For safety's sake: We need to talk about Us

Andy Cowper (Health Service Journal 12/03/18) has long been suggesting we need an NHS Chief Anthropologist due to our cultural problems, which he describes as ‘massive and largely undiscussed’. As no such job advert has been forthcoming, shall we get on and do this work ourselves? 

Let’s deal with the ‘massive’ bit first. Many aspects of culture feel enormously nebulous and beyond our direct influence. Yet much of the culture we work in every day is co-created between us and by us. That’s between you and me. And me and my next person. And you and your next person. And so on. 

So, this is about Us. Policies, procedures, even values statements are useful but blunt instruments for mandating or regulating our behaviour towards one another. Day to day, it comes down to how we interact and engage together. Norms of social interaction don’t just happen. We co-produce them in all in our interactions. And that is largely within our control.

So, massive? Yes. Beyond us? No. 

But even if we accept that some of this is within our influence, why would any of us use precious time talking about Us?
Take an emergency department where they have openly started talking about Us. Why on earth would they spend time doing that, when they have queues into the corridor, poorly patients to treat, beds to find, targets to chase, vacancies to fill and if possible, the chance to go for a wee during a shift?

Take a cancer unit, where they have openly started talking about Us. Why on earth would they spend time doing that, when they have backlogs of treatment plans to check, scanners to commission, complex care to coordinate, new roles to invent, funding agreements to negotiate, and if possible, the chance to gulp a cup of water during clinic?
Why would they bother dedicating time to talk about Us? 

Because they want patients to be safer. That’s why. 

The evidence is increasingly clear that where staff feel safer, patients are safer (eg http://ascopubs.org/doi/full/10.1200/JOP.2016.013300) Elsewhere, Amy Edmondson offers a compelling, extensive and Harvard-grounded case for why we need staff to feel psychologically safe.  
And if you spend time with NHS teams around the country, and ask the question – if you discuss the undiscussed - many staff say they don’t feel safe. 

Many feel scared. A lot feel afraid. Some feel dread. 

What are they scared of? Some stuff, you might expect: 
Scared of making a mistake. Scared of being struck off. Scared of feeling you haven’t been able to care for someone as well as you want to.

Some possibly less expected: 
Humiliated for asking a question. Ashamed to say I can’t cope. Embarrassed for crying. Petrified to face the ‘firing squad’. Sick before a meeting. Publicly pulverised. 

Their words, not mine. This is not a problem with any particular emergency department. Or any particular cancer unit. I hear these vivid descriptions up and down the country, from mental health to stroke rehab. From commissioning to service transformation. From board rooms to staff changing rooms. 

And who is doing the humiliating, the embarrassing, the shaming? Us – you and me. And me and my next person. And you and your next person. And so on. It’s not because we are unkind, insensitive people. It’s because we are human. And when human beings are under pressure or fear, we behave in predictably defensive ways – often by being less than compassionate to each other. Studies around the world for decades have proved it.

So, fellow anthropologists, what does culture have to do with Us? 
Well, no good patient care happens by anyone on their own. ‘Us’ is always involved, in the foreground or background. It might be a small Us, like a tiny team. It might be a huge Us, like a set of STP partnerships, and all sizes of Us in between. The foundation of good care is Us. So perhaps we need to talk about Us wherever we are in the care system. 

Easier said than done? Yes, for at least 3 reasons. 

First, it takes time. Yet an emergency department decided this was so important that they carved out afternoons to do just this. If something matters enough, it is amazing how time for this work can be enabled. 

Second, because we’re often unsure how to talk about Us in a way which feels safe and appreciative. One of the common things people tell me after starting this work is: ‘We’ve never talked about this stuff before.’ Why is that? Often because we don’t know how to start the dialogue, which feels potentially too sensitive.

Third, because it means taking ownership and accepting our sliver of responsibility for how we each contribute to the cultural norms we co-create. It means acknowledging that ‘culture’ is not simply something ‘out there’ over which we have no influence. And it is easier to attribute the culture to ‘them’ (whoever they are) than to inquire into what we collectively do to shape our own experience of Us.

Together we shape how we communicate, relate, trust, help, challenge, support each other – or not. And it takes courage and a belief that this stuff matters to start a dialogue about Us.
But that dialogue can only be started by one person, and it is not an NHS Chief Anthropologist (much as that might help raise awareness of this issue).

It needs to start with you – and me. And between me and my next person. And you and your next person. Let’s own the part we can play in creating our own cultures. And let’s make this a priority. For the sake of patients and staff in increasingly stressful times, we really need to talk about Us. It’s safety critical that we do.