How we behave towards each other is the single greatest factor in how well our teams will perform
Chris Turner (2017) at the Learning from Excellence Conference
Having had the chance to observe many conversations we have come to understand that there are multiple dynamics that get in the way of people talking to each other and there is clear evidence that people too often choose silence over speaking up. Cultural rules of what one can say and cannot dominate the safety world and the NHS.
These are just a few:
Fear
People fear being judged and blamed, especially fear of being blamed unfairly. People fear being seen as incompetent, stupid and ignorant. When they feel like this it is far preferable to stay silent that say something that everyone will judge them for. This fear of embarrassing themselves can go as far as people not pointing out when the wrong body part is about to be operated on or the wrong drug being administered. The fear pervades at all levels of the organisation from the board to the frontline. People fail to speak up at boards, in meetings, at the bedside.
As Steve Shorrock says…
What people fear most of all is not the judgement of those who are most distant from the work, whose judgements are relatively rare. What people fear is the judgement of those closest to the work – their co-workers.
People fear raising the issue of judgement and blame by colleagues because they fear being judged and blamed for raising the issue.
Groups
There is clear evidence that humans have a strong need to belong within a group which can override the need to speak up. Discussions concerning safety are a mixture of what people will say and what they wont say. In particular people find it really hard to discuss patient safety issues in a group, but will mention them in private. What this means is that vital information can be omitted unless people are given the space and opportunity to open up in a safe way. In order to say you feel unsafe in a work situation you need to feel safe enough to point it out.
We are as groups, our own worst enemies. We demand fairness from others but continue unfairly to blame others.
Steve Shorrock (2016)
Power and status
Fear and silence are exacerbated by power. Power takes multiple forms. There is the power of people, the power or the organisation, the power of the targets and goals. Wiggins and Hunter talk about the different types of power:
- Position power – the job and status of a role or position in the organisation
- Reward power – the power to reward some and not others
- Expert power – the power of having more experience and expertise than others
- Information power – the power of gaining, holding and using information
- Personal power – the power of loyalty, friendships and the desire to please
- Coercive power – the power to punish
Our bias gets in the way
For example, confirmative bias where there is a tendency to see patterns in random events so we come to conclusions that might not be right but we stick rigidly to them or we believe that the knowledge and information we have is the right one so we use this to influence the rest of the group. We quickly make judgements on people based on very little information. We also tend to listen to only information that confirms our preconceptions or views – which makes it hard to have a conversation with someone else.
Or outcome bias when the same “behaviour produce[s] more ethical condemnation when it happen[s] to produce bad rather than good outcome, even if the outcome is determined by chance.” For example if a healthcare professional makes an error that causes no harm we consider them to be lucky. If another person makes the same error resulting in injury to a patient we consider them to be blameworthy and disciplinary action may follow. The more severe the outcome, the more blameworthy the person becomes. This is a flawed system based upon the notion that we can totally control our outcomes.
Or hindsight bias – ‘why did you do it like that’ or ‘I would never have done that’ or ‘the knew-it-all-along effect’ usually happens after an event has occurred and sees the event as having been predictable, despite little or no objective basis for predicting it. It may cause memory distortion, where the recollection and reconstruction of content can lead to false theoretical outcomes.
Over confidence
People can be overconfident which again convinces them they are right. The dominant speakers are often the ones who fail to listen. The dominant voice may not be single individuals but having an unbalanced group in the room.
“are you really listening or are you just waiting your turn to talk”?
Robert Montgomery
Human characteristics
The reluctance to speak up is directly related to the culture of the team, the unit, the practice and the organisation. Human beings differ in the way they interact with each other depending upon their personal characteristics.
For example; introverts versus extroverts, shy people versus confident people, male versus female.
Women and Men are often referred to as from two different tribes, each with a set of rules, beliefs and behavioural expectations. There are also stereotypes attached to how we differ in respect of communication. These are the sort of things that people say about females and males:
- Females are more empathetic, able to read body language and pick up nonverbal cues
- Females are better listeners
- Females are overly emotional, meandering and lack authority
And….
- Males adopt commanding physical positions and displays of power
- Males are direct and to the point, blunt and insensitive
- Males are too confident
Stereotypes exist for a reason, lots of women like to chat about their feelings and lots of men don’t but by saying that all men and all women are like that means we put people in a box and label them. We then expect them to act accordingly. Our gender impacts on how we communicate but so do a number of different variables.
People behave and communicate differently depending upon their mood, the circumstances, the stressors, their role, their race and their status. The tips and tools to communicating effectively apply no matter which gender you are. It has everything to do with helping people speak out, helping people listen, respond and act.
What can we do differently?
Thankfully there are a lot of people who are also thinking about this conundrum (see references). We and others believe that it is possible for good conversations to be the norm and have a few ideas to think about:
- Reframe what you say in a positive way; in conversations, emails, texts, tweets, feedback and so on
- Provide others with positive feedback so that they can learn from when they get it right and want to replicate that behaviour
- Use a set of ground rules of respect, kindness, humility and civility
- Slow down and create the opportunity for people to come to you with new information, questions and ideas – like our gathering round the ‘Kitchen Table’ idea which is simply that – an opportunity for a conversation
- Reflect on your own power balance with others
- Notice if you interrupt too much
- Avoid jumping to conclusions before hearing as much as you can. If you suspend your reaction to what someone else has said, instead of blurting out your reaction or even providing what you think is the answer that you can learn something quite different from what you expected
- Find ways to hear from the people who are too frightened to speak up for example meet with people in a neutral place to diminish the reminders of the power associated with someone’s office or pairing up or buddying to share views
- Reduce abstract language, acronyms and jargon
- Deepen individual skills and practice things like asking different questions that are based on genuine curiosity and listening
- Be bold enough to admit that you don’t have the answer – be honest
- Use first names only rather than job titles and biographies
- Develop a culture of psychological safety. Any conversation needs to help people feel safe to talk and to ask questions
- Pay attention to the way the conversation is restricted or encouraged by the language and the participants themselves
- Pay attention to who is in the room, how the individuals engage with each other, who dominates and who is silent – if you notice all of these things you will go a long way to creating the right conditions for an effective conversation to take place
- When you are arranging a meeting or conference, provide less time for the speaker and more time for the audience or participants to discuss
- One of the hardest bits……. allow for the silence to linger. Silence is often because the people you are with are simply reflecting, have a conversation with themselves in their mind and will respond if you give them time. If there is silence don’t just fill it – wait for thoughts and questions to come
Above all we need to help people engage with each other, participate in meetings, events where they can learn to talk to each other, strengthen relationships, challenge and share ideas and share concerns. It needs to be highly interactive and provided in a positive way that helps people talk in small groups.
When you are genuinely interested in what others are thinking and feeling it gets easier and easier.
References
- Nancy Dixon (2017) Building a ‘speaking up’ culture in Teams via www.nancydixonblog.com
- Schein E (2013) Humble Inquiry: the gentle art of asking instead of telling
- Robert Kegan and Lisa Laskow Lahey (2016) An Everyone Culture: Becoming a Deliberately Developmental Organisation – Harvard Business Review Press
- Amy C Edmondson (2012) Team: How organisations learn, innovate and compete in the knowledge economy – Harvard Business School
- Amy C Edmondson (1999) Psychological Safety and Learning Behavior in Work Teams – Cornell University Administrative Science Quarterly (44, 350-383)
- Catherine Turco (2016) The Conversational Firm: Rethinking Bureaucracy in the Age of Social Media – Columbia University Press
- Sean Stevens (2017) The Fearless Speech Index: Who is afraid to speak and why? Via www.heterodoxacademy.org
- Liz Wiggins and Harriet Hunter (2016) Relational Change Bloomsbury Publishing
- Steve Shorrock – http://www.safetydifferently.com/just-culture-who-are-we-really-afraid-of/
Patient Safety Now 