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Improving teams
in healthcare
Resource 3: Team communication
Developed with support from
Background
In December 2016, the Royal College of Physicians (RCP) published
Being a junior doctor: Experiences from the front line of the NHS.1 This
report identified the breakdown of the medical team as a central
factor contributing to the low morale and disengagement felt by
physician trainees. This is also reflected in previous RCP reports.2 The
benefits of high-quality team work in healthcare are well recognised.
Effective team working has been shown to reduce medical errors,3
increase patient safety4 and improve patient mortality rates.5 It also
leads to better staff outcomes including reduced stress6 and improved
job satisfaction.7 The RCP has produced a compendium of reports
aiming to promote high-functioning team working in the medical
setting.
In this resource we focus on team communication.
Breakdown in communication has been identified as a
leading factor in adverse patient events8 and was cited
by the Francis report as a major cause of inadequacies in
healthcare delivery.9 Unfortunately, in medicine, effective
communication and teamwork is often assumed and
training in this area not prioritised. This resource aims to:
> highlight the importance of effective communication
in healthcare
> identify potential barriers to good communication
> explore what good communication looks like and
tools to help achieve this.
2
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
What is good team
communication?
‘Good communication is the accurate and unbroken transmission
of information that results in understanding’.10
In one journey, a patient will receive care from multiple
individuals from different teams across different healthcare
sectors. Effective communication is essential both within an
individual team and between teams to ensure co-operation
and coordination of care.11
The World Health Organization (WHO) describes ineffective
communication as a leading cause of inadvertent patient
harm.8 In an analysis of 2,455 sentinel events reported
to the Joint Commission for Hospital Accreditation,
communication failure was the root cause in over 70% of
events.12 Furthermore, ineffective team communication
leads to duplication of tests13 and delays identification14 and
treatment15 of deteriorating patients. Communication deficits
are especially common at the interface between primary
and secondary care. They can culminate in adverse events,
including an increase in preventable hospital admissions.16,17
The benefits of good communication are not limited to
patients. Effective communication improves job satisfaction,
increases staff retention and facilitates a culture of support
and trust.18 When individuals have confidence that their
opinions will be heard, they are more likely to speak up. This
maximises use of the team’s internal resource to solve issues
and improve performance.
What are the barriers to effective
communication in healthcare?
Healthcare is becoming increasingly challenging and
complex, with multiple recognised barriers to effective
communication. A key step in facilitating effective
communication is recognition of these barriers; teams are
then well placed to deploy strategies that overcome them.
Barrier 1: Interprofessional communication
Professional groups have historically been trained to
communicate in different ways, for example, doctors
have traditionally had a more succinct approach to
communication with an emphasis on facts, while
nurses have had a more holistic focus.11 This can lead
to misunderstanding and misinterpretation of the
communicated message. Tools like SBAR (Situation,
Background, Assessment, Recommendation – see
page 5) have been developed to bridge these differences.
Interprofessional education (where different healthcare
professionals learn and train together) is another helpful
approach to help overcome these barriers.19
Barrier 2: Fear of failure
There is a culture embedded within healthcare, where mistakes
are too often viewed as a personal failure. An incorrect
expectation of error-free clinical practice, leads to individuals
being reluctant to communicate errors.20 This can be overcome
by enabling a team culture where professionals are able to
raise concerns and admit errors in a safe environment, where
blame is not attributed. When an individual is able to discuss
their mistakes in a supportive environment both the patient and
team will benefit. Further guidance on changing team culture
can be found in Resource 2: Team culture.
Barrier 3: Human factors, stress and fatigue
Healthcare professionals operate in times of increasing stress
and workload. Inherent limitations of human memory, and
the impact of stress and fatigue, influence our ability to
communicate effectively.21 This is further influenced by the
environment in which we work, including distractions and
interruptions. Everyone, no matter how skilled or experienced,
can make mistakes and may communicate poorly during
stressful times. Given this, it is all the more important that
there are communication structure mechanisms, eg checklists,
with failsafe mechanisms to reduce the chance of error.
Barrier 4: Team instability
Team stability (where the same individuals come together
to work on collaborative tasks) has been shown to improve
communication by building effective relationships and
understanding of colleagues. Shift work, and the changing
delivery of healthcare, results in dynamic teams with
constantly changing members and therefore a lack of
stability. Shift work also means that there is more handover
of care than ever before, with poor communication
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
3
recognised as a cause of increased patient mortality.13
Toolkits and guidance on effective handover are helpful in
ensuring the safest possible transfer of care (see below).
Barrier 5: Inconsistent technology
Technology can be used to enhance communication.
However, within the NHS we have not reached consistency
in the use of technology between healthcare teams, which
can present a challenge. An increased focus on shared
technology systems, including patient record sharing
between primary and secondary care, should enhance
communication between teams.
Barrier 6: Hierarchy
Hierarchy within healthcare remains a substantial barrier
to the free flow of information. This is discussed elsewhere
in this series, in Resource 2: Team culture. In summary,
where team members feel intimidated, they are prevented
from speaking up and challenging seniors, even in critical
situations. This can occur within professional groups (eg
foundation doctors and consultants) and between them
(eg nurses and doctors). There are national drives to promote
a culture of speaking up, including the Freedom to Speak
Up Guardians.22 These guardians work with trust leadership
teams to foster a culture of empowerment, allowing workers
to speak up to protect patient safety.
How to achieve effective communication
Effective communication is not something that occurs by
chance. It requires active development and prioritisation
from organisations, team leaders and individuals. Here are
some simple steps to consider for all interactions:
Introduce yourself and clarify your role
Listen attentively and allow people to complete their
thoughts
Ask questions for clarification
Check for understanding of what has been said
Invite opinions from those who have not spoken
Be aware of communication barriers, eg hierarchy
Use objective not subjective language
Show mutual respect
Consider setting: right place, adequate time, no
distractions
Be aware of body language, both given and received:
facial expressions, eye contact, posture.23
4
TeamSTEPPS is one example of a strategy employed by
healthcare organisations to improve communication.
Developed jointly by the US Department of Defence and
the Agency of Healthcare Research and Quality, it has
demonstrated improvements in institutional communication
relating to patient safety.24
Organisation-wide training programmes are beneficial, but
often difficult to implement. Conversely, there are multiple
tools used by teams within the NHS that greatly improve
communication and require less training and expense to
adopt.
Example 1: Team brief and debrief
A team brief is a short session, at the start of a shift or clinical
activity, that enables the team to come together to discuss
objectives, outcomes, roles, responsibilities and safety issues.
Effective team briefs lead to better patient safety outcomes.
The following questions are recommended by TeamSTEPSS
to structure a team brief:
Who is on the team?
Do all members understand and agree goals?
Are roles and responsibilities understood?
What is our plan of care?
What is the availability of staff during the shift?
How will workload be shared?
What resources are available?25
Debriefings allow the team to come together after a shift,
procedure or difficult situation to reflect on what went well,
what went wrong and how things can be improved. They
provide a structured mechanism for members of the team
to speak up in a blame-free, supportive environment and are
designed to improve team performance via reflection. They
can also reinforce positive behaviours. Debriefs are discussed
further in Resource 4: Team development.
Example 2: SBAR
Adapted from the US Navy, SBAR is an effective tool
that provides a commonality in communication structure
and can be used in almost any clinical setting.26 The tool
allows staff to share concise and focused information,
empowering professionals to communicate assertively and
effectively. It also helps users to anticipate the information
needed by colleagues, encouraging critical thinking. The
fact the tool is focused on data decreases the likelihood of
misunderstanding, which can occur with more implicit styles
of communication.
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
Example 3: Call-out and check-back
Situation
What is going on
with the patient?
Call-out is a technique used to communicate critical
information in an emergency.25 The clinician calls out
questions and commands, ensuring that all team
members are simultaneously informed of updates and can
anticipate the next steps. It also allows for more accurate
documentation. During the call-out the clinician should
direct information to a specific individual.
Check-back is where confirmation is sought that information
given by the sender is received and understood. It is a
closed-loop communication strategy; the sender initiates a
message which the receiver accepts and confirms, the sender
then verifies the message.
Call-out
Background
What is the clinical
background or context?
Team leader
Dr Jones, what is the
airway status?
Dr Jones
Airway is clear
Team leader
Dr Jones
Dr Jones, are there
breath sounds?
Breath sounds
are decreased
on the right
Assessment
What do I think
the problem is?
Check-back
Doctor
Nurse, give 0.5mg
IV atropine stat
Recommendation
What help do I need?
What should we do to
correct the problem?
Doctor
Correct, 0.5mg IV
atropine stat
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
Nurse
0.5mg IV
atropine stat?
Nurse
0.5mg IV
atropine given
5
Example 4: Two-challenge rule
Example 5: Critical language – CUS
The two-challenge rule is designed to empower all team
members to ‘stop’ an activity if they sense a safety concern.
This rule is adapted from aviation where the two-challenge
rule allows one crew member to automatically assume the
duties of another who fails to respond to two consecutive
‘challenges’.
A mechanism to overcome the hierarchical nature of
medicine is to adopt the use of critical language, derived
from the CUS programme at United Airlines. Here, there
was recognition that a culture of hierarchy can lead to
indirect language and uncertainty about the seriousness of a
situation. CUS stands for ‘I’m concerned, I’m uncomfortable,
this is unsafe’, and is a three-step process that provides
clarity, ensures that everyone stops and listens and is alerted
to the seriousness of the situation.20 The CUS tool should be
used only for serious and urgent issues, where the concern
is significant. By embedding this notion of the use of critical
language within healthcare, there is clarity of message that
can overcome hierarchical barriers.
The first challenge should be in the form of a question,
the second challenge should provide some support for the
team member’s concern. The team member challenged
must acknowledge the concerns. If this does not result in
a change, then the person with the concern should take
stronger action, this may be talking to a supervisor or the
next person up the chain of command.
Example 6: Checklists and read-back protocols
Challenge 1
‘Are you sure that x is correct?’
Response
no change in action
Challenge 2
’I think that what you are
doing is incorrect because…’
Response
A checklist outlines the criteria for consideration in a
particular process.27 These are useful in some clinical
situations; they provide a memory prompt, thereby
decreasing the risk of error. Perhaps the best known of
these is the WHO surgical safety checklist,28 which is used
extensively and led to a significant reduction in surgical
morbidity and mortality. Checklists are commonly used
in interventional procedures and briefs and debriefs. It is
important to be fully attentive when using checklists as there
have been instances where they have led to medical errors
because of automated procedures.29
Example 7: Huddles
Complementary to briefs and debriefs, huddles occur part
way through a shift or team task. Team members come
together to review activity, allowing re-establishment of
situational awareness. They are then able to review plans
and adjust as needed in response to ongoing care needs.
Huddles are popular in clinical settings and there is good
evidence to show that they improve information sharing and
communication, increasing capacity for eliminating patient
harm.30 Huddles are also beneficial in creating a sense
of a community coming together, strengthening overall
commitment to the team and improving morale.
no change in action
Escalation
Escalate concerns
to senior
6
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
Lessons from the ward
Quite a few units have introduced a
safety huddle in maternity to identify
current women that are of concern and
review staffing. We did have a staff
morale issue and staff reported not
feeling ‘cared for’ during their shift as
they rarely got breaks and no-one ever
offered them a drink. Thus we introduced
the 11am huddle where we produce tea/
coffee/cold drinks and biscuits.
– Midwife
Example 8: Handover
Poor communication during handover is associated with
increased patient mortality and morbidity.13 With the
introduction of more shift pattern working, communication
during handover is more essential than ever. In an RCP
survey in 2010, 34% of members reported no handover
timetabled into working patterns and only 33% of members
agreed that handover was done well.31
Handover between shifts should include (adapted from
1000 Lives Plus):
adequate time without interruptions
The good and
the bad: team
communication
The following examples will help to put into context some
of the issues raised in this resource around effective team
communication. They are theoretical, but many healthcare
professionals will identify with them using their own
experiences, both good and bad.
The good…
An on-call team is coming to the end of a busy night
shift. When dealing with a peri-arrest patient, the
registrar mistakenly instructs the nurse to prepare a
medication 10 times the standard dose. The nurse asks
the doctors to repeat the dose and issues a challenge.
The foundation doctor also questions the dose. The
registrar is receptive to the challenge, reviews the British
National Formulary (BNF), and clarifies a correct dose
with the nurse. The nurse calls out the dose before
administration.
clear leadership throughout
exchange of sufficient and relevant information
d
iscussion around clinically unstable and unwell
patients, with clear and unambiguous plans
description and assignment of uncompleted tasks32
Handover of a specific patient should include (adapted from
1000 Lives Plus):
a
summary of critical care stay, including diagnosis and
treatment
The bad…
A busy day on the acute medical unit delays the
opportunity for handover to the night team. Key
information about Mrs Y, a deteriorating patient, is
only communicated to the registrar on call and not the
wider team. Later that night, the on-call foundation
doctor is bleeped about Mrs Y. They do not receive an
SBAR and have not had handover from the day team,
so fail to appreciate the seriousness of the situation.
a
monitoring and investigation plan
a
plan for ongoing treatment, including drugs and therapies
p
hysical and rehabilitation needs
p
sychological and emotional needs
s pecific communication or language needs32
The RCP has produced a toolkit and template to aid effective
handover.31 Other helpful resources include the TEAMSTEPSS
resource25 and 1000 Lives Matter resources.32
Improving teams in healthcare Resource 3: Team communication © Royal College of Physicians 2017
7
Key recommendations
H
ealthcare professionals must be aware that failures
of communication are the most common root cause of
adverse incidents.
H
ospital trusts, governing bodies and team leaders
have a responsibility to nurture a culture where
professionals feel able to communicate concerns and
admit errors in a safe environment, where blame is not
attributed.
A
team brief and debrief should be a formal part of
all team activities. Of crucial importance is ensuring
awareness of members’ roles and responsibilities,
especially in ‘short-lived’ teams (eg on-call teams).
S imple techniques such as SBAR, call-out/check-back
and the two-challenge rule should be adopted as
standard within healthcare organisations.
H
andover should be an activity incorporated into rotas.
It must target the objectives mentioned in the previous
section and occur between all on-call activities as a
minimum.
Conclusion
This document explains why teamwork and effective
communication is of critical importance in achieving
safe patient care. Errors in team communication
are a leading cause of adverse patient events
and contribute to low staff morale and retention.
The complex environment in which healthcare
professionals work leads to barriers in effective
communication. Time spent developing team
communication, including supporting leaders in
creating a culture of openness centred on patient
safety, can help to overcome these challenges. There
are some specific communication tools which can
be effective in reducing adverse events and bridging
differences between interprofessional communication
styles. There must be a commitment from
organisations and practitioners to invest in improving
team working behaviours and team communication
to ensure safe delivery of care for patients.
Further information on team working can be found
in the accompanying resources on building effective
teams, team culture and team development.
Resource produced by Dr Nina Dutta, Dr Jude Tweedie, Dr Lewis Peake and Dr
Andrew Goddard.
The RCP and HEE will be working together to embed the principles of teamwork
outlined in this document within the training environment, so all doctors in training
programmes are supported by a team or a ‘modern firm’.
For a list of references used in this resource,
visit: www.rcplondon.ac.uk/improvingteams
Improving teams
in healthcare
Resource 2: Team culture
Developed with support from
Background
In December 2016, the Royal College of Physicians (RCP) published
Being a junior doctor: Experiences from the front line of the NHS.1 This
report identified the breakdown of the medical team as a central
factor contributing to the low morale and disengagement felt by
physician trainees. This is also reflected in previous RCP reports.2 The
benefits of high-quality teamwork in healthcare are well recognised.
Effective team working has been shown to reduce medical errors,3
increase patient safety4 and improve patient mortality rates.5 It also
leads to better staff outcomes including reduced stress6 and improved
job satisfaction.7 The RCP has produced a compendium of reports
aiming to promote high-functioning team working in the medical
setting.
This resource focuses on team culture and is one of the
Improving teams in healthcare series. The document will:
> outline the features that impact on team culture
> describe the interaction between each of these features
> offer practical steps for improving team culture in an
environment with limited resources.
2
Improving teams in healthcare Resource 2: Team culture © Royal College of Physicians 2017
What is team culture?
‘The set of underlying rules and beliefs, usually unrecognized, that
determine how everyone in your practice interacts with each other and
with patients. Culture is the way an organization “does business”.’8
How individuals in a team interact or communicate with
one another is a key determinant of team culture, as is the
reaction to bullying and the opportunity for individuals to be
able to seek help when needed. Continuity is important for
team development, but the principles outlined below are just
as relevant to short-lived teams.
Saying thank you, celebrating success and creating an
open environment all contribute to creating a supportive
setting, and are described in further detail below. Discussing
mistakes, near misses and perceived failures in a constructive
manner is also vital. An article in the New York Times
highlights the profound personal cost of near misses
and mistakes to the healthcare professional.9 The article
describes how ‘the instinct for most professionals is to keep
these shameful mistakes to ourselves’. The belief that such
events will be held against team members can be a barrier
to discussing them openly.10
The following four principles are essential to creating a
positive, effective team culture:
Encouraging members to seek help when needed
Celebrating success and acknowledging contributions
Promoting an open and honest culture
Challenging unprofessional behaviour
Resources for supporting doctors in need
NHS Practitioner Health Programme:
http://php.nhs.uk/
Royal Medical Benevolent Fund:
http://www.rmbf.org/
BMA Doctor support service:
https://www.bma.org.uk/advice/work-life-support/
your-wellbeing/doctor-support-service
Encouraging members to seek help
when needed
‘The connections formed… are vital if we
are to survive a lifetime exposed to death,
despair and disability. They protect us,
support us and sustain us.’
– Dr Claire Gerada, RCGP William Pickles lecture
Doctors have worryingly high rates of suicide, depression,
self-medication and alcoholism.11 There is often incredible
dedication from all members of the healthcare team; half
of the national workforce attended work between July and
September 2016 despite feeling unwell.12
A high-functioning team will encourage every member to
ask for help. The most efficient teams can adapt, merge roles
and cross professional boundaries when unexpected events
occur. It must be stressed however, that persistent rota gaps
inhibit teams from acting in this fluid manner. Adaptive,
responsive teams cannot compensate for chronic and
dangerous understaffing. The RCP and related organisations
lobby actively for adequate resourcing, safe staffing levels
and a focus on retention of dedicated staff within the NHS.
Within the team, creating an open environment where issues
can be discussed and addressed at an early stage will reduce
the impact on the individual, team and organisation. It is
part of the professional duty of all healthcare practitioners
to consult with other colleagues if there is a risk that a
practitioner’s judgement or performance could be affected
by ill health, and to follow any guidance received.
Where team members reveal health issues to the group, it is
vital that they are treated with compassion, confidentiality
and neutrality. It is useful to be aware of some of the
resources available for support and advice.
Improving teams in healthcare Resource 2: Team culture © Royal College of Physicians 2017
3
Celebrating success and acknowledging
contributions
Promoting an open and honest culture
Achievements in medicine occur every day from completing
a procedures list though to running a successful take,
finishing an audit, launching a new admissions pathway or
receiving a complimentary letter or thank you card from a
patient or colleague.
For teams to thrive and maintain high-quality care,
an honest and open culture must be present, with
communication pathways that support and enrich. The form
of communication (face-to-face, digital) and the frequency
of meetings will impact upon a team and its outcome, but of
greater importance is the nature of this communication and
the respect and courtesy shown to all team members.
Achieving targets is an excellent opportunity to celebrate
success. It is useful when goal setting to include some ‘quick
wins’; objectives which are meaningful and can be achieved
in the first quarter of any process. Celebrating these early
wins is essential and will help to enable a team to go on
to sustain more difficult and challenging times. Patients’
compliments can also be used to celebrate team working.
‘A culture which did not provide a
supportive working environment for staff, an
atmosphere of fear of adverse repercussions,
and a lack of openness.’15
The simplest way to show appreciation for another member
of the team is to say thank you. Working within the
unremitting pressures of the current healthcare system, it
is easy to become blind to the contributions of others. A
simple acknowledgement makes people feel positive and is a
great way of highlighting the strengths of team members.13
It is also free, uncomplicated and requires no mandatory
training. Healthcare professionals often comment on the lack
of appreciation that they receive from senior management
– the drive to change this should start where most influence
can be had, ie in local teams.
Interestingly, team performance is most improved when
the team as a whole is rewarded for good work rather than
singling out individuals.14 This reinforces that professionals
are working together as a team, with collaboration and
communication central to achieving and exceeding their
role, rather than just a group of individuals working alongside
each other. When recognising a team’s good performance, it
may be useful to seek external rewards. Examples of awards
in healthcare that are specific to teams include: the Royal
College of Physicians Excellence in Patient Care Awards, the
Health Service Journal Awards and the BMJ Awards.
Lessons from the ward
‘For me, team working is getting the
team away at the end of a night shift,
buying biscuits/cake when on the weekend,
offering to do assessments and saying
thank you at the end of a shift’.
– Francis inquiry report
Supportive cultures flourish when teammates spend time
together away from front-line clinical care. This may be
as simple as having a coffee break together or extend to
regular social events. It may appear to be low priority in
an overstretched health service, but camaraderie, fun and
friendship between colleagues are characteristics of a good
team.13
Supportive teams enable mistakes or near misses to
become learning events for all team members. Creating
a culture of learning in healthcare teams is one important
method of reducing harm and improving patient safety.16
Culture change comes from a commitment to utilising
all events as a platform for learning, to wholeheartedly
encourage all members to participate and treat these events
compassionately without blame or shame.
A core part of fostering respect in the team is by encouraging
members to have frank and challenging conversations.
Disagreements, diversity of opinion and critical appraisal
of goals are fundamental to success. Rudeness, lack of
tolerance of different viewpoints and a ‘keep your head
down’ culture are prime markers of a dysfunctional and low
achieving team.
Encouraging feedback and flattening the hierarchy have
both been shown to be effective in creating open, honest
teams.
– Consultant physician
4
Improving teams in healthcare Resource 2: Team culture © Royal College of Physicians 2017
Encouraging feedback
Routinely seeking feedback from all members
of the team, and encouraging others to do the
same, is one of the most effective mechanisms
for creating an open team culture and improves
collaboration and teamwork.
In healthcare, feedback is often relegated to
a once-yearly event, occurring awkwardly
during an annual appraisal. Repeated,
relatively high-frequency feedback is
considerably more beneficial than oneoff, especially if it occurs soon after a
complex learning event.17, 19, 20, 21
Feedback done
well improves:17
> patient safety
> clinical skills
> personal development
But what is the best way to deliver
feedback? It seems most effective
when:19
it is delivered by a supervisor
or respected colleague
it is done frequently
it includes specific goals
and action plans
it aims to decrease negative
behaviours
t here is significant scope
for improvement.
Feedback should be accurate and focus on
behaviours, not personalities. Specific examples
of the behaviour, and the impact on the team,
are useful; this is true for both positive and
negative feedback. Encouraging feedback
allows issues to be identified and addressed early,
preventing teams from falling into destructive
practices such as bullying and undermining.
Feedback done
badly can:18
> knock confidence
> be hurtful
> lead to cynicism and
disengagement
Lessons from the ward
We listened to the juniors and restructured our team. Feedback led to:
> clearer week plans on a Monday: Which consultant was on? Which registrar to contact?
> a post-board round coffee
> open feedback after a lunchtime teaching session to raise issues and ensure support
> a bronchoscopy rota for juniors to attend
Our juniors felt the benefits of better team work and lower stress levels, with clearer
plans for the week ahead.
– Consultant physician
Improving teams in healthcare Resource 2: Team culture © Royal College of Physicians 2017
5
Flattening the hierarchy
Healthcare remains one of the last professions with strongly
entrenched hierarchies. This is ‘counterproductive to
establishing and running teams where all members’ views
are accepted’.22 The best teams capitalise on a diversity of
viewpoints and reach consensus through negotiation and
priority setting.21
‘Flattening the hierarchy’ moves teams away from a rigid
flow of information progressing up the scale of seniority,
towards a fluid exchange. It enables a first year doctor to go
directly to a consultant or ward sister with information, when
this is of most benefit to the patient. It does not advocate for
a loss of respect for senior clinician experience or authority,
but acknowledges that the contributions and opinions of all
team members are crucial. Hierarchies in medicine can be
both within and between professions, eg the higher status
afforded to doctors over nurses and healthcare assistants.23
Groups with steep hierarchies tend to have members who
are less satisfied, less motivated and more inclined to leave
the group.24 Hesitancy to speak up leads to the insufficient
transfer of information from junior to senior members of
staff, which in turn can result in serious errors and adverse
events.25 Flattening the hierarchy allows all team members
to feel heard and have the confidence to speak up.26
Suggestions for lowering hierarchy include:27
creating inclusive atmospheres with daily briefings
c onsultants specifically asking juniors to ask
questions and verbalise uncertainties
routine feedback between consultants and juniors.
Lessons from the ward
‘WhatsApp has proved for us an
invaluable tool. Its use has played a
vital role in our day-to-day organisation,
rota planning and, just occasionally, the
distribution of some very silly jokes. We
have seen the growth of a community
of friendship that has transcended all
grades of doctors. It has even resulted
in the budding of a new WhatsApp
group allowing friends to stay in touch,
when placements take them elsewhere
Lessons from the ward
‘What is the reverse ward round? Well,
simply put, the registrar (it can be any
grade of doctor, but I suggest i
