Guest Blogger David Naylor
A few years ago I interviewed six people who had a reputation for being ‘constructively awkward’. They worked in a variety of community and NHS settings and told stories that seemed to inform the attention now being paid to speaking up and the duty of candour. They told stories, for example, about confronting people in a train carriage about mobile phone use; of crewing a yacht and noticing a buoy in the channel, being laughed at by the crew for saying the obvious and then being thanked by the captain for their attention; and insisting that a consultant find another way of explaining a child’s treatment in words that the parents could understand.
These are small stories that impacted on a few people but they are important moments. Moments when the internal conversation (‘I need to say something here’), underpinned by sufficient self-authorisation led to speaking out loud. A moment of refusal; that one was not prepared to let things go un-noticed; an act of confronting to point out what may be being ignored.
What I learnt from my research and my own experience is that I notice much more than I speak to. Obvious you might say, but consider the observation of Robert Francis on the frequency of the word ‘hindsight’ (123 times) and ‘benefit of hindsight’ (378 times) in his report . We see more and know more than we speak to; and sometimes this has consequences for others.
However, simply demanding people ‘speak up’ more and be more open, transparent and candid is insufficient advice to help you and me overcome the mechanisms that can silence us.
This is not an NHS problem. Our history is replete with moments when a blind eye has been turned. As I am writing, Dame Janet Smith’s report into Jimmy Savile is being discussed. A further example of how the context in which one finds oneself can strongly influence the decision to speak or not, even though one knows deep down that something is not right, not okay.
The trouble with speaking up is that it is disruptive. Not agreeing is to suddenly feel the anxiety associated that the risk of expulsion from the group holds for us. Our evolutionary advantage as a species is in part based on our ability to work cooperatively. However, in the hierarchically governed world that most of us work in, cooperation is expected and demanded. As a consequence, we have lost the knack of disagreeing and the skilful, respectful curiosity about one another’s thinking and frames of reference.
How many meetings have you been in where the real task seems to be getting others to bend to your will? While this may be ok in situations where immediate action is required, and these actions are clear, agreed and rehearsed; it can be unsafe when the situation is hard to read and complex. Here, the insistence on agreement will suppress curiosity and a full investigation of what is really going on. Culturally, we may have taken a backward step back to a time of ‘the old ingrained dislike of being interrupted, which seemed like a mutilation’ (Zeldin, 1998, p.33).
The term ‘constructively awkward’ holds in mind the dilemma we face when we notice something and feel we should speak up. We need to point to what may be being ignored and do so in ways that keep relationships going. Based on what people told me the following may help if you’re interested in thinking about your own constructive awkwardness.
- Pay attention to your internal dialogue, because it can help build one’s sense of authority to speak up. Coming across a situation that one finds troubling can evoke an internal conversation, because there is something going on that threatens one’s sense of oneself as an ethical person. What does a person like me do in situations like this? So, first of all you have to allow this conversation to develop so that it creates a pause in the forward trajectory of your thinking. To do this you need time and to be curious about and tolerant of your own thinking and feeling.
- Expect to be disrupted by your emotional reactions; one’s values are after all being challenged. I interviewed a priest who described giving his congregation ‘both barrels’ in the Sunday sermon after an unpleasant episode of discrimination. While some people seem to assume that the expression of emotions is unwelcome and should be kept private, this is risky. Emotions are data. Their suppression removes from the scene clues about how things are actually working in practice. There is a tendency to ask patients and relatives to speak to emotions, but this maybe is a way of avoiding the deployment of our own feelings to deepen our understanding of what is going on.
- We need to hone the skill of ‘backtracking’. Given that we can ‘lose it’, apologising with good grace and returning to the point one was trying to make is worth practicing. This means giving oneself the benefit of the doubt.
- We need to create a context for others to speak up. I am a senior consultant at The Kings Fund. When I speak I expect people to, at the very least, allow me the time to speak. My role, my title, my name badge and the building I work in underpin my sense of authority. If that is the case then it must also be reasonable to assume, if you do not have these accoutrements speaking up is a tougher ask. If you are a junior doctor, a patient or a third sector leader you have to rely much more on what can be a fragile internal self-authorisation process. So, how you model the culture of conversation (think back to Zeldin) in your team or department can help determine if people speak up. One thing to pay attention to is: where is the dissent and who has not spoken? If everybody agrees with you then you’re not far from trouble.
- Accept that you will worry about looking and sounding stupid. As one interviewee described it ‘the plonker factor’. This seems like an inevitable self-inflicted micro aggression on one’s temerity to go against what maybe yeas of socialising not to question, be rude or be emotional. Be wary of the voice that says that people as senior as me should know this already or do not behave like this.
Finally, it’s not all about anxiety. Acknowledge that there is some pleasure to be found in putting people right; influencing what is going on; and generally questioning what is going on.
 Great Britain. Department of Health (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London, The Stationary Office. (HC947).
 BBC Trust. The Dame Janet Smith Review Report (2016). London.
 Zeldin, T. (1998) An intimate history of humanity. London, Vantage.