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Abstract
Introduction Effective clinical leadership can seem at a loss in the current National Health Service (NHS). The following reflection describes how a peer support network for menopausal symptoms and introduction of free sanitary products in female changing rooms proved greatly beneficial to promoting genuine equity in a Welsh NHS theatre environment. The latter aimed to help female staff working in time pressured and high stress environments on days when they are caught out by their menstrual cycle.
Method The Driscoll reflective model has been chosen to critically appraise these behaviours, providing an opportunity to focus on the details of the event, analyse the impact of behaviours and evaluate best future practice.
Conclusion This is a pragmatic, tangible and cost-effective approach to creating gender equity in a busy NHS environment.
- clinical leadership
- behaviour
- health system
- improvement
- communication
Data availability statement
No data are available.
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Introduction
A peer support network for menopausal symptoms and the introduction of free sanitary products in female changing rooms proved greatly beneficial, aiming to help female staff working in time pressured and high stress National Health Service (NHS) environments on days when they are caught out by their menstrual cycle.
This situation resulted in feelings of psychological safety for team members. The following reflective piece does not include identifiable information and the confidentiality of individuals and organisations have been protected. The Driscoll reflective model has been chosen to critically appraise these behaviours as the model has clearly defined stages which provide an opportunity to focus on the details of the event, analyse the impact of behaviours and evaluate best future practice.1
Discussion
‘What happened?’
The behaviours of compassionate leadership in this scenario began with two clinical leaders meeting to discuss physiological issues regularly impacting female members of their teams. A Consultant Surgeon approached a Theatre Matron to discuss how the daily activities of staff can often be impacted by the physiological changes experienced by women including menses, menopause and fertility issues.
This was prompted by several recent experiences shared by colleagues. The two leaders held informal discussions with team members to listen to personal experiences, thereby addressing the situation and exploring the nuances of each lived experience. These actions and behaviours reflect the ‘attending’ and listening component of compassionate leadership, when individuals pause to acknowledge and inquire about suffering in the workplace.2 This resulted in staff expressing gratitude and describing a sense of feeling heard and valued.
The personal experiences of staff revealed the nearest hospital shop selling sanitary products was a 30 min round trip from the operating theatre. Staff often have staggered and short breaks when working in a theatre environment to ensure safe staffing. Staff also expressed feelings of stress during these situations, feeling uncomfortable explaining the reason for requiring a longer break.
Another staff member experienced auditory symptoms associated with menopause.3 A hypersensitivity to sound made it challenging for the team member to concentrate in a busy operating theatre with multiple conversations occurring simultaneously, a radio playing music and instructions between members of the operating team.
Menopause is a physiological stage in a woman’s life associated with an absence of menses as ovarian follicular activity stops. It is described clinically by the absence of menstrual period for 12 months. In the UK, the mean age of the natural menopause is 51.4 Perimenopause describes the years prior to the menopause which is characterised by a wide spectrum of symptoms associated with the endocrinological and biological changes experienced by women during this time.4
The two leaders addressed the issues described with empathy and invested time to understand the difficulties. This allowed identification of gaps in the current system and possible solutions, including making free sanitary products available in female changing rooms, thus demonstrating the other three key compassionate leadership behaviours: understanding, empathising and helping,.2
To avoid NHS procurement delaying the availability of these products, staff developed an informal network and opted to purchase products themselves. This approach was positively received by staff due to feelings of belonging and a ‘home team’ which fostered a sense of social support.5 The request to replace sanitary products following use was at the team members own convenience and was not mandatory. This also ensured inclusion of individuals who may be unable to replace products as readily, for example, students and visitors.
Similar feelings of social support were nurtured by introducing monthly menopause coffee mornings, providing opportunity for staff to discuss their symptoms, particularly those impacting their work and to share advice. Senior theatre matrons were invited to enable escalation of suggested solutions. All colleagues were invited irrespective of gender therefore enabling inclusion of all team members who may experience menopausal symptoms, for example, trans males and non-binary staff. The primary objective was to facilitate discussions in a safe space.
‘So what?’
Stress and patient safety
These workplace behaviours took place in an NHS surgical theatre environment which is often extremely time pressured, understaffed and involves multiprofessional collaboration to complete high stress activities.6 Staffing gaps and workload pressures are strongly associated with higher levels of stress and burnout among NHS employees.7 Surgery also remains a male dominated profession. A recent UK survey conducted by the Association of Surgeons of Great Britain and Ireland identified high rates of perceived discrimination among female surgeons with descriptions of a ‘glass ceiling’ in surgical training, accounts of gendered language and inflexibility to part-time careers.5 These perceptions can result in a lack of belonging for women working in surgical environments. Unconscious bias and gender appropriateness in medical training is still high, with lower representation of women in surgical specialties.8 A lack of belonging, feelings of discrimination and loneliness are described as gravely damaging to human well-being and likely to contribute to heightened feelings of stress.5 9
On reflection, the situation described includes stressful workplace activities and employees who are predisposed to higher levels of stress due to a perceived lack of belonging within their working environment. High levels of personal stress cause behavioural, physiological and psychological injury to employees as well as negatively impacting patient safety.2 9 The negative impact of healthcare professionals stress on patient outcomes is highly evidenced. A 3-year study conducted by the Mayo Clinic found doctors are more likely to be involved with a major medical error when experiencing personal stress.10 A similar large-scale study including 7905 surgeons found a three times higher major medical error rate over a 3-month period when surgeons were experiencing symptoms of burn-out and described as highly stressed.11 The NHS England Staff Survey has repeatedly demonstrated that clinical environments with staff who feel unsupported and stressed are associated with worse outcomes of patient satisfaction and financial performance. Reduced staff stress will improve patient safety and patient outcomes.2 9 The leadership behaviours in the described scenario addressed the core needs of individuals, reflecting an authentic approach to inclusivity. The help aimed to reduce stress and were insightful solutions proposed by leaders who had attended to the situation, understood the problem and sought to find empathic solutions. The ‘Healthier Wales’ workforce strategy 2030 ambition published by Welsh Government aims to develop a health and social care workforce which feels valued, motivated and engaged.12 13 The scenario demonstrates how compassionate leadership behaviours enable the ‘Healthier Wales’ national ambition to be realised.
Self-compassion can be a useful coping mechanism for stress.14 Work productivity and commitment to group activities have also been found to benefit from team members expressing self-compassion.15 16 This scenario encouraged team members to embrace self-compassion, by supporting them to recognise and make time for difficulties they might be experiencing. This effectively validates such problems and promotes a process of self-compassion. Self-compassion has also been described as an effective mechanism to improve perception of self and emotional stability particularly in comparison to basing self-esteem on favourable self-evaluation.17
Workplace culture and psychological safety
Psychological safety in the workplace is characterised by staff feeling confident to speak out about uncertainties, errors, as well as being more likely to have a supportive attitude to change introduced to improve a service.2 This was demonstrated in this example by staff sharing their personal experiences with leaders. Feelings of psychological safety in the workplace are developed through clearly defined shared goals, values and an openness to learn from differing opinion. These feelings are nurtured by teams meeting frequently and building supportive relationships.2 18 The development of a menopause network within the theatre environment open to all members of staff demonstrates a willingness to learn as a team. This promotes the development of psychological safety for staff members personally affected by menopausal symptoms. The inclusion of all other staff members, irrespective of gender was also important, developing a positive, open culture. Workplace culture is created through our experiences and interactions within teams. Teamwork thereby plays a central role to developing organisational culture.19 A supportive environment helps employees cope better with difficult work situations and generally excel in the workplace.20
‘Now what’
Behaviours of compassionate leadership include effective, inclusive and collective leadership which is embedded within organisational systems.2 The practical implementation of such leadership qualities can be explored by using the ‘DAC’ model of effective leadership described by The Centre for Creative Leadership.21
‘Direction : A clear, shared, inspiring vision and goals’.21
The national direction of how to lead a healthcare workforce in Wales has been set by the ‘A Healthier Wales Plan 2018’.12 A recognition of the struggles of individuals and a commitment to ensure a workforce feels valued is further stipulated by ‘Our Workforce Strategy for Health and Social Care’.13 The 2030 ambitions describe a workforce which is motivated and engaged.12 This scenario involved staff having a shared goal of making things better for all. This was achieved by leaders actively listening to the difficulties faced by staff and placing importance on well-being. The national endorsement for this leadership style is important for the future and ensures all teams within a system are directed to adopt a similar compassionate approach to staff difficulties.
‘Alignment: The efforts of people and teams aligned and springing from the vision’.21
Alignment of efforts is produced by effective, inclusive teams described as ‘real teams’. Such teams have high levels of psychological safety, an ability to partake in shared leadership and are capable of co-ordinated working across boundaries.2 18 This scenario included an initially small team with many differences in profession, seniority of healthcare experience, gender and ethnic background. The smaller team grew in number due to a shared objective of raising the profile of the cause and engaging in intrateam discussion, indicating a successful alignment of efforts. Inclusive teams are more innovative and have improved productivity.2 Therefore, achievement of consistently higher-quality patient care requires prioritisation of inclusivity within teams. Inclusive teams have clear roles and are empowered as individuals to partake in a shared, collective leadership approach.22 The Duty of Quality requirements of the Health and Social Care engagement act (2015) published by Welsh Government and provide domains and enablers of quality.23 Enablers of high-quality care include a culture of valuing people, strong leadership, a commitment to quality improvement, forming a whole system perspective for these efforts and ensuring data propagates knowledge.23 The enablers to healthcare quality can be considered as a metric for successful team alignment. Productivity of teams can be measured through engagement with quality improvement and innovation.2 The NHS Wales menopause policy was published in 2018 and provides a comprehensive overview of the support employees require in the workplace when experiencing symptoms of the menopause. This document describes the need for risk assessments and reasonable adjustments. Aligning organisational policy to the physiological needs of employees is likely to be a highly effective approach in delivering compassionate leadership.
Commitment: Developing trust and motivation.21
Trust between team members appeared to flourish in this scenario as efforts addressed the core needs of individuals. Core needs are described by the ‘ABC’ framework—autonomy and control, belonging and competence. Autonomy and individual empowerment was achieved as the leaders in this scenario understood the work schedule of the team and aimed to develop an equitable and just work environment. Prioritising the core needs of individuals will build trust and efficiency in teams.2 Recognising and appreciating differences has been described to increase feelings of inclusivity.24 Genuinely supportive teams appreciate and advocate self-care, recognising the important role self-compassion holds in making individuals more altruistic and able to help others.25 Trust between individuals and organisations similarly flourishes when conflict is managed with a constructive and ethical approach. Chronic interpersonal conflict is associated with destructive teams with limited ability to achieve high quality patient care.26 Such potentially toxic situations can be compassionately confronted and prevented by facilitating space for careful listening to each other’s perspectives, ensuring all opinions are valued and are underpinned by a commitment to reach a shared understanding. Aggressive and intimidating behaviour should be challenged by considering the behaviours as separate to the individual.2 Interestingly, trust within teams is developed when teams deal effectively with bullying, harassment and discrimination. Leadership and followership are also important to ensure staff are up to date with evidence regarding the dangers of racism, sexism and discrimination to personal health, life chances and mortality.2 A greater emphasis on civility, respect and compassion particularly with those of different backgrounds to us creates environments in which individuals feel safe to be open and trusting.27
Civility in healthcare
‘Civility Saves Lives’28 is an initiative developed by a team of healthcare professionals in Coventry, West Midlands which emphasis the destructive impact of incivility in healthcare environments. Behaviours of rudeness, bullying and aggression must be replaced with compassionate leadership behaviours within the NHS if progression and sustainability of the system is to be achieved.2 Civility has been further explored and described as civility of ‘politeness’ and moral civility or ‘public mindedness’. The latter is a robust approach to civility which involves respecting others as free and equal in respect of their liberties, fundamental rights and civic standing rather than merely civility of polite speech alone.29 Moral civility provides the means to achieving democratic values, psychological safety and genuine inclusivity. The insightful gender equity initiatives discussed in this paper provide an excellent example of how moral civility can be achieved by implementing compassionate leadership.
In contrast, a superficial approach to civility, which is void of respecting others as free and equal in terms of their fundamental rights has been described as harmful to genuine social justice. Zamalin, Detroit Mercy Assistant Professor of Political Science explains how civility has silenced marginalised voices in his book ‘Against Civility: The Hidden Racism in our Obsession with Civility’.30 Academic Professor Sugrue has similarly described how misguided pursuits of civility have enabled a dismissal of concerns to racism in American history.31 Kundnani questions whether democratic action is always antiracist in his Guardian Opinion piece. There are two kinds of antiracism. Only one works, and it has nothing to do with ‘diversity training’. Kundnani describes the merits of direct corrective action which addresses social mobility and racial inequity in comparrison to costly diversity training packages, etc . The example in this paper is related to gender equity rather than antiracism, however, the sentiment of direct and corrective action is equally relevant.32
Conclusion
In conclusion, the workplace behaviours outlined in this scenario resulted in psychological safety due to the difficulties experienced by staff being listened to with genuine interest. This enabled a deeper understanding of the problem and an opportunity to authentically empathise. It was followed by the implementation of specific and targeted help which was well received by team members. This reflection addresses a pragmatic, tangible and cost-effective approach to creating equity in a chaotic and busy NHS environment. The impact of such action is greatly beneficial and we must be mindful of the need for directed action alongside policy documents and training packages. A lack of compassion and moral civility significantly hinders clinical performance and creates a grave risk to patient safety.24 As we consider the recent NHS workforce strikes, the rapid rise of healthcare professionals leaving the UK in search of more favourable working conditions and the fragmented relationships between professional unions and government, this highlights an urgent need to re-establish a solid pillar of moral civility throughout the UK health and social care system before it is too late.33
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Acknowledgments
Thank you to all involved in this scenario and others throughout the NHS who practise excellent compassionate leadership skills despite continued pressures and workforce shortages.
References
Footnotes
Contributors All work has been produced by the corresponding author.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.