Article
Maintaining confidence is vital to effective, safe practice. Lack of self-confidence or, arguably worse, over-confidence or arrogance cannot only result in harm but induce stress in colleagues and team members. Understanding the root causes of error can aid learning and a move away from the blame of self and others. Accepting and offering detailed factual, positive comments, as well as critical feedback, supports active learning.
This article applies to all who work in dentistry and oral surgery and aims to increase awareness of the importance of a balance of confidence in practice without the perils of under- or overconfidence, and the potential effects on performance of behaviour and clinical safety.
Confidence is crucial whatever we are doing, especially in a high-risk environment and task. This could be oral surgery or dentistry or, in my past profession, flying a Boeing 747. However, in a world of fallibility, how do we maintain a balance of confidence without slipping into the two significant dangers – depression or arrogance?
How do we handle our errors? Have you ever ‘enjoyed’ a voice in your head after becoming aware that you've made an error of any kind, let alone pulling the wrong tooth or operating on the wrong side? I used to suffer the iniquities of the voice and tone of a certain Scottish TV chef ranting at myself. ‘You complete idiot!’ and far worse. For decency, I've omitted the expletives, you'll be delighted to know. If your self-criticism is joined by the similar words of your manager, colleagues and possibly family and friends, how could you maintain a resilient balance of confidence? Let's be frank; some healthcare professionals have suffered acute depression and worse, have caused severe harm to a patient without intent.
I believe one solution is understanding types and root causes of mistakes. These have been extensively explored in academic research by such individuals as Professor James Reason and Professor Rhona Flin of Aberdeen University, who have researched extensively in aviation, the nuclear industry, oil and gas and healthcare.1 The subject, of course, is ergonomics and human factors. However, I must confess that I am a failed academic – City University LBMA – Left By Mutual Agreement. However, I've been a trainer and course developer since 1992 in commercial aviation and 2002 in healthcare.
How would it be if, post-error, instead of a harsh critical voice in your head you replaced it with the voice of humility, reason and empathy? Burn-out starts with stress and emotional overload. We are all urged to offer compassionate care but compassion starts within and to our all too human colleagues. One method of coping is understanding the ‘human condition’. How we make apparently stupid mistakes. Sadly, I continue to make mistakes on a regular basis. I find that I can generally work out how I've done it – not concentrating, not listening, mind on something else, taken on something which I'm not adequately skilled at, for instance. The last time I was caught speeding in a car, it was due to driving too long without a break at the end of a long busy day and not paying sufficient attention. I even knew the fixed camera was there but didn't see it and had forgotten the speed limit. Happily, a speed awareness course was all I endured. I learned some useful stuff too, even though I thought I already knew it all. Of course, I rate myself as an above average driver. However, allegedly over 80% of drivers rate themselves above average.2 Could the same apply in oral surgery and dentistry?
Recently, I spoke at a pharmaceutical conference to a high-profile audience and followed an eminent professor. I spotted a misspelling on his slide 3 and (at substantial personal risk!) decided to mention it in my presentation as evidence that we can all make mistakes and just what if that typo had been in a drug prescription or patient notes? Tragically, status and experience have proved no protection against error. The World's worst air disaster killed 583 people in 1977.3 As you can read, the primary cause was the action and inaction of the Captain of the KLM aircraft who was the most senior Training Captain in the airline.
Let's consider blame. Many high-performing professionals in all industries tend to be self-critical – in a balanced way not much wrong with that. However, acknowledge culpability. Does it do any good? Has it ever been proven to stop mistakes happening? Other than briefly making you feel good, I haven't been able to find much use for it. Rather like wetting yourself, I'm told, it produces a nice warm feeling, briefly, and then you have to do something about it. It is the British way to be quick to blame and slow to praise. I believe it is long overdue that we changed that ‘culture’. However, I am not recommending letting the frequent offenders off the hook. I mean those few who cannot or will not accept their fallibility and often seek to lay blame on others – The ‘Special Ones’. Although we ought to consider whether those who've erred have been adequately trained or appraised or, indeed, investigate whether the processes and equipment are fit for purpose? It is hard to look at those systemic issues. Much simpler and easier to blame the last person to touch it. But rarely does that solve the problem.
Praise is another issue. It's not especially British to praise after all. We don't say much beyond a simple ‘thanks’. What about a spot of detail instead? ‘Thanks, it was really helpful when you pointed out that I had the wrong patient notes, imaging, wrong patient’. On the rare occasion when I get offered positive feedback, I will always ask what I did in particular. If delegates enjoyed a class or conference presentation, what was it that they found useful? Gratitude alone is pleasant, of course, but knowing specifically what worked means I have more chance of repeating that. Once running a bespoke training session, I asked experienced nurses what they would like to hear at the end of the day. As one, they replied ‘thank you and what for’. The clinicians present were stunned. ‘But you've been doing the job for years, and you must know what right looks like!’ ‘Yes’, came the reply ‘but it is so much more helpful if you say exactly what for’. I could not agree more.
However, do we accept praise or shrug it off with a throw-away ‘just doing my job’?
Could it be that by not accepting positive feedback we are part of the culture of not offering praise? The whole concept about learning from excellence is perhaps a subject we could usefully return to? But it does seem to be part of healthcare in general that praise is not part of ‘the way we do it here’.
Many years ago, a friend said ‘it is a kindness to accept praise’, and I would struggle to argue with that.
There is already far too much work-place stress around – short staffed, wrong skill-mix, crammed clinics, changes to the list and awkward patients and colleagues. Let alone the personal baggage from home life, which we often think we can leave behind while at work.
So, when faced with having made mistakes, are you initially blissfully unaware? But, when the evidence points in your direction, along comes the voice of blame from within and without.
The first reaction could well be sheer disbelief. There is a term for this – Cognitive Dissonance.4 ‘I've been doing this job for many years, I can't have made a simple stupid mistake!’. Some of our more challenging and challenged colleagues could even seek to blame others. Hubris does appear to be alive and well, unfortunately. The problem with arrogance is that it garners remarkably little respect apart from those who also ‘enjoy’ the same views of their abilities. The compassion and empathy that we are all urged to demonstrate could, I suggest, be directed inwards to ourselves and outwards to others – understanding, empathy and compassion for all.
Delivering training in Human Factors recently I asked the question ‘What makes the difference between a good and bad day at work?’. Normal responses tend to be communication problems, inexperienced team members, changes to the plan, late start, overruns and the like, as well as equipment issues. A very senior clinician stated that he only liked working with his ‘usual’ team. Well, entirely reasonable. He then went on to say that when he worked with other than ‘his team’ the nurses appeared stressed and made mistakes. I asked what I thought a reasonable question. ‘What do you do to help them?’ Utter astonishment came back. ‘What do you mean what do I do? This has nothing to do with me. It is them!’ Ah!
Self-awareness and emotional intelligence can contribute massively to the success or otherwise of a day, as I'm sure you know well. Which leads some of us to ask ourselves how self-aware are we? This is a fundamental aspect of Emotional Intelligence (EQ) as defined by Daniel Goleman.5 Ok that's old news, but only to those who already ‘get it’.
It's an interesting discussion to have about whether your personality changes with age and maturity. I'm sure we've all got our ideas on that. I believe that personality stays pretty much constant, but maturity (hopefully) brings an increase in emotional intelligence which affects our behavioural responses to people and situations. We learn what works. Well some of us do. Those a bit short in the EQ stakes, which includes empathy, self-regulation and social awareness, struggle to get it.
Can EQ be trained and acquired? I believe yes if your mind is open. We are all role models in some sense. Consider the effects of adopting behaviour in your workplace which takes into account the needs of others, patients and colleagues alike? Consider the positive impact on your workplace. In my day, in aviation we dispensed with the services of a few senior pilots who couldn't work with others under pressure without losing their cool and resorting to abuse and bullying.
Training on ‘being nice to people courses’ was tried but to no avail. Maybe they could fly a plane technically, but there is more to it than that. Commercial aircraft are designed to be flown and managed by a team. Even fast-jet pilots of fighters have to be team members these days. The days of Maverick (aka Tom Cruise in Top Gun) have gone. There have been too many instances of the absurdly named friendly fire for that.6 Do you remember the feedback from the ship's Captain to Maverick after a particularly risky manoeuvre? ‘Son, your ego's writing cheques your body can't cash!’ Good advice for us all?
These days airlines don't recruit pilots. Monkeys then? They look for team players first and foremost and teach them to fly. Imagine that in dentistry, oral surgery and healthcare in general? Of course, aviation, far from being a perfect match for anything in dentistry, is a good model of how to learn safety lessons. Both professions though are primarily focused on risk management.
With risk management in mind do you always have a plan B in mind and, even better, shared with your team, nurse or colleagues? What would we do if …? Say an uncontrollable haemorrhage? Cardiac arrest? Pulled the wrong tooth? Pranged a nerve? In one recent study of dental error in Spain, the most likely opportunities for error include implant treatment, oral surgery and endodontic therapy. Of these, 44.3% of errors were found to be preventable and avoidable.6
After many years of working in training and coaching could I suggest an open mind is step one? None of us is the fount of all wisdom, and things do go wrong. Mistakes happen. It is a threat-laden world. If your colleagues or support team make an error, it doesn't mean that they are ‘bad people’ as the press would have us believe. A fruitful way to proceed is to try and work out not so much what someone did but why? Assuming you haven't slipped up and hired a psychopath, whatever he/she did must have seemed like the right thing. However, why then, with post-hoc analysis and a nice cup of coffee or tea, does it all seems so obvious? Were they holding on to a load of personal concerns that use up available capacity? Were they adequately trained and supported? What about their resources? Is IT working ok? Paper notes legible? How about your processes?
It's always the easy option to blame the last person to touch it, whatever that is. To go through the system and ask the more challenging questions is much harder. Did we recruit and train the correct candidate? Do they have enough support and resource? Is our software updated? Do we treat them with respect? Do they feel motivated, empowered and enabled? Do they have autonomy, mastery and purpose? Do they have adequate breaks? Are we unrealistic in the workload we insist on them because we are so much in demand and so important? Have they had breaks and been fed and watered?
So, in conclusion, aviation has some commonality with dentistry and healthcare in general, but it is not a perfect match. Both are mostly focused on managing and reducing risk. A fresh pair of eyes from other professions can ask some useful, if awkward, questions. Sometimes these may seem unpalatable but, from a safety point of view, surely the current status quo is unsustainable. The occurrence of avoidable harm simply must be reduced. I believe in the necessity of an understanding of the basic concepts of human factors. However, being human is no excuse for mediocrity and accepting the status quo. It should instead be a motivator for self-development and improvement.