Courage in Healthcare: A Necessary Virtue or Warning Sign?

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Shibley Rahman & Rebecca Myers

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    Dedication

    Shibley Rahman would like to dedicate this book to his mother, Hasna.

    Rebecca Myers would like to dedicate this book to her father, Edward, who taught her to stand up and speak, and to her mother, Ann, who taught her to sit down and listen.

    About the Authors

    Dr Shibley Rahman is an academic physician by training, having graduated in medicine and completed his PhD at Cambridge University. He has a particular interest and specialises in wellbeing and long-term conditions. His other main focus includes employment rights and organisational culture, having completed his Master of Law and MBA both in London.

    Rebecca Myers has over 30 years experience of working in and with the NHS and is an experienced board-level director, coach, OD practitioner and clinician. She has designed, facilitated and led inter and intra organisational change and leadership programmes. She recently returned to part-time practice working in community nursing, and is currently lead facilitator of Schwartz Rounds in an acute hospital and an independent Organisational Development Specialist. Her management work has also included time within social services and the voluntary sector and her coaching career spans nearly 20 years having coached hundreds of clients including NHS Board members and senior leaders at the Department of Work and Pensions, Education and Voluntary Sector. She is a member of the British Psychological Society, The Royal College of Nursing, the Royal Society of Medicine and the Alzheimer’s Society and holds a BSc in Psychology (London), an MSc in Organisational Change (Ashridge) and postgraduate qualifications in Mentoring, Coaching and Group Dynamics (Tavistock).

    Acknowledgements

    Firstly, we should like to thank SAGE for taking on this project, which, we feel, is an important topic for all those working in or using health and social care services.

    We are both grateful for the substantial support received from the editorial and production staff at SAGE, and their guidance at several points during the process. We are especially grateful to anonymous reviewers who provided constructive feedback on the original proposal and the subsequent advice from those whose work we admire, including Jenny Rogers and Valerie Illes.

    With this title, we also benefited enormously from the many people who made contributions directly or indirectly through the stories they shared with us, the research they have conducted on the subject or the examples they have shown us in our personal and professional lives. The names and details in the specific case studies have been changed to protect the anonymity of those involved. They are just some examples of the courageous work that takes place every day in social care and the National Health Service.

    Publisher’s Acknowledgements

    On behalf of the authors, SAGE would like to thank the academic lecturers who reviewed the content of the book, helping to shape and influence it for the better.

    • Adriana Arcia, Columbia University
    • Peter Ellis, Independent Nursing and Health Care Consultant, Writer and Educator
    • Benny Goodman, University of Plymouth
    • Lisa Jennison, University of Hull
    • Daniel Kelly, Cardiff University
    • Fiona Timmins, Trinity College Dublin
    • Roger Watson, University of Hull

    Introduction

    Success is not final, failure is not fatal: it is the courage to continue that counts.

    Winston Churchill

    In the week where we finally delivered this manuscript to our publishers, the unveiling of a statue of suffragist Millicent Fawcett, an important figure in the votes for women campaign, had just taken place in Parliament Square. She was sculpted holding a banner with the words, ‘Courage speaks to courage everywhere’.1

    Delivering good healthcare demands both rational and emotional work, and it is this emotional work that requires courage of those involved. Courage is both contextual and a highly personal phenomenon. For example, at the point of submission of this book, one of the authors does not know how soon it will be before his own mother passes away, or whether an operation to clear bleeding in one of his eyes will allow restoration of sight ever again.

    The idea for this book came about after the authors had written a blogpost, asking the question, ‘Are we contributing to a culture of fear?’ Recognising that what gets talked about gets attention, the authors wanted to get people to think about how every day, across the work of those in health and social care, everyone – be they leaders, politicians, staff, patients or ‘service users’ – is pursuing difficult ‘life’ and ‘work’ narratives that require them to draw on their emotional and moral courage. The junior doctor in the emergency department who has to tell a relative that the urgent scan shows there is widespread cancer; the medical secretary who takes the call from the husband and tells them their wife has committed suicide following their diagnosis; the patient who is told they have a degenerative illness which will threaten their whole identity and have profound impact on their role as the main earner in the family; the middle manager who has to tell the surgeon she cannot operate as there are no beds.

    All of these situations require courage and people to be supported in doing this work. Yet, we hear people say that staff need to have courage to speak up when they have concerns or admit they have made a mistake. Patients talk of the fear of making a complaint in case of eliciting a punitive response. We believe that this should not require courage and if it does, it tells us that the culture and relationships in which this courage is required are dysfunctional and need attention. It is striking that, in the limited literature which exists on courage, the emphasis has been on the individual rather than the wider environment.

    We know that it is in this second area that courage gets the most attention.

    The main observation is that the call for courage can have both negative and positive outcomes. It can be beneficial for enabling therapeutic relationships and diverse aspects such as wellbeing and innovation, but it can be a negative experience even if there are benefits ‘against the odds’ such as in whistleblowing.

    We wanted to explore with the reader the everyday courage in the work of healthcare so that it gets recognised, valued and nurtured, and to look at how the current experience of overcoming fear to question and challenge the ‘system’ can be changed to a more positive one where questioning and pointing out risks is ‘just the way things get done around here.

    We have divided the book into separate chapters but want to emphasise that these issues are all connected and it is only by looking at things in their entirety that we understand the true complexity of why healthcare requires the courage of all who are involved in it.

    We have tried to write in a way to get you to think about the subject but also the role that you do and could play in creating the conditions for courage when needed to flourish, whilst removing the need for it when it should not be required.

    In the end, all of us contribute to the circumstances we encounter, and it is in recognising that, that we can draw on our power and influence to make a positive difference together.

    About this book

    This book looks at courage in healthcare from various points of view of the people involved, ranging from politicians to professionals, manager or leader, to patient or service user. The book is not intended to be an all-inclusive, complete analysis of courage, but is intended as a launchpad for us all to respond to the sensitive issues which courage often ensnares. We have deliberately tried to emphasise that these issues do not belong to ‘silos’ of particular people, but cut through a range of different experiences. In our attempt to combine the research in this area with the everyday practices and experiences of healthcare, there are aspects of this book you might find highly technocratic, but others which you find highly personal too.

    Chapter 1 – What is courage?

    As individuals, ‘courage’ as a cognitive and behavioural characteristic involves both a response from the mind and body, and the cognitive processes of decision making in the face of risk and uncertainty whilst perceiving fear. Courage in individuals can contribute to courage in organisations, but the context of this is all-important. Courage notably can be intimately linked with other traits such as compassion or resilience. This chapter will look at the neurocognitive processes of courage, but will also look at how courage, whilst called for in NHS policy,2 can be linked all the way back to the philosophies of Plato and Aristotle. But a major gap in our understanding is how whole systems determine the manifestations of individual courage, and this gap will unfortunately manifest itself throughout the book.

    Chapter 2 – Courage to care

    Courage to care and courage in being a carer are quite profoundly different things. This chapter is about the ‘courage to care’. Health and social care professionals are subject to constraints in time and finances, which may compromise their ability to care, and these can also be pertinent for unpaid family carers.

    To care for another requires you to become emotionally involved. Being emotionally involved can mean you are vulnerable and get hurt and this is why it takes courage to care. However, if you believe that a central tenet of care is not just what you do to someone but caring about them as a fellow human being, it is impossible not to get involved.

    Chapter 3 – Courage to lead

    Courage is also critical to people who run the NHS and social services. Lessons can be drawn from the leadership styles of people who have brought about and exhibited great courage, bringing widespread change, such as Gandhi or Martin Luther King. But courage to lead doesn’t have to be of the charismatic variety, but could simply be transformative or technocratic in approach in achieving healthcare targets. It could be possible to ‘measure’ courage one day, to solidify it as a desirable characteristic.

    By the nature of the work, healthcare requires difficult decisions to be made. Stepping forward to lead in any scenario, whether as the domestic on the ward to offer a suggestion on how to do something different, or the decision of a politician to invest in some services at the expense of others, can be difficult. When these decisions are filled with difficult emotions such as fear of getting it wrong, distress at the impact it will have, or upset, leading requires courage.

    Chapter 4 – Courage to live and die

    Courage can be extremely personal too. Courage historically has been couched in the language of adversarial combat, and this runs in parallel with media messaging about conditions such as cancer or dementia. This chapter will consider whether it is appropriate to consider cancer or dementia as a ‘fight’ – in that there are some cancers, for example, where complete remission is a possibility. The alternative will be considered where rehabilitation with a long-term condition is positively promoted. The chapter will conclude with personal reflections on coping with potential death. While anything can happen to anyone at any time, the preparation for death is important, for example, in palliative approaches; and has implications for individual reactions to life-changing illnesses and the lives of close carers.

    Chapter 5 – Courage to challenge

    The CIPD defines someone as having ‘the courage to challenge’ as someone who ‘shows courage and confidence to speak up skilfully, challenging others even when confronted with resistance or unfamiliar circumstances’.3 This chapter has as its focus an extreme form of such a challenge – colloquially called ‘whistleblowing’. The term ‘blow the whistle’ has long been felt to be a strong phraseology for the courage to speak up against negative work cultures where things have gone wrong. Problems have still remained pursuant to the Public Interest Disclosure Act (1998) which is supposed to protect public sector employees. And yet speaking up courageously is often needed to promote patient safety, a key duty of all registrants in healthcare. This chapter will describe the individual experiences of people who have spoken out against the system, including misdiagnosis of important conditions, criticising poor clinical care and speaking out against child abuse. A more helpful way of framing these sensitive issues might therefore be a ‘courage to challenge’, in a way that promotes teamwork and conflict resolution. Unfortunately, too often people who speak out find themselves emotionally and intellectually ‘burnt out’, and the chapter will consider the pivotal need to protect staff wellbeing too. The chapter will consider why the narrative is framed so much in an adversarial way, and how possible ways forward could mean that it is easier to have courage to speak out in future.

    Chapter 6 – Courage to flourish

    The chapter will consider how a more substantial re-thinking about healthcare systems might be needed, such as a less retributive approach to healthcare regulation and a more inclusive way of organising and providing healthcare that opens it up to more diverse views on what is happening and why, in order to promote organisational development and learning. We will try to bring together some of the themes which have emerged in our discussion of courage in this book. Fundamental to thinking about how courage can ‘flourish’ is the answer to the question: Under what professional, personal and environmental conditions should someone need to show courage and when does the need for courage suggest there is a problem?

    A final note

    Writing this book has not been without its own challenges. For one of the authors trying to care for his mother as her needs accumulate, whilst juggling personal physical health issues, has required huge courage to keep going. Finding a way to write together from very different backgrounds and experiences and accepting we disagree about different aspects of the work have created the courage to be honest with each other about our different interpretations of events. We have also negotiated the balance of the academic literature on this subject with the day-to-day reality of working in the NHS.

    We hope that you find some of the topics which we discuss interesting and relevant to your views, research or form of practice, and will motivate you to think about possible avenues for further exploration in this important area.

  • Final Thoughts

    We believe that courage takes place in a relational context and is actually a function of an individual, group or wider systemic environment.

    Courage is, of course, at the risk of a paralysis by analysis, even from simply defining it. This book has tried not to settle on a definitive definition of courage, though it appears to us that courage is a quality needed by professionals and patients alike when facing situations that leave us feeling vulnerable and fearful and in navigating the emotional tenacity effective healthcare can require. Intuitively, it seems that all clinicians, practitioners, patients and service users, need some courage, but the question of the need for courage in healthcare becomes much subtler and more complex the more you look at the nature of courage in healthcare.

    Is the need for courage inevitable to practise medicine and provide healthcare? We would argue, Yes.

    Should we accept the ever-present need for courage in challenging each other and the ‘system’ when seeking to improve the conditions for those using the healthcare system and those working in it? We would argue, No.

    Is courage in healthcare a necessary virtue or a warning sign?

    Thank you.

    Shibley Rahman and Rebecca MyersLondon, April 2018

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