It’s not what you say, it’s how (and why) you say it - Tribe Culture Change

When Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and lead member of the National Advisory Group on the Safety of Patients, found it extremely difficult to raise a concern with the team caring for his wife, you have to wonder what hope there is for the rest of us.

Yet speaking up and questioning authority is a perennial stumbling block which faces anyone operating in a hierarchical organisation, not just in the NHS.

Language and perception

The use of language and perceptions of the words we use may form part of the solution. We talk of challenging people but look at the definition below, are we really looking to engage in some form of battle when we have a problem? Probably not.

Challenge: A call to someone to participate in a competitive situation or fight to decide who is superior in terms of ability or strength.

Is it any wonder then that people feel a challenge is a criticism of their abilities, values and beliefs? Let’s take this a step further and explore what it is to criticise:

Criticism: The expression of disapproval of someone or something on the basis of perceived faults or mistakes.

It’s perfectly legitimate for people to raise concerns and seek information and clarification, and we do this through asking questions, not through the use of potentially negatively-associated language which implies a challenge, and thereby induces feelings of criticism:

Concern: Something that make (someone) anxious or worried
Question: A sentence, phrase or word that asks for information

Can you see the distinction between the approaches? If you regard an issue as expressing a concern and ask questions that lead to resolving it, you’re much more likely to gain cooperation and results, rather than obstacles and defensive attitudes.

Other barriers to raising concerns

Apart from language what other factors stop us raising our concerns? Let’s return to our healthcare example, although you’ll notice there are still parallels with any hierarchical workplace.

• Halo Effect: the effect (usually beneficial) that the manner, attention, and caring of a provider have on a patient during a medical encounter, alternatively he/she is a nice person therefore they must be a good doctor
• Deference to expertise: not in the sense usually referred to when looking at high reliability organisations but simply that we hand ourselves over to the doctor, nurses and allied health professionals and assume (hope) they know better than we do, simply we put our lives in their hands as the experts
• Fear of the response and consequences: will it affect my treatment and care negatively; don’t recognise there might be a problem; I don’t know what to say or how to say what I want to say

In the end, this has to be a two way street. We need to encourage and empower patients and staff to ask questions, to seek information and clarification and educate healthcare professionals to be good receivers of a question and not to see a concern raised as a challenge, criticism or insult.

We can all help this process along by praising staff for good care and practice, this will help legitimise our individual concerns when the time comes to ask a difficult question, such as ‘have you washed your hands’, simple you would think.

In recent weeks I’ve made visits to my dentist, GP, undergone minor surgery in theatre and visited the occasional pub, I’ll leave you to work in which environment I questioned a staff member’s practice!