A senior surgeon walks into the emergency department to review a patient in the resuscitation room. He does not introduce himself and is not wearing any identification, though he clearly seems to know what he is doing. He assesses the patient and then tells the emergency department staff nurse to give the patient a litre of normal saline and leaves the room. The nurse does not do this as it is not prescribed and she did not know who he was. The surgeon returns later and is angry to find that his instructions have not been followed. He says that the nurses on the surgical wards would have followed his instructions to the letter and that he would obviously have written the fluids up later.

In this case, both parties were exhibiting behaviours that would be acceptable in their normal environment. Due to a collision of behaviours in an unfamiliar environment, patient care suffered.

A community’s awareness and tolerance of acceptable behaviours is important, as in many cases it allows departments to be more effective, with adopted behaviours directly reflecting working practice. Tasks that require strong individual leadership, such as some types of surgery, promote and reward more assertive behaviours. Tasks that require longer term multidisciplinary interactions, such as psychogeriatrics, promote and reward behaviours that are collaborative and less hierarchical. It is likely that individuals with certain personalities will be attracted towards specialities that reflect their personality traits, but their behaviour will also be learned through immersion in the working environment.

Ineffective Behaviours

Regardless of the range of locally acceptable behaviours, there will be some that are considered unacceptable, particularly if they may lead to patient harm. Addressing unacceptable behaviour is important, but difficult. A challenge can become a confrontation if handled badly, but it cannot be ignored. The process using Eric Berne’s (1964) theory of transactional analysis (TA) can be most effective in dealing with unacceptable behaviour or bullying.

TA is premised on the notion of adults occupying one of three role states:

the parent (P)
the adult (A)
the child (C)

A desirable interaction is A–A and a departure from this is likely to be counterproductive in the long run. This does not mean that accepting a P–C dialogue cannot generate agreement or, probably more accurately, compliance. What it does, however, do is to create a climate of deference or other suboptimal form of behaviour.

The aim is to remain in an ‘adult’ mode of behaviour, focusing on the desired outcome and not letting anger or intimidation deflect one from what is thought of as right and what is safe. A simple statement such as, ‘I understand and sympathise, but this is what must be done to ensure a safe outcome,’ can be highly effective and forms a structure to support the assertion techniques described in Chapter 6.

Beyond a problematic encounter itself, there are some important steps available for more formal feedback to individuals. Strategies include:

feedback from educational supervisors
annual appraisal processes
360 degree feedback
patient feedback
complaints
adverse incident reports

This list is not meant to be exhaustive, but illustrative of the range of longer feedback mechanisms available. Managers and senior clinicians must be able to support colleagues in understanding and then acting on any adverse feedback.

Positive Behaviours

Organisations and managers often seem to focus their efforts on the resolution of adverse behaviours, while paying little attention to the reinforcement of positive behaviours. Arguably, the reinforcement of positive behaviours is equally important as it promotes role modelling within the workplace. While positive feedback may be delivered through all the mechanisms described above, articulating positive feedback publicly is likely to lead to a copying of such behaviours by other members of the team. As a rule of thumb, a senior clinician should aim to publicly give three times as much positive feedback as negative feedback.

Summary

Behaviour is more important than personality in the workplace. Behaviour at work can be influenced, but personality cannot. If adverse behaviours are recognised it is important to resolve them. Positive behaviours should be publicly reinforced.

Personal Exercises

1 Access an online personality scoring questionnaire and complete it. The Myers–Briggs Type Indicator costs between US$39 and 109 and is available at http://www.myersbriggsreports.com/?gclid=CKnc5-DataoCFcFP4Qod2WMd5g. This includes a full report and a brief telephone discussion with a qualified interpreter. A more basic version is free at http://www.keirsey.com/sorter/instruments2.aspx?partid=0.

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