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The myth of the humble surgeon?

Could you lead the way in your practice to flatten the hierarchies that are present? How do behaviours limit performance and safety within your team?

01 March 2021, at 8:40am

So perhaps the title is a little in jest, but the impact of humility in leadership can be massive. It affects not only workplace culture and the atmosphere surrounding individuals and teams, but consequently it impacts on performance and thus the safety of the patients under our care. Considering how workplace culture is affecting our own veterinary practice – for better and for worse – is time well spent.

(Senior) behaviour dictates culture

The behaviour of staff, particularly senior staff, goes a long way towards creating the workplace culture.

It is perhaps most telling to ask those working for more senior staff what they think the workplace culture is like. Whether positive or negative, the individual is often less aware of the culture they create than those working for them.

Question first, command second

The concept of “question first, command second” is one whereby, no matter our seniority, we ask people what they think should be done before telling them what to do/what we think. This doesn’t necessarily mean that the plan will change, but it is recognised that if you give orders first and then ask people what they think they are likely just to agree with you. A culture where speaking up is actively encouraged and voices are heard is one where error will be caught before it occurs.

Learn to ask open questions and practise confident humility

“Confidence is not about being 100 percent sure that you can achieve everything. Confidence is about being aware of your limitations, and also the fact you’re human and you may make errors. And it’s being able to say to other people…‘this is something I’m not too familiar with, let’s talk about how we can do this and I’ll listen and I’ll work out a plan’. That to me is confidence… the reality is, people respect leaders who can engage with a team and can use a team sensibly… especially in these really tricky situations.”

Martin Bromiley OBE, Chair Clinical Human Factors Group

Martin Bromiley’s wife died under general anaesthetic during a routine surgery. The expert team resuscitating her tried to intubate for 20 minutes, without changing their approach. Nurses tried to speak up but they weren’t heard. In his own industry, aviation, Martin was used to the question “why did this happen” being asked in relation to aviation accidents; such investigation into the related systems errors, beyond the highly skilled individuals involved, that led to the incident were not so apparent in healthcare.

How does one go about practising confident humility? This in no way undermines your expertise and/or skillset. Veterinary surgeons are talented individuals with extremely high levels of training. But there is an admirable strength in those experts who can be confidently indecisive, who can competently lead their team through a process, potentially but not always to a solution. When safe to do so, giving your team the opportunity to say what they think is going on is not deferring, but instead gives you the chance to assess the whole picture and to listen to other sources of information. This kind of action models strong leadership, shows confidence and develops the team as a whole.

Speaking up and what prevents it

We are all responsible for the standards in our profession and what we see occurring in day-to-day practice, be that first opinion or in a referral hospital. For the safety of patients under our care and the standards of care we commit to deliver, we must develop a culture of speaking up, and as superiors we must be ready to listen.

Having a shallow hierarchy within the team allows for all team members to speak up without fear. It provides an opportunity for any team member to intervene should they think they need to. This is not a case for suggesting the student nurse dictate to the diplomate how to perform the surgery for a portosystemic shunt. But a shallow hierarchy throughout the hospital does allow for that student nurse to speak up (without fear) when, for example, there is a concern about blood pressure during the surgery that the other professionals in the room haven’t noticed. The nurse may be right or wrong, but the channels of conversation must be open and free. Then, on that rare occasion where an error does go unnoticed by experts, it is caught and mitigated against. Creating that open culture and developing positive behaviours among all levels of the team must be done ahead of time however, so that when things do go wrong, the safety net is already there. The culture of speaking up can and does save lives, both in human and veterinary medicine. You may have heard of the human healthcare project “Civility Saves Lives”. Our behaviours really can be a matter of life and death.

Behaviour and culture when things are going well directs behaviour when things are not going well, either today or in a future clinical situation. We must recognise the importance of this before we are in a critical situation where a life is at stake. As highly skilled professionals with lives in our hands, we have a responsibility to work on improving patient safety from all angles. This includes developing our excellent clinical skills, but also developing non-technical skills such as flattening workplace hierarchies, improving communication between our team members and actively working on improving workplace culture, all of which impact patient safety and clinical outcomes on a daily basis.