking about empowerment, protection, prevention, proportionality, partnership, and accountability/ transparency. Here are three case histories.

A large healthcare organization

The staff survey at a hospital showed that there was a culture of bullying. A senior doctor had experienced bullying at the hand of two senior nurses. An admin worker refused to participate in the survey because she had experienced bullying and she thought the forms weren’t confidential. Other organisations experienced the team as bullying in meetings. The overall ethos was ‘that will never change’. The Chair had emailed everyone to ask them to report their concerns to him. Only one person had come forward.

A conversation with him produced some ideas. The bullying had structural elements in that line management responsibilities hadn’t been taken seriously. The appraisal form didn’t give an opportunity for staff to talk in a proactive way with their appraiser. Is the appraiser the same as the line manager? Do staff want supervision/ mentoring/coaching. Could a safer structure be created? How about changing the bullying and harassment policy into a dignity at work policy? This would provide more clarity about how people raise small concerns and get a proportional response. This would then empower the staff.

Then there was the subtly undermining language used in bullying. What would be the effect of learning about non-violent communication? Marshall Rosenberg uses the principles of talking giraffe or talking hyena (Rosenberg 1998). He gives some graphic descriptions on YouTube of giraffe and hyena talk using glove puppets to show the different styles. This could be incorporated into a development day. Maybe there could be an experiment of an excessive politeness day which staff could then reflect on. Maybe there could be a deliberate rudeness day. Maybe there could be a ‘four compliments before criticism’ day. The idea that we all have choice can then be embedded (Kline 1999). This idea could be discussed at the staff development day.

A care home

The staff had been demoralised by the death of a patient who had had three ambulance journeys to and from the hospital on the day she died. Her death was in hospital which was not what she had wanted. This had been taken seriously enough to have a practice review. The practice review became therapeutic when the home manager had a conversation with the safeguarding panel members. She needed to be empowered to regain her nursing profes[1]sionalism. She didn’t have to report all concerns to CQC or safeguarding, only the ones that were serious. At review three months later, she was busy creating a safe working environment where staff raised concerns at once and were able to sort them out quickly to prevent escalation. She admitted honestly and transparently that at times the work was hard and she would have a meltdown. She then shut her usually open door until she had regained her composure. This modelled for staff the reality of the toughness of the job and also that staff can manage their own distress. Her availability created a psychologically safe environment in which staff could then begin to learn, be curious about their patients’ lives and illnesses and raise concerns (Garvin et al 2008).

Going through the case report, it became abundantly clear that many people were accountable in the chain of the dying woman’s ambulance journeys. It wasn’t just the care home’s fault though the care worker had felt unsupported. This non-blaming, seeking-to-understand approach relieved a lot of stress. The idea of the unsupported care worker then developed into discussions about who was out there to work in partnership with them on end-of-life care. The deciding right team and the local palliative care team were to develop sound relationships with the home to ease the burdens of care at the end of life. The process of relationship-building to support the care home will develop and improve over time. The simple question which opened up the conversation was ‘how can we help?’

A senior manager at a large hospital

This manager had sought advice about where to begin with her tired, distressed and sad organisation. Having listened to the previous two cases, these are the points she took away to think about:

• dignity at work policy
• empowerment and support of key people
• managers being visible and accessible
• occupational health and HR fully playing their role in staff wellbeing
• developing wellbeing champions in most teams
• nicking good practice’ from elsewhere, a culture of curiosity
• options for staff like mindfulness training in a rebranded form that sounds less ‘fuzzy’
• valuing staff and the resources they have that aren’t tapped into, with simple questions ‘what are or have been your passions? how would you like to use them at work? a different form of curiosity.
• creating a sense of belonging
• creating buddying or co-mentoring partnerships to support each other
• enabling staff to control more of what they do.

It is interesting to reflect that one of the principles of solution-focused therapy describes how different solutions are from problems, and also how problems don’t even have to be clearly described to find the next steps forward. The ideas defined above all seem to point to relationship[1]building as the way forward, supported by good language and positive thinking.

References

• Garvin D, Edmondson A, Gino F (2008) Is yours a learning organisation? Harvard Business Review (March).
• Kline N (1999) Time to think: listening to ignite the human mind. London: Cassell.
• F (2014) Reinventing organisations: a guide to creating organisations inspired by the next stage of human consciousness. Millis, MA: Nelson Parker.
• Peters D (2016) Report on Tomorrow’s Doctors: a symposium of medical teachers. JHH 13 (2) pp 36–37.
• Rosenberg MB (1998) Non-Violent communication: a language of life. Encinitas, CA: Puddledancer Press.
• West MA (2012) Effective teamwork: practical lessons from organisational research. Hoboken, NJ: Wiley