Speak up

WHEN relationships are under pressure, communication is one of the first things to suffer. Communication failure is the highest-ranked contributor to risk, safety failures and significant adverse events. But creating an environment in which ‘difficult’ conversations can be made less threatening and more productive does not happen by chance – all the team have to play their part. Understanding how to manage the ‘authority gradient’, and being clear about what assertiveness is, are two elements of success. The high-pressure world of aviation offers important lessons.

Imagine the scene: a crew of professional and skilled pilots are picking their way around turbulent shower clouds as they descend towards the airport. The bright lights of the airport and the town are occasionally visible through the gaps in the cloud but the rest of the mountainous island is invisible. Some of the radio equipment at the airfield is not working which will make the approach more complex. Once below the cloud they can’t see the town or the airfield and the first officer is worried. They are below the height of Nimitz Hill and not on the normal route.

There are two sides to this dilemma. The captain is working hard controlling the flightpath in difficult conditions. In an ideal world he would want the first officer to speak up with his concerns but, right now, being told that things are not going well could be heard as criticism and make a difficult situation worse. Meanwhile, the first officer has the constraints of junior rank and inexperience to overcome in addition to any social inhibition when making comments or contributions.

DILEMMA

The issues facing the crew are repeated in high and not-so-high-risk environments the world over. Psychologists describe these issues as power/distance. In aviation we talk about this as the authority gradient, or the difference in authority between the senior and junior team members. If the gradient between them is steep, the boss will have a tight grip on proceedings and can appear decisive. Bosses often have high control needs and steep authority gradients are superficially effective in 'getting the job done'.

The down-side to this is that juniors may feel they are merely ‘units of labour’ and be reluctant to communicate or contribute observations and insights. Over time the juniors may lose the capacity to think for themselves and become dependent on the boss for even the most trivial decisions.

Shallow authority gradients have their drawbacks too. Giving every team member licence and opportunity to comment and contribute over every matter can slow decision- making or stop it altogether. Responsibility may become blurred. At the extreme, it may be that the nominal leader will carry the responsibility for a committee decision which they personally thought to be inappropriate or did not have the authority to implement.

MINIMISING RISK

There is no one-size-fits-all solution. Shallow gradients are good for team-building and generating solutions when either the nature of the problem is unclear or where the remedy is neither routine nor obvious. Steep gradients are often appropriate in a crisis or where immediate action is required but may add risk because the decision-maker is isolated from the insight of his or her team.

In the world of general or dental practice, partners are likely to have a bias towards independent decision-making (steep gradient). It is part of their professional training as most patients will expect a quick decision about their care. For other staff in the practice there is the impact of a distinct and longstanding professional hierarchy which can mean that many decisions are referred upwards. This is reinforced by the perceptions of the risk to patients if decisions are not sound. Over time, both the will and ability of more junior staff to make decisions, even in administrative matters, is eroded.

Taking decisions locally requires competence and confidence. Appropriate training can deliver competence but confidence can be reinforced or shattered by the working relationships. With pilots, a collapse of confidence often leads to a loss of competence. When this happens, an instinct of self-preservation is triggered which results in that individual saying and doing as little as possible (steep gradient). Other members of the crew take up the slack since the task has to be completed, but the individual feels marginalised, reinforcing the steep gradient.

The safety risk is increased if the decisionmaker becomes overloaded. Overload is a killer. In aviation we say: "When I am overloaded I become incompetent (make unforced errors) and my judgement goes (make poor decisions)". Our single, limited-capacity brain has to control our movements and activity at the same time as making sense of what is going on and taking decisions. So, when demands in one aspect are high, performance in the other is compromised. The study of 'human factors' and the practice of Team (Crew) Resource Management, which is used in aviation, centres on creating an environment in which overload is proactively avoided.

Communicating effectively when the workload is high is critical to safety, but creating the appropriate environment and developing the necessary skills has to be undertaken before the workload increases. We need to be able to recognise the signs of overload in ourselves as well as in our work colleagues because this will be the time when our ability to communicate is most seriously compromised.

MANAGING THE AUTHORITY GRADIENT

Seniors must make themselves approachable and juniors must be competent and confident in their role. Seniors should invite juniors to speak up with their concerns or professional contributions and juniors must make those contributions clearly and professionally.

High risk often sits alongside high workload. Agreeing a small, appropriate group of phrases to be used whenever high workload or high risk is recognised is important. If anyone, particularly someone under pressure, has to interpret the nuances of what is said, a significant risk to safety is introduced. A professional language with agreed phrases is powerful in addressing this. Without it, we often fall back onto inhibited social language. We fail to ‘talk straight’. We use hints and soften any statement which may be seen as a form of social challenge either to protect ourselves from retribution or to save face on of behalf our colleague. In protecting ourselves and our egos, we put others at risk.

In the aeroplane story, you may see all the possible inhibitions - social, professional and hierarchical - mixed with high workload and uncertainty. We have a cockpit recording which illustrates what happens in real life. The first officer’s words of warning were: "The weather radar is our friend this evening". Precisely what he meant we will never know. The aircraft crashed into Nimitz Hill with no survivors.

Phil Higton is director of training with healthcare training firm Terema