This is the first of a series of stories about workplace culture, and how individuals and organisations engage, often unwittingly in a macabre dance of collusion which, it is suggested, is the real reason for burnout. How does your organisation affect you? What practices are you forced to uphold that inwardly cause you cognitive or emotional dissonance?
Why do we feel we have to be perfect? And why do we feel so bad when we are not?
Is it embedded deep within our personalities from birth, a genetic feature, passed on from one generation to the next? Or is it part of the all encompassing impact of our surroundings and the prevailing behaviour of those we most closely encounter?
Is the need to be perfect due to nature or nurture?
How realistic is it to expect us to be perfect, when we are dealing with other humans in a profession that is constantly developing its knowledge base and its practices? How can we be all things to all people when each person requires us to be something different? In all of the professions that serve people in their darkest hour, how can we always get it right, always be who others want or need us to be, especially within the confines of overstretched resources, often with one clinician doing the job of at least two? Does perfection even exist in healthcare? Is there ever a “right way,” or do we just seek the best way for this person on this day?
How far is the way we deal with our imperfect practice influenced by the way our organisations deal with our imperfect practice? As practising professionals we are often afforded little room for error, and sadly that means that we do not always cope with mistakes in a way that offers learning and development rather than recrimination, self loathing and the feeling that we are not good enough.
Our mindset has a huge role to play in how we react to falling short. We are governed by our internal, and other’s external expectations of us, which are often dissonant, causing us anxiety. This is where I would suggest the slew of mental health related issues originates.
Many of us have an internal growth mindset (see Carol Dweck’s work in this), believing that if we try harder, apply ourselves to learning, we will fare better. And this is a mindset that has been correlated to improvement in practice and less stress when things occasionally go wrong. A growth mindset believes that the infrequent mistake offers an opportunity to reflect on and to change or to develop both our practice and our view of it and our relationship with that practice and with ourselves.
The other end of the spectrum is referred to as the fixed mindset. Those with a fixed mindset believe that ability is inherent and usually determined at birth. They talk of natural talent believing that what they can and cannot do is fixed. They are very focused on appearing to be good, and they dread failure because they believe it is a negative statement on their ability. They will go to great lengths to avoid being seen to fail.
I wonder what percentage of people have growth mindsets when they initially enter the healthcare professions? I imagine more than those who do not. What role then, does clinical training play in developing fixed mindsets in its learners? What impact does working in the NHS have on our growth mindsets? How far does the prevailing culture try to turn us into having fixed mindsets instead?
We know that an exclusive belief in a positivistic worldview of biomedical sciences has had a detrimental and limiting effect on the practice of healthcare by ignoring that which we cannot see, test or subject to a randomised control trial. Similarly the political control which subjects healthcare professionals and their work to measurements of arbitrary and easily measurable components leads me to wonder whether medicine’s mindset is forced to be increasingly fixed. If this is so, how far has this led to the internal conflict within health care professionals who believe in a growth mindset but are restricted in practising it by the mindset of the profession they serve? They have fixed mindsets increasingly placed upon them with every set of targets, every refusal to provide better resources and every inspection visit.
How much of the moral injury currently felt by healthcare professionals is due to a culture of the fixed mindset? We refer to ‘burnout’ as if professionals have used up all their birth-bestowed abilities and are now running on empty, like a clockwork doll whose batteries have run out. The very term ‘burnout’ implies a fixed mindset. But what if the internal, emotional and moral issues were caused by the mixed messages that are everywhere in the NHS? One example is that it may sometimes be called a ‘learning culture’ but less than perfection is vilified and mistakes are not tolerated or even in some sad cases, not even recognised. Another example is the ‘patient centred’ focus when measurement and financial reward is all about how few resources are utilised.
And what about the identity of the clinician, educator or manager? They joined this profession to help others, to learn and grow and assist others to do the same. And yet if, when they try to do that, they are punished, forced into a fixed mindset of measurement and minimalism, is it any wonder that things are covered up? When there is no opportunity to learn from mistakes and fixed mindsets become the organisational norm, that’s when the scandals that reach our tabloids will happen. If professionals cannot jointly process mistakes, share learning and build together a way towards better practice, then a culture of festering fear occurs. And fear leads to cover ups, which are always, ultimately exposed, but not before lives are needlessly lost.
Whilst Dweck’s work is of interest to all educators and relevant to all learners, we must look beyond the individual. What mindset does your department, organisation or profession encourage? What words does it use? Is it obsessed by the delivery of measurable commodities or does it prioritise the individualised development of others so that they may take on the mantle of self improvement and agency? The former is restricted by a fixed mindset and is probably restricting us too. Attempting to provide a professional practice that empowers and enables within a fixed mindset culture is guaranteed to make the best of us question what we do and why. And that, I suggest, is the real cause of moral injury.
We would welcome any story ideas about this topic, relating the cultural mindset to experiences of burnout or emotional exhaustion. Contributors need only send us an outline of a story and we can help to create a piece for the blog.