Over the last few years I have developed a teaching module for educational supervisors looking at how we give and receive feedback alongside some regional training for paediatricians on professional skills including reflection and resilience, maintaining wellbeing at work, feedback and leadership. And more locally we have been looking at the civility saves lives campaign. One of the lovely things about running workshops with a colleague is the wisdom you gain from the conversations to enable the ideas to form. Each time we meet to run the workshop and in the conversations in between our thinking moves on that little further. We use to think of these days as the ‘softer skills’ or the ‘fluffy bits’. I think we now all recognise how important they are not only for us as professionals but for the patients and families we look after. Patient safety and quality of patient care is dependent on our communication, performance and behaviour. The discussions we facilitate with trainees and trainers, has also developed as this wider understanding becomes a shared dialogue.
The challenge for me often, is to know where some of the ideas and information come from. I love to read both books and via twitter the blogs and articles I find or are sent to me. More recently I have got better at gathering some of these concepts and trying to visually represent them as a sketch note. I have realised how visual I am when thinking about new concepts, but appreciate some like to read so a blog can be a good compromise.
Radical candor is a great read to get us started. Kim Scott talks about how we can improve our relationships at work, by being clear about what we are saying. Many of us will recognise that at times, we don’t always have, the Goldilocks combination of challenge and support. We probably have a quadrant we slip into when feeling less brave. I at times, am tempted to sugar coat feedback and need to be brave to be clear about my impression. Brené Brown’s work adds to this. She talks about how being ‘clear is kind, unclear is unkind’ when having brave conversations and providing feedback. I find this helpful. It is kinder to talk to someone than about them. It is also much more helpful for you, your colleague and the wider team.
Many of us like to think we are up front and speak our minds. Some are good at the high challenge. We set high expectations for ourselves and often come from a high achieving, perfectionist background. We can at times forget, we also need to provide support when having these conversations. Radical candor becomes challenging when we don’t provide support and we feel triggered by the conversation and unsupported. Obnoxious aggression is the term Scott uses I prefer stab in front. If we receive feedback in a very triggering way we mount a stress response. In sympathetic overdrive our communication is challenged. We reduce our non verbal skills, stop listening as we arm to fight, flight, face or freeze. If we increase the support and kindness in how we approach the conversation we reduce the triggering effect and move into the better place to have the conversation. Stone & Heen explain triggers to feedback in more depth. These can be related to truth, relationships and identity. They get in the way to how we receive feedback and therefore what we learn from it. They are also very relevant in wider conversations.
Arguably more undermining, is the talking about someone rather than to them. This is challenging for all and does much to undermine team relationships. Scott talks about manipulative insincerity. When we stab someone in the back we don’t have the clear, kind conversation to enable a two way dialogue. We talk about them, gather opinions on them and generate a culture where all are affected. If we have concerns then we need to be brave and share this information. In gathering feedback for junior doctors, we need to ensure we can then as supervisors deliver this in a clear way.
I often struggle to process and interpret anonymous feedback. I see feedback as a conversation rather than a one way process. If we don’t have the chance to clarify, reply or discuss the comment or challenge, then we may misinterpret, dismiss or be very unclear and upset. I understand the need for a broad view in feedback. I also understand the need to ensure we are able to be honest when there is a hierarchy for example with patient feedback. But I would love to see the feedback we give as professionals and colleagues to be more open. Some of the best and most frank conversations I have had, have been with medical students and doctors more junior than me. I often ask at the beginning of a clinic for feedback on an aspect of my consulting. At the end as we discuss the wider clinic, I then ask what they thought. It can be painfully clear, they have not only watched really carefully but also taken the job I have asked of them really seriously!
We know from the civility saves lives campaign, how important these conversations are, to build a team culture that is inclusive. Everyone needs to feel empowered to speak up and ask questions or for clarification. We model this every day, by how we communicate with each other, as more senior and more junior colleagues. I often think our colleagues in non-clinical roles are witness to many of these conversations. Do we include our cleaners, porters, ward clerks, secretaries and admin teams, receptionists and managers when we ask for feedback? As a junior doctor as now, I gain much wisdom from the multi-professional teams I work with. The different professional background can often enable a viewpoint that can be refreshingly different.
Psychological safety is also key. We often talk about the days of a firm with fondness. I certainly benefited as a very new doctor from working with a consistent team. We need to be creative in how we approach this, with the constraints of our shift systems. If we increase the psychological safety within our teams, we move from working in the anxiety zone to the learning and high performance zone. As Edmondson describes, this can be done as a team. The team members do not need to be the same each day to achieve this. Our clinical and educational supervisors are also key. Often we have a team of clinical supervisors. In reality each senior member of the medical team is a clinical supervisor. The psychological safety is created with the team on shift and is multi-professional. In addition we need to create a safety net of colleagues we can talk to. For junior doctors that could be an educational supervisor or another trusted colleague.
We all need someone and somewhere to go to off load and reflect with. This is often done informally over a cuppa. Many of us have a few wise owl colleagues and / or friends and family, who know us well and this can be very helpful. For junior doctors in rotational posts this can at times be challenging. The importance of shared rest spaces where we can relax and have down time, facilitates the chance to get to know each other a little better.
Finally, we need to remember when having these conversations that we are all different. We need to ensure the conversation takes place in a kind supportive way for both. We must be mindful and open to discussions that enable a more open understanding around diversity and inclusion. As supervisors, we are responsible for creating the psychological safety to enable the conversation to take place. This can at times be as part of a handover or a ward round, is better if it is expected and two way. We can also ask for feedback on something. It is much less triggering having a conversation that you are expecting. We need to feed up and across.
To finish with the wisdom from Dumbledore ‘It takes a great deal of bravery to stand up to our enemies, but just as much to stand up to our friends’. ‘Differences of habit and language are nothing at all if our aims are identical and our hearts are open.’
Anna Baverstock is a Paediatrician in Taunton and lead for doctor wellbeing @SomersetFT.
With thanks to the many wise owls who have facilitated workshops and helped frame the above discussion.
Books to peruse in more detail:
Thanks for the feedback Stone and Sheen
Daring greatly and Dare to Lead Brené Brown
Radical Candor Kim Scott
The fearless organisation Amy Edmondson
Also their ted talks are great if you prefer to listen rather than read.