Listening to the footballer Michael Owen on breakfast TV recently was fascinating.
He's always been highly competitive not least with himself. He spoke of his struggles to deal with the psychology of getting older and not being the man he once was.
As a footballer, this was due to his body no longer being able to do what it could and consequent injuries. He had to admit he couldn't outsprint the younger guys. His stamina was not what it was, and his joints and muscles were letting him down.
He told of the reaction from one of his famous senior colleagues accusing him of being idle, overpaid and lazy. The guy used to be a friend but when the going got tough…perhaps not so much a friend.
How do we deal with the passing of years? Can we accept our ageing?
A few years ago, the realisation that my once perfect vision was deteriorating hit me hard. I hid the fact for a while because I thought it would stop my flying career. I needed glasses! The point I was having double vision when tired was a requirement for a prism and not that unusual! Then along came the heart condition – turned out to be a wiring problem solved by a pacemaker! Even retained my private pilots' licence through all this.
But underpinning it was a fundamental undermining of my self-confidence. A denial that I was mortal. You see, I'd barely been ill in my charmed life. Case of flu, bitten by an African tick one time in the Kruger Park in South Africa (moral – don't walk through long grass with shorts on!), chickenpox as a kid, but nothing serious.
You see, both my parents died comparatively young by today's standards. Father at 66 from a heart attack having had a stroke a couple of years before. Mother the next year from a recurrence of cancer aged but 61. I'm well beyond those years already. Suddenly I didn't feel like superman.
I've just been to the fabulous English Lake District again. Managed plenty of good walking and climbing and I'm reasonably fit for my age. But probably time to admit I won't scale Scafell Pike again. I could do it I'm sure, but don't kid myself. Coming to terms with that can be a struggle for some of us to accept. Michael Owen has had to face it at a much younger age – he isn't even 40 yet!
Generally, as we age, we gain more experience and knowledge and, to some extent, skills improve. However, there comes the point when our dexterity begins to wane. Also, perhaps some of those riskier things we used to enjoy are replaced by a more considered approach. I have become a slower (fractionally), more considerate driver, albeit still way above average of course!
With passing years, sometimes the air of authority grows, although of course, we are highly approachable. But in colleagues' minds, there may be a tendency to trust, possibly too much? "Don't worry about Trev, he's been doing this for years, he knows what he's doing …"!
Life is competitive. We need that balance of confidence without arrogance that I've mentioned before. "I'm not difficult to approach, I'm just damn good at my job, the best in fact."
Where is this going? Well, it's made me wonder about some of the problematic behaviours I see and hear about – in healthcare. Three times recently, I've been asked to come and help organisations where they are experiencing uncivil behaviour. In particular, in each case, with tutors of junior doctors.
Just because we experienced abuse when we were young ourselves does, in no way, excuse us doing the same. Although that is exactly what I heard from a foreign female doctor tutor last week.
I will return to this theme in a future blog. But in the short term, perhaps look in the mirror.
How do senior medics cope with getting older? What's the famous old saying? Physician heal thyself!
Listening to the footballer Michael Owen on breakfast TV recently was fascinating.
Often we get commissioned to train front-line teams because an error has been made.
After all, they were probably the ones involved at the 'sharp end'. How, though do the managers behave? In fact, what defines effective management culture?
To become even more specific, what is the relationship between managers and staff at all levels?
I've written before about organisation culture and who sets it. The Board will think they do, but in reality, it is the middle and senior management, and even team leaders, who deliver the actual version.
Erik Hollnagel refers to Safety 1 and Safety 2.
Safety 1, as I'm sure you're aware, is essentially backwards-looking. In effect, waiting for the next problem and dealing with the fallout.
Safety 2 is forward-looking, as in proactively looking for future issues and trying to head them off.
To achieve this, you need an empathic approach, one that seeks to understand, not what someone has done, so much as why it seemed like the correct action when hindsight might have proved it in error.
I argue that to behave in this manner, managers up to the top need to comprehend what these Human Factors are; how they affect good people trying to do a complex job under frequently very challenging conditions.
Any organisation I work with, I ask the staff if they know or have met their Chief Executive and Board. Guess what? In struggling organisations, the answer is normally along the lines of "well I've seen their picture" or "I've been at a meeting where we've been lectured at and told off".
An interesting example was a little while ago where I asked a roomful of senior leaders, in front of their Chief Exec, whether they worked in a learning or blame culture. Quick as a flash, the CEO said, "This is not a blame culture!"
However, one of the clinical leads was waving their hand and when prompted said, "This is absolutely a blame culture, and I and all my colleagues are practising defensive medicine because we don't feel safe!"
So let's look forward in Safety 2 fashion. What does it take?
One of our long term clients that have long since implemented a turnaround in culture, and saved thousands of pounds in the process, started by getting us along to talk to the Board. We were given just 30 minutes to enlighten them! Oh boy.
The words Human Factors came up at every subsequent Board meeting, and suddenly they fell in that they didn't know enough.
We were invited back to give them a short training course on what affects peoples' abilities to work safely and effectively. Things like:
- Allow them to be human – give them adequate breaks and resources.
- Examine processes – do they work? Or do you get workarounds because they are not fit for purpose?
- Are equipment and training given so that it is easier to get it right than get it wrong?
- Have they and their managers had some form of training in understanding these issues and the effect on performance?
- Are they treated with empathy and understanding or needless, useless blame?
Sadly many of our clients come to us with the problems.
Often the CQC have told them off because of failings in performance or harm.
This is not difficult. It is no big secret that the way to get high performance is to look after and respect your workforce. Again a part of Hollnagel's Safety 2.
I ask people do they feel like a resource or a liability, a risk?
None of us is immune from error. We don't do it on purpose.
To paraphrase Sidney Dekker from his book 'Just Culture', don't resort to blame but try to understand why somebody thought the action they took was the correct thing to do. Ask why it made sense to them at the time.
Do this, and you will see…
- a reduction in staff absence through sickness
- better staff retention
- more people applying for jobs
- fewer incidents
- reduced spend on compensation
You know it makes sense!
Contact us for a chat about how we can help move your organisation to Safety 2.
Widely reported in the news recently was the story of a gentleman who went into the hospital for a routine bladder procedure and left having received a circumcision.
70-year-old Terry Brazier was awarded £20,000 in compensation following the "never event" at Leicester Royal Infirmary last summer. The hospital said it was "deeply and genuinely sorry".
The news story shows that never events continue to happen. In my experience, there are as many of these incidents occurring today as there were before the focus on never events started within the healthcare sector.
Receiving a circumcision instead of a Botox injection into your bladder is, I suppose, unfortunate and distressing. But think of what else could have happened.
We know of one case where a young patient was supposed to have scar tissue removal on his scrotum but received a vasectomy instead. This mistake was truly devastating for the young man, and impossible to reverse in this instance. The surgical team also suffered immense distress when they realized and that is a subject for another day.
It makes you wonder how these never events come about. Surgeons don't purposely set out to operate on the wrong side or to carry out the incorrect procedure. But these never events are not diminishing statistically, despite apparent safeguards put in place to protect against them. And I find that extremely alarming.
One of the things we find, when asked to go into a hospital and try to help prevent further incidents and rebuild morale, in the wake of an avoidance harm incident, is that interruptions and distractions often feature.
Last year, I was training and coaching in a surgical unit, when I was called into the neighbouring theatre which had just experienced their own never event. It was a wrong side nerve block, thankfully resulting in no devastating harm, but certainly with the potential to cause real damage to the patient. Distraction was a factor there. The anaesthetist and assistant had been chatting about their respective weekend social life. That was just after they had completed the mandatory 'Stop before you Block' check.
A good friend of mine, a senior Emergency Department Consultant told me the biggest safety threat of all is managing your environment, both externally (interruptions) and internally (self distractions). Just not thinking or concentrating.
In the aviation profession, we follow the 10,000ft rule. When flying commercial airliners, anytime you're operating below 10,000ft above the ground, you enter a social lockdown mode. There's no discussing your next round of golf, or your plans for the weekend. We call it the 'sterile flight-deck'. It equates roughly to the first and last 10 minutes of the average commercial flight but as you descend below 10,000 feet altitude is a mandatory safety check so we combine the two at that convenient moment.
There are times and places for social chit-chat. There are times and places for focusing on the task at hand.
When pilots aren't concentrating on flying the plane, that's when things tend to go wrong. It could be something relatively harmless like a bit of speeding (!), or it could be more severe like flying too close to another aircraft, or a hill, or radio mast.
It's positive to see some hospitals now introducing their own 10,000ft rule. The team are advised of the threats to safety at the briefing stage and reminded to make the safety call. Someone in the team says "10,000ft", and everyone goes silent. There are no interruptions, no distractions, focus. They could also be briefed to announce any concerns that they might notice and ensure a response – think of the 'Gorilla' video! Attention mechanism etc.
When you reach the crucial part of the procedure, the part where things have the potential to go wrong, that's when the 10,000ft rule is activated. You don't allow anyone else to enter the room and phones are switched to silent.
In the case of the gentleman receiving the circumcision, the compensation payout and negative PR can help focus attention on the causes and prevent them from happening again. A lot depends on how embarrassing the never event is for the hospital in question.
There are never any winners when there is avoidable harm. But I'm still not sure that everyone in healthcare takes never events as seriously as they should.
How many of us consider ourselves to be better than average drivers? 78% of people on the roads think they are better than average. If you've got a mathematical bent, work that one out!
But what's the biggest killer on the roads? Probably complacency.
There's a great quote by Captain E J Smith, the captain of RMS Titanic. "I never saw a wreck and never have been wrecked nor was I in any predicament that threatened to end in disaster of any sort." Now does that ring any bells?
The number of times we meet people - and I've been doing this job for 30 years - and they tell me they don't need a checklist, or they don't need to change their approach. That's complacency at work.
It's almost like famous last words. We witness this a lot, where people kick back and say, "Why do I need a checklist? Why do I need to do briefings?" But when you look back at the root cause analysis of incidents, did everyone involved know what was going on?
That leads us to consider the whole idea about naturalistic decision making and pattern matching, with most decisions made during the day taking place without really thinking. We make decisions about what to wear or what to eat, without much thought at all. The same goes for walking, breathing, eating; doing the vast majority of things everyday. OK I accept the more stylish of you do think about what you're going to wear, but look around you. Plenty don't!
There's a bit of a danger in healthcare, where people have been told they should be so good at their job, that they can do it without thinking. In that respect, human factors concepts become heresy. Because what we're suggesting is that, you should always engage your brain and not make assumptions.
May I suggest that the high-performing professional is always thinking, "Is there something here which tells me I could be wrong?" Is there a contrary indication?
In over words, we need to look to overcome confirmation bias; the belief that, once we've made a subconscious decision, we're right. Humans tend to disregard anything that doesn't fit that initial pattern matching, our naturalistic decision making. It goes a long way to explain why complacency is such a factor because we're all sure that we're right.
I recently experienced complacency at work in an operating theatre. There was a change in the order of the list, with a patient elevated to the front of the queue because they were in greater need of surgery.
But instead of rubbing out the names on the whiteboard, the theatre team just reversed the order of the numbers listed alongside the names. It was worse than that, in fact; rather than erasing and rewriting the numbers, they added the revised order of numbers in a different colour.
As I watched this take place, I thought, "Why wouldn't you just rub out the numbers so there is no chance the order can be confused?"
Next time you come across someone who seems unduly pedantic and almost obsessive on checking everything. I almost guarantee that they'll be someone who found out the hard way and they really don't want to go there again.
Where does complacency play a role in your professional life, and what steps can you take to stamp it out?
Have you ever ticked a box on a checklist, without carrying out the check?
Worryingly, this is part of the culture in some of the hospitals we visit, where we often hear about people ticking boxes on checklists, despite the item patently not being checked.
We know the item wasn't checked, because there's been a subsequent fault, like a retained swab despite the checklist claiming all of the instruments were counted at the end of the procedure.
The boxes are all ticked, yet there's been an error. So, how the heck can that happen?
To counter this issue, I will show medical professionals examples of the checklists we use in aviation, the majority of which have no tick boxes.
As pilots, we don't tick boxes. Instead, we make it a matter of personal and professional discipline that you do the check.
If you are interrupted during the check, you start it again. In other words, it's not about ticking the box.
Aviation also has standardised responses that are pertinent to the item. Such as...
"Flaps?" response - "checked and set 20, green light on"
"Landing Gear?" response – "down and three green lights"
Note none of the responses are "yup" or "OK".
So maybe "antibiotics?" response - "administered (and state which one)"
"Surgical site marking?" response – "seen and cross-checked with consent and operating list"
There's an important question here for managers; how do you audit the correction completion of a checklist?
Do you just go and count the ticks and boxes? Are they aware they're being audited? Do your people get in trouble if a box isn't ticked?
I think this is about understanding the purpose of checklists; what they are for and for what they are not.
Are they a 'read and do checklist, for example, check the patient's name and date of birth, and then actually do it? Or are they a 'challenge, response' checklist? "Yep, I've already checked the patient's name and consent, or date of birth."
It's about understanding the purpose of the checklist, how to use them correctly, and how not to use them.
There's a scene in the movie Sully, where the co-pilot works through an emergency checklist, following a catastrophic bird strike on both engines. The co-pilot works through this checklist with Captain Sullenberger, despite familiarity with the various steps to take.
Despite what would have been memory items, they take out the checklist, and they work through it together. When you're in a hurry, with a life-threatening incident taking place, you use a list to ensure your memory hasn't let you down.
Earlier this year, I watched a senior nurse in theatre proudly complete the timeout check from memory. We had already spoken about the check and how it wasn't about the ability to recall the items from memory. Despite that conversation, he immediately slipped back into his usual way of doing it.
What was particularly interesting was, of course, he forgot something on the checklist. A consultant surgeon picked him on the missing checklist item.
This experience made the point beautifully that our memories are fallible. The use of checklists is not about how clever you are.
Being professional is about doing something the right way, every time, such that it's the way you do it when you need it the most. That one time when your luck runs out.
The nurse that checked me into a private hospital for the procedure told me my name; "Hello, it's Mr Trevor Dale, isn't it?".
She proceeded to tell me my date of birth too, and what I was scheduled to have done that day.
After confirming "yes" to all of her questions, I asked her to start again and ask me my name instead of telling me my name, as she was supposed to. She responded with "yes I know I'm supposed to but …" Clearly, she didn't understand how dangerous that can be. How many times has the wrong answer been given because often patients don't like to cause upset' or they're merely stressed or ill and didn't hear correctly, or just didn't want to argue? The doctor knows best?
Many of you have had this particular issue where you've ended up with the wrong patient or made incorrect assumptions.
There's a funny story of a gynaecologist running a clinic in a part health care, part social care environment. She entered the waiting room and said, "Mrs Patel," and this woman said, "Yes." And she said, "Please would you come in and would you get undressed? I'm going to examine you."
The gynaecologist gave her patient a hysteroscopy and said, "Everything's fine. You'll be pleased to know no problem at all." And the lady said, "But I came here for housing benefit?"
And of course, it's the wrong, Mrs Patel. By the way three days later, a lawyers' letter arrived – invasive procedure without consent!
Over the years, I've met a lot of people in health care and social care who have experienced the same issue.
A consultant doctor recently told me he ended up telling a patient he had terminal liver cancer. It was only when he said to him, "Would you like to look at your scans with me?" that the patient told him he hadn't had any scans, and the doctor realised he had delivered such bad news to the wrong person.
Healthcare professionals are often embarrassed to ask their patients, "Could you tell me your name?".
I observed an ODP, a few years back, saying to a patient, "It is Mrs Jones, isn't it? Your date of birth is blah. And you're here to have your left knee operated on aren't you?"
Which is fine, but his colleague I went with separately said, "Now I know you're going to hear this 20 times today, Mrs Smith, but this is just for your safety, could you please tell me your name and your date of birth and what you think you're here for?" Which of these approaches do you believe is safer?
I observed another interesting one, only last week, where there was a chap who was very ill, with sepsis amongst other things and a kidney stone and multiple comorbidities. He was under heavy sedation at the time, and the ODP asked him, "Why are you here?" Of course, he didn't know and said as much in reply.
One of the ODPs asked the question in a much more effective way; "Do you know what's wrong with you?", to which the patient explained he had been told he had a kidney stone.
There's another case we know recently where a junior doctor went and consented a patient, said, "It's your right leg, isn't it?" Yes, here's an arrow on your leg. They got the consultant to countersign the consent.
The patient had dementia and didn't know if it was Christmas or Easter, let alone which leg it was. And of course, as luck would have it, it was the wrong leg.
Asking leading questions is part of human nature. It's a quick and easy approach, rather than what we prefer to see during a team briefing or safety huddle, which is "Does anyone have any concerns?"
So instead the lead says, "You're happy, aren't you?" It's closing the conversation down. People got to put a real effort in to ask a question or say they're not happy.
Whereas if you say to someone, "Do you have any concerns?", it opens up the conversation to the rest of the team.
Bearing in mind that some people are more reticent, and need to think things over and weigh up whether they're essential or not in their minds, then it's allowing them to speak up, especially if there's any level of hierarchy involved.
This issue of leading questions ties in with different nationalities and cultures experiencing different attitudes to people in authority, something identified by Hofstede's work on power-distance and nationality.
There was a Swedish lady on a course only last week, and she found all this stuff about deference to people in authority to be quite funny. And I said to her, "Do you know that the Swedes have the lowest inbuilt attitude to hierarchy of all the nationalities in the world?"
Her attitude in an open class discussion was precisely that as a Swede, and the Swedes do have a very flat hierarchy. And if anything, I think it can produce the reverse result, where they have difficulty showing appropriate respect to people in authority.
The consequences of asking leading questions can be pretty alarming, so please don't do it! Always ask open questions.
Being a pilot has been described as being 99% boredom and 1% sheer terror, but it is rarely both – honest! However, like healthcare, it is fundamentally about managing risk and therefore managing workload.
In the world of aviation, we have a magic word - "unable" for those rare occasions when we cannot comply with, for instance, air traffic control instructions.
If air traffic control instructs the pilot to turn left, or climb, or descend, and for any reason, the pilot can't do it (for a technical or weather-related reason, for example), then the pilot will say "unable".
If you've watched the movie 'Sully' the miracle on the Hudson, you might remember Captain Chesley "Sully" Sullenberger using the magic word "unable" when requested to turn to Teterboro airport. He uses the magic word, and nobody questions it.
Here at Atrainability, we've been introducing this Magic or Safeword concept to healthcare for some time. Critical teams could usefully have a magic word in place so that they can communicate effectively during procedures.
Of course, there needs to be a degree of sensitivity in choosing this magic word. It might upset a conscious patient to hear "Gorilla on the loose" or similar.
Some teams use the phrase "stop the line." This approach comes from the Toyota production line, where any member of staff is empowered to halt production if they see someone unsafe, inefficient, or ineffective taking place.
Some are using "10,000 feet", a reference to the other much-used aviation phrase that signifies no distraction or interruption for the time being. It comes from standard practice when commercial planes are near the ground – below 10,000 feet altitude. That's roughly the first and last 10 minutes of a typical flight.
We have the evidence from countless 'black boxes' that you're more likely to have an incident when not focused on the job in hand. In aviation, either enjoying the view "ooh look there's my house!" or discussing something inconsequential.
But "stop the line" or "10,000 feet" can be quite cumbersome and perhaps a little imported. It's preferable, I believe, for teams to devise their magic word.
There's a surgeon I know in one NHS hospital, as part of his daily team briefing, he asks what magic word they will use that day. That's a great approach to get teams to engage with magic word principle, but of course, if members of the group switch over during the day, it can be potentially problematic if someone new doesn't know the magic word of the day.
Some hospitals have a magic word at an organisational level. But that could feel like it's being imposed upon them. There's so much in healthcare where people need their independence, for their motivation and empowerment.
What matters is that every member of the team should feel able to stop what is taking place if they think anything is unsafe, or something needs to be clarified. They might say "unable" or "stop".
My wife and I have a magic phrase in case of emergency.
During a recent holiday, she said to me, "Trevor, I need you to help me!" She had caught her finger in a sunbed, causing a nasty injury and lots of blood when it was released. By saying, "need!", there was no doubt she need help Now. No confusion, no uncertainty.
Clarity is so important.
When you're piloting a plane and taking off or landing, your focus is quite reasonably ahead of you, so you're not making eye contact with your colleagues on the flight deck. Naturally, that means you can't detect non-verbal language like shifting in your seat with concern, as we would in ordinary life.
The same could apply if masked and gowned in a complicated or stressful clinical procedure.
When you use a Magic or Safeword, it's essential its use doesn't result in resentment from colleagues. We've got some way to go within the healthcare profession to understand this. Some cultures find it harder than others to accept the use of a magic word without associating it with disrespect or failure to follow a hierarchical structure.
So, to summarise, have you ever experienced a situation where someone either didn't speak up and challenge or wasn't heard or was misunderstood. With hindsight would a Magic or Safeword possibly have helped? I know some of you have got this already. Please spread the word!
I spent some time in a major NHS Trust the other week, delivering two days of training at a large hospital.
The training involved very senior management, and I took the opportunity to mention the recurring incident which involves two syringes of colourless medicines being mixed up on the scrub tray.
I asked the senior management in the room, "So how do you do it here? Do you colour code the syringes, barcode them, or add labels?"
A senior nurse in the room spoke up, explaining she put Steristrips on each syringe and writes onto these. But there's no standard hospital protocol, designed to prevent the potentially severe mix-up from happening.
Sitting in the corner was the senior manager responsible for all elective surgery in this hospital. She sat there with her mouth open, realising there was no guideline in place designed to avoid or trap an easily preventable mistake.
I had an email exchange with her the following morning, and she confirmed she had a team working on the problem straight away.
What if I hadn't delivered training at that hospital? What if she hadn't attended the course that day?
Sharing best practice and national standards are sadly sorely lacking in the medical profession.
We're aware of another hospital, where recently an anaesthetist told me she administered a child with Adrenaline, not Fentanyl. This is important because Fentanyl is an opioid, slowing the heart rate. Adrenaline speeds it up.
Following the medication mix-up, the team were questioning why the child had become tachycardic, thinking something must have been seriously wrong with him. Only on return to the anaesthetic prep-room was the mix-up noticed.
Probable cause? Working with a new ODP, who drew up the drugs in an unfamiliar way and cross-checking was secondary to social team building.
Sharing best practice is so important. It is a shame that there is rarely time for medical professionals to spend a little time down the road with their colleagues at other hospitals, learning from the way they do things.
You attend a conference, and someone will often share best practice. But they tend to talk about their own hot topic, their specialist research area. It becomes hit and miss whether you attend relevant sessions.
There are locations around the country, and indeed around the world, that have solved significant issues. But sadly all too often others don't know about it.
This reminds me of the famous Donald Rumsfeld statement, about the 'known knowns' and 'unknown unknowns'.
Working out your unknown unknowns by sharing best practice between different teams is a really valuable but arguably essential step.
I was delivering some training recently at a hospital which was using the latest version of Datix, the instant reporting system. They have the newest release in place, which allows you to report no-harm, near-miss incidents; something the old system would not let you do. We checked the drop-down menus together and confirmed this capability was included.
During a quiet moment later that day with the senior management, I asked about their near miss reporting. They gave me a puzzled look, and asked what I meant by near miss?
When I explained what I meant, they told me they didn't do that. This prompted a conversation about how near misses are the luck element that results in not harming patients.
It became clear that the management at this hospital had not thought of near-miss reporting in this way before. They were bright people and very nice people, very well-intentioned, but it just hadn't occurred to them.
What it seems we often do at Atrainability is point out the obvious.
By getting members of critical teams to think about those danger areas they already know about, and they need to be proactively addressing, it helps them recognise the tip of the iceberg.
These are the dangers sitting right in front of us. But the real threat is submerged below the surface. When no harm is done, there are no visible means of damage caused.
Analysing near misses comes back to root cause analysis. There will probably be several underlying conditions at play.
For example, if you have a nurse who is going to be scrubbing with a surgeon, who has never carried out that procedure before, compared with a nurse who has. The nurse who has carried it out before is likely to know what the surgeon needs next before they even ask for it.
In that scenario, it's important to know before you get started whether your colleague knows what they are doing, or not, because in one case it's going to be a bit longer, and require a lot more communication.
From my background as a pilot, a mandatory reportable incident is anything which had the potential to cause harm. It's all about that word, potential.
Where potential to cause harm is identified in the medical profession, it's essential those near misses are analysed and understood, before changes are introduced to reduce that potential in the future.
The hiatus was because the last time I flew I didn't do it well.
The weather, a year ago, had been admittedly not great, gusty and bumpy, and I didn't handle it well and the consequence was my inner confidence was damaged.
Yesterday the weather was perfect. No clouds and almost no wind with excellent visibility.
Flying light aircraft is quite high risk. Only one engine is not nearly enough!
Fresh in my mind yesterday was the picture of the burning crashed aircraft splattered across the M4 in South Wales. They all survived. Phew.
The instructor instils confidence. He used to fly and instruct on Concorde. Knows a thing or two and particularly how to rebuild confidence.
I've been flying solo since 1967 close to 52 years but that balance between confidence and arrogance is a very thin line.
But there's other stuff in play here.
I fly with a small flying club. Their insurance dictates I need to do three landings in 90 days to be qualified.
The National regulator – the CAA – requires that I fly with an instructor once a year and fly 12 hours in the next 12 months.
Oh, and I need to pass a basic medical too. Last week I flew across country, just a few minutes to get used to handling again, then flew several circuits and landings including two non-normal ones.
One was without landing flaps – practising in case they fail one day and another simulating engine failure. The instructor checks I can do it but also it builds my confidence.
Some of those I meet who criticise the comparison between aviation and medicine would do well to consider all that.
The other main message which fits anywhere – always have a plan B.
Like knowing I could cope with a mechanical malfunction or weather-related problems.
Much as I love flying the one thing I always do is consider what could go wrong and try to be one step ahead. I don't always succeed of course and that's when I get worried.
No, it's not paranoia it's experience and good training.
Instead of thinking only about culture, it's important to consider the climate too. That we can influence.
Culture is probably something stemming from the organisation. But climate, that's what's happening here in this room, right now.
You can influence climate at the start of the day, for example, by whether or not you smile and make eye contact.
Climate is affected by whether or not you take an interest in others not just yourself. Effective leaders are like actors. They think before they enter a room and focus on what matters not on themselves alone. A smile is the simplest act.
Icebreakers affect climate. They might not affect culture, at least in the short-term, but they can and do change the climate. That's why basic politeness and making sure everyone knows everyone's names is so crucial. It should also set an appropriate hierarchy gradient.
I recently spent some time working with critical teams in an NHS hospital north of London.
They had been working with an interim unit manager, and I was told this individual had some perfectly valid ideas. But the way they presented their ideas was very aggressive, very authoritarian, and managed to destroy morale in the team.
Everyone was left feeling hacked off. The effect was palpable.
A new manager, above this theatre manager in the hierarchy of the hospital, was appointed and got straight to work doing what I thought was an excellent thing.
First of all, they asked the clinicians and staff what they thought. They had also heard from the chief executive that members of the team were unimpressed, but they took the time to speak to individuals to understand their views.
I heard from someone else that this approach gave the new manager tremendous credibility. Engaging like this with the front-line staff, while not entirely unheard of within the NHS, is it seems , all too rare, particularly of course in dysfunctional areas.
And the front line staff all told the new manager, "We're finding it impossible to work with this manager. They've made life here very unpleasant." The services of the team manager were swiftly dispensed with.
Fortunately, they were agency staff, so this process was straightforward, and the individual responsible for the negative climate was dismissed within a couple of days. It's at this point they asked Atrainability to come in, to work on a rebuild.
It was a very pleasurable experience because there was nothing wrong with the people themselves. They weren't in any trouble for making frequent mistakes, so our role was very much to emphasise the positives.
On that note, a small but very positive thing happened while I was there.
I asked, "What makes your day go so well here?". A couple of people in this room of 30 pointed to their new theatre manager, and said, "You know, Bill has made such a difference. He's so good to work with."
I had just been talking about the difficulty people experience in accepting praise, and of course, Bill turned to them and said, "No, no, no. It's not me; it's you!", the typical response we expect to see from those who struggle to accept praise.
I didn't say a word at that point, because it could have caused Bill some embarrassment but then when we broke for tea this happened: Bill asked if he could say something to the room.
Bill turned to his colleagues and said, "I've just done exactly what Trevor said. I shrugged off your praise. What an example! I just want to say to everyone; thank you so much for saying nice things about me."
It was a fantastic learning point; unscripted, but he had just gained another level of self-awareness.
Everyone in the room appreciated it because they saw a real-world demonstration taking place right in front of them. And we all had a really good laugh, with an immediate positive change taking place to the climate in that room.
It just shows what happens when you emphasise the obvious.
This is the reinforcing that leaders of critical teams need to carry out. They need to accept praise too, and then react accordingly, being a role model for their teams.
Remember, you can have a personal impact on the climate, every day.
Inappropriate and unprofessional behaviour is cited as a problem area across many professions, and health and social care is no exception.
There are two significant aspects to consider – why do people behave inappropriately and what effect does it have?
Taking the first of those it could be just plain awkwardness in that they can get away with it, or perhaps they think it's harmless and just a stress-relief and fine if they apologise.
Could it be a lack of insight?
Shortage of emotional intelligence could be present perhaps because no one has ever told them?
Alternatively, it could be a result of illness or stress.
We know of one older person whose behaviour changed for the worse and ultimately it transpired they were suffering from an aggressive form of cancer.
The evidence is of course crucial. The excellent work of Christine Porath demonstrates the devastating damage done to performance and motivation.
Cognitive function diminishes by over 60%, and almost 40% of people on the receiving end of bullying intentionally reduce their performance.
There is however another aspect – could I be part of the problem?
Is my behaviour winding you up? That is, for some of us, a tough question.
The Atrainability training works through the root causes and helps delegates to consider their contribution either directly considering more effective behaviour or by not helping 'difficult' colleagues adapt their behaviour.
For managers, perhaps the realisation that they need to deal with the inappropriate and unprofessional behaviour is the critical message.
Learning from excellence through the practice of debriefing is a hot topic in healthcare teams. We hear this being referred to as appreciative inquiry; a model that seeks to engage stakeholders in self-determined change.
The model assumes that the questions we ask tend to focus our attention in a particular direction.
Organisations then evolve in the direction of the questions most persistently and passionately asked.
I'll often ask the healthcare professionals who attend our training courses whether they have a chat at the end of the day about how things went? "Yes, of course, we do."
But do you have this conversation in any real detail? "No, not really".
You would, we hope, if things have not gone well but how often is that? Maybe 1% of the time?
So, we don't really discuss the 99% of times when things go well. What effect does that have on morale?
At Atrainability we recommend three simple questions:
-Is there one thing that I or we do well?
-How about one thing I or we could do more of?
-Or maybe one thing I or we could do less of?
The crucial word is of course 'could'. Not 'ought' or 'should' because that is telling someone how to behave and no-one likes that. 'Could' makes it a suggestion, a nudge, if you will. Not a command.
Adult to adult conversation in practice. Thoughts offered with honesty and accepted with humility.
Naturally, people generally debrief if thing went wrong. This is good practice, far better than the alternative of sweeping the error under the rug.
But how often does it go wrong, rather than right? If we assume things go right 99% of the time, then most of the time these conversations, and any appreciative inquiry, are rarely taking place.
We want to be having these conversations. "It was really great when you pointed that out and said I was wrong. Do that again, please."
This is about reinforcing positives, which people don't do often enough.
Another challenge, especially within the healthcare profession, is that people don't accept praise. They shrug it off. "I was only doing my job".
Perhaps this is a cultural thing for us Brits, making us feel uncomfortable when someone heaps on the praise.
It's certainly a cultural issue within healthcare where we become so used to the extraordinary, it becomes ordinary.
Last summer, an extraordinary video of a nurse in the accident and emergency department at Leicester Royal Infirmary went viral on the Internet.
It showed 36-year-old nurse Caroline Clayton-Barker, along with several of her colleagues, putting herself in danger to protect patients from a man with a knife.
At one stage in the video, she comes face-to-face with the knife-man, before running to safety herself.
Despite Clayton-Barker later recounting that "It was like a horror film," she also told reporters she was just doing her job. "I don't feel brave, it's just your job, it's your duty of care to protect your patients."
In reality this was way more than 'just her job'; the lady performed exceptionally.
But on a more mundane level team members are doing great work daily but often just shrug it off.
We know that morale is low within the NHS. Staff recruitment and retention are both a huge challenge.
You can argue that working in the healthcare profession is often a thankless task. Nobody is saying thank you, and nobody is accepting the praise. This creates a vicious cycle.
If we don't accept praise, I reckon we get in the habit and don't offer praise as well.
Having the end of day conversations on the 99% of occasions where things went right, giving praise, and accepting praise, these are all excellent ways to get better and all feel better.
When things go wrong in healthcare - administering the wrong drug, treating the wrong patient, operating on the wrong site or patient - these are the mistakes we see. Sadly, avoidable harm is not decreasing and the annualised cost increasing in our litigious society. £2 billion outgoings for NHS Resolution in 2018, up from £1.7 billion the previous year.
What people often don't do is report the near misses, or near hits as we prefer to call them.
There's plenty of understandable reasons for not reporting the near hits.
Firstly, nothing has actually gone wrong. It's hard to report a near hit when it didn't result in a bad outcome for the patient.
Secondly, reporting systems tend to be very cumbersome and time-consuming; not something you would look forward to at the end of a long shift.
The boxes within these reporting systems don't always fit the scenario. When no actual harm has taken place, some of the older systems don't have a way to report the near hit from their drop-down boxes.
Another major reason healthcare professionals fail to report the near hits is because nothing tends to happen when the issue is raised. All too often, there's no reply to acknowledge the report or even say thank you.
If there is an acknowledgement, frequently nothing is seen to change. From a management point of view this can be frustrating because not all solutions can be visible. We know of a case of senior management following due process with a case of bullying but they can't publish that they put a warning on a personal file because naturally that is confidential. But staff see no change in behaviour of the culprit so don't waste time offering follow-up reports!
One more reason; when you report near hits, you don't always feel safe.
We are aware of one situation, involving a clinician working with a new colleague. They were chatting together, slightly distracted, and the new team member got the controlled drugs out in a different way.
The clinician knows they should have checked before administering the drugs, but they were distracted. They gave the wrong one of the two colourless solutions to the patient. Fortunately, there was no lasting harm to the patient, but this was a near hit.
The clinician decided to report the near hit. They were aware that the same had happened with some of their colleagues in the past. Human factors were involved, with a weakness in the drug-labelling system making the error easier to occur.
The result? After reporting the near hit, the clinician came under scrutiny from senior management. They were not thanked for raising the near hit. Instead, the management started looking into how many near hits the clinician had previously reported, comparing their frequency of reporting to management.
The irony in this is, they made the clinician who reported the near hit feel victimised. Yet management still went ahead and changed the process, to reduce the risk of the same near hit retaking place. Dishonest management in our opinion.
When I was flying jumbo jets with my former employer, there was a company policy of error reporting ethics. If you made a genuine human error and confessed it, you would not suffer any disciplinary action or consequence to your career.
If however you deliberately broke the rules or made an error then tried to hide it, you would be facing due process. And quite rightly too.
Airlines too, recognise the tip of the iceberg issue. If a near hit is reported, it's likely to be part of a much bigger problem, hiding below the surface.
The more comfortable thing for management to do is to discipline the last person involved; the nurse, doctor or pilot receives punitive action as a result.
The hard thing to do is to get to the true root cause of the issue.
Why did the person make the mistake that resulted in a near hit? Perhaps they were not adequately trained in the procedure. Indeed the process itself could be unfit for purpose. The staff member might have been working for many hours without a break. They could have been experiencing personal issues at home, with a sick or dying relative, distracting them from the task at hand. We know of one recent case where this was a major factor.
In the long term, it saves you money to take the hard option and tackle the system issue which may be indicated by the hidden mass of the iceberg, floating below the surface.
So please report near-misses or as we say regard them as near-hits. The message for managers is please encourage reporting and respond with compassion for the reporter. The bulk of the iceberg represents a threat to us all.
It is, of course, inappropriate to speculate on the possible cause of the tragic Ethiopian Airlines crash. However, the reaction offers lessons I believe.
The authorities in Ethiopia and China have grounded the same model virtually instantly until root causes are understood and appropriate measures have been taken.
It may be significant that the aircraft is the same new model as crashed in Indonesia in late 2018, or it may not. Risk management is the name of the game.
One of the contributing factors in Indonesia was the new safety feature built into the aircraft software. The concept was to improve the way the aircraft responds to an unwanted state and is supposed to be an aid.
It is called the Manoeuvring Characteristics Augmentation System (MCAS). It is designed to prevent the aircraft from falling out of the sky in an aerodynamic stall.
However, it appears that the manufacturer, Boeing, did not incorporate the knowledge of the system in its training to crews. Many qualified crews around the world have stated that they nothing about the system's existence.
To compound the problem, it appears that the Indonesian aircraft may have been despatched with a known technical problem which the ground engineers may not have been able to reproduce on the ground.
In other words, the safety system responded correctly, but the suspicion is that it was being fed erroneous data from a faulty sensor. In this case the AoA (angle of attack) sensor – which detects the airflow over the wings.
Some of you may be aware that a cost saving feature is that this latest model of Boeing 737 is deemed to require only 'differences' training if a crew is qualified on the earlier model. They do not do a full technical knowledge course just learn and are assessed on the differences.
It seems the new safety feature was not included. Human error by the manufacturer? The result in a non-technical sense is a loss of situation awareness – how and why the aircraft is reacting.
Those of you who remember the tragic Kegworth crash in January 1989 which started with the crew identifying the wrong engine in an unclear flight situation and ultimately crashing across the M1 motorway in England's East Midlands.
Of the 126 people aboard, 47 died, and 74 sustained serious injuries.
Implicated was the pilots not being aware that the right engine supplied the air conditioning to the flight deck as opposed to the left engine in previous models.
The smell of burning was a small misleading clue. They had only completed a very brief 'differences' course.
Airbus have also suffered accidents in the past because the aircraft was so advanced and complicated that crew struggled to understand how the plane was reacting.
History can repeat, but we learn the lessons the hard way.
I flew six different airliners from four different manufacturers in my career. Comprehending what was going on was sometimes tricky and fundamentally down to how well the crew knew the aircraft. In other words, training.
In other professions such as healthcare, we all involve people trying to comprehend what is going on.
Healthcare professionals face a much more difficult job because no two patients are the same even more so than with aircraft. Knowledge and understanding are crucial, especially in how any one of us can get it wrong and right.
Human factors has been mandatory training in aviation since 1995, and even that can't prevent everything. But it sure helps.
I've presented training packages to several NHS Boards and senior management teams. Not surprisingly cost is a feature. Some get it; some seem to struggle.
After all, finding a direct correlation between safety and training is not easy.
But precisely who initially said, "If you think training is expensive, try having an accident"? I'm not sure, but it has been attributed to many wise people over the years.
In our everyday lives, people are typically polite to each other. At social events, we carry out personal introductions a matter of course.
So why is this behaviour not the norm in healthcare?
When working with healthcare teams that are sometimes experiencing challenges with safe team workings, we often observe a reluctance to introduce ourselves by name - especially our given first name.
When I joined my first airline employer in 1971 that was indeed the case.
The Captain was always addressed as Captain or Sir, on and off the aircraft.
I still vividly remember my first BOAC flight as a very lowly second officer under training. The Captain was a very senior manager and trainer, and he exacerbated the situation by referring to me to his chums in the bar in Manhattan as 'one of those bloody cadets still wet behind the ears'. What an excellent example to set.
It was an example I chose as a model of what not to do when I finally achieved Command 18 years later.
Furthermore, I made a point of never introducing colleagues as 'my First Officer' or 'My Cabin Crew'. These are professional people in their own right and deserve all the respect associated with it.
This is an important issue because failure to use given names in the workplace can create a significant barrier to people speaking up when they have doubts about safety.
Why would any professional want to place an additional block to open communication, especially if someone's' life could be at stake?
I met one senior clinician in the last few months who looked with abject horror when I suggested they make a point of introducing themselves by first name at a pre-surgery huddle! "I really don't think I could do that", she said! Why on earth not?!
The unit in question has an appalling staff attitude survey result, a string of 'Never-Events' and 'near-misses', a high sickness rate and high staff turnover. Go figure!
The excellent Rob Hackett in Australia had the astonishingly simple idea a while back of putting name and job title on his theatre hat. This has become known as 'the theatre cap challenge'. Odd isn't it that it should even be regarded as a 'challenge'!
It's quite amusing to hear all the excuses why people can't adopt this simple practice of the theatre cap challenge in their own unit.
Infection risk? Well, there is a chap out there making them integral in theatre caps. You could invest in a few to get you through the week if you like your own personalised hat.
Power is granted, respect is earned.
We must not forget either that using titles can help in difficult situations.
As an airline captain, there were many occasions where a colleague referring to me as Captain Dale was useful to re-establish appropriate hierarchy in front of passengers or an engineer.
The other week I was delivering a talk in Bath, to a room of around 100 healthcare professionals, ranging from medical students to retired senior consultants.
When I reached the end of my talk, I asked how people in the room felt about using first names? I explained that when you have to think about titles and ranks, you are creating an additional barrier to someone helping you out when you need them the most.
I don't mind if you introduce yourself as Professor John Smith, but I prefer if you call me Professor Smith. This might not be as beneficial as working on a first names basis, but it sure beats the all too common introduction, "We all know each other don't we?" which equates to "You all know me, don't you? .. and you don't matter".
Do get in touch to discuss how our human factors training for critical teams can help you maintain and enhance safety.
Many organisations do not perform exit surveys and so understanding why people leave is a problem to start with. Perhaps they don't really want to know. It's easier to blame the NHS and pressure of work, targets etc.
For example, Atrainability worked closely with a world famous specialist hospital a little while ago which was suffering high turnover of junior nurses in a particular department.
The view from the top was:
"The nurses come here to get our good name on their CV's and then move on."
However, anecdotally people were leaving because it was not a great place to work.
Team-working was verbally espoused but reality was somewhat different. Work as imagined was quite different to work as done depending on your level in the hierarchy.
One nurse told us she had worked her entire shift without any offers of help, breaks or support while the band 6 and 7 nurses had a nice relaxing time. You can imagine the atmosphere when we presented our findings.
This is by no means unique as many of you will know.
This very week I've listened to my best friend's wife explaining that she is burned out and leaving the profession the she loves. The reasons? She is a specialist sister in intensive care who is often told to work in other departments. She has been sent to A & E, theatres, wards and even the other sites in her trust which is 20 miles away.
She has simply had enough.
What a tragedy which is personal, institutional and cultural for her and us all.
In London there are 8000 nursing vacancies and huge doctor numbers too, so making your job one that people want to come to must be worth working on?
Staff retention rather than repeated training costs is a very worthwhile investment, and turning from a Blame Culture to a Just Culture is a crucial start.
A worthwhile part of team-working is delving in to emotional intelligence and a fundamental concept within that is of course self-awareness.
Get in touch and discuss with us how we could help your teams, including the senior level of course.
Trevor Dale, Human Factors Specialist
- Civility Saves Lives
- Group GP appointments - a breeding ground for error?
- Waverley BIG Awards Finalist
- Human Factors in Practice
- Free conference this November
Civility Saves Lives
Civility when dealing with colleagues and patients may seem like stating the obvious, but sometimes what should happen in theory isn't what happens in practice.
Civility Saves Lives is the self-funded, collaborative project led by Dr Chris Turner, a Consultant in Emergency Medicine.
Why does civility matter? Uncivil behaviour not only greatly impacts the reciepent, but it is also proven to have an extended impact beyond the recipent. At Atrainability, we refer to this as 'Mood Contagion'.
Many professionals have been on the receiving end of rudeness, belittling and bullying. Most are told or feel like 'that's just the way it is'; but if the NHS truly wants a Culture Change behaviours and attitudes at all levels need to adjust. The project aims to raise awareness of what can be done, whilst sharing stories from other professionals as well as relevant, evidence based academic papers.
Atrainability's Trevor Dale has recently been speaking about the importance of civility at Patient Safety Collaborative for Kent, Surrey & Sussex. If you'd like to find out more about how Human Factors training and Civility fit hand in hand, request more information by emailing firstname.lastname@example.org.
We also highly reccomend taking some time to look at Christine Porath's work. Her book 'Mastering Civility - A Manifesto for the Workplace' has recieved excellent reviews in The New York Times as well as from high profile authors and leaders.
Group GP appointments - a breeding ground for error?
There has been a recent report about the NHS considering group GP appointments as an option to help alleviate the waiting time for patients and in an attempt to manage the growing shortage of GPs.
Although further details on this are needed, we at Atrainability believe that this could very well be a potential breeding ground for Human Factors error, our main concerns from a Human Factors perspective include:
• BEHAVIOUR & COMMUNICATION: The patient relationship with their GP, being confident to raise real concerns. How does the GP manage a room with some extraverted (verbose) people and some introverted (more private & more inwardly driven)?
• SITUATION AWARENESS: Potential error when adding correct patient notes to correct individual files - how will this be managed from a group sessions?
• CONFIRMATION BIAS: A group may have similar symptoms, but will this lead to the same path of care? The correct diagnosis? Could things be missed?
Are you a GP?
We'd appreciate your thoughts on the subject. Email us in confidence: email@example.com.
Waverley BIG Awards Finalist
You may know that we've been training health and social care teams across the UK for the last 16 years, however you may not realise that we're classified as a small business. Which is why we are delighted to have been selected as a finalist for Waverley's B.I.G Awards 2018 in the category of 'Customer Delight'. We'll keep you updated on the results which will be announced on 19 October.
Human Factors in Practice
Reminder! Free Future of Healthcare Conference this November
Atrainability are proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at The Future of Healthcare Conference, which is free to attend event on 6 November in Exeter.
The conference brings you speakers from a wide spectrum of specialties. The aim is to inspire & teach NHS staff from all departments, as well as patients, on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance. Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter.
As I'm writing this, it's only Wednesday, but we have already been made aware of four unrelated never-events at seperate healthcare providers. The unfortunate truth about committing to a Human Factors training programme is that many organisations put it off, until they receive a wake-up call in the form of a never-event, a near miss, bad press or from the CQC. Someone gets told this needs to be addressed, and that's when our phone starts ringing.
The first tragedy of so many harm related incidents is that on reflection they could have been avoided.
That's one of the reasons this headline in the National Health Executive: "NHS pays out record £20m compensation for brain-injured teenager" caught our attention, but also because it's potentially the largest compensation pay-out in NHS history.
The second tragedy of avoidable harm is that the suffering of all those involved doesn't end with the error.
The judgement suggests the error was avoidable. Hence Human Factors behaviours will likely have been suboptimal. In this particular case, not only did this nameless young lady have her full enjoyment of life tragically taken from her, but also her parents and entire family.
We can only imagine the emotional toll that they have endured for the last eighteen years to have this life changing error acknowledged and receive some form of compensation towards her ongoing care.
Let's also recognise the effect on the healthcare team involved. It's likely that disciplinary action would have been taken, but they have almost certainly been haunted by the knowledge that they could have avoided or trapped the error.
The third tragedy of avoidable harm, is that it sadly continues to occur.
There will always be mistakes in healthcare, but embracing a Human Factors mindset can enable your team to be confident in modifying the actions and behaviours that affect safety.
Atrainability have over 16 years' experience in training and supporting healthcare teams on their individual journeys to truly learn, become more effective and begin to change behaviours for the better. If your teams are performing highly now, consider helping them to stay 'consciously competent' and avoid the trap of complacency.
Please get in touch and let's see how we can help your teams.
The General Medical Council has reflected the importance of recognising Human Factors in the development of generic professional capabilities for post graduate medical curricula.
The context for this is the GMC's core guidance for all doctors, good medical practice, which sets out what is expected of doctors including communication, partnership and working with patients. (National Quality Board Human Factors Concordat 2013)
Many Deaneries have incorporated Atrainability's Human Factors modules in their curriculum, since 2012. The list is growing year by year and the repeat bookings speak for themselves.
Atrainability are now taking bookings for Foundation Doctors Human Factors Training for the next academic year.
Human Factors is strongly recommended to become a mandatory part of Medical Education and our courses match the Medical Leadership Competency Framework.
Focus points include:
• how and why errors are made and practical tools to avoid and trap them
• safe decision making during a stressful day
• situation awareness - recognising the signs that things are going wrong and dealing with that situation
• effective escalation - overcoming the barriers to open communication and shared understanding in a high workload environment
• dealing with difficult people including, sadly, colleagues
We have over 6 years' experience in delivering training aimed at the next generation of healthcare professionals in a manner that is tailored to their educational needs.
The Human Factors behaviours related to safety are crucial both for the patient and also the professional confidence within the Doctor while they are in the most high risk part of their education.
If you have already finalised training for 2018/2019, we'd be happy to discuss your training programme for the next academic year.
Some sample feedback from recent participants:
"Outstanding course, incredibly useful"
"This should be mandatory! Very interesting to learn how other industries such as aviation can apply to medicine"
"Leadership & management is crucial but often overlooked in medical training. Clear, practical advice that I can start putting into practice now."
"Useful to receive formal teaching in things that it seems we are expected to already be aware of e.g. challenging authority. Good presentation, kept engaged throughout."
"Important concepts to reflect on, extremely useful to be exposed to this early on in our career"
We would be happy to discuss your individual needs at your convenience. Please contact us here.