Author: Tom Bannister / Editor: Charlotte Davies / Codes: SLO7 / Published: 10/06/2024

This blog starts to explore workplace culture. I will not be able to do justice to the depth and nuance of this topic. But I offer you this invitation to join me on a journey of self-discovery in three parts. What is culture? Why is culture so hard to change? What can I do about it?

What is culture?

If you want to see how culture works in an Emergency Department (ED), just confidently announce that it is looking “quiet” today.

Immediately, you will be admonished.

The taboo around “the Q word” is so strong that anyone in the department will gladly police your behaviour. A healthcare support worker will happily tell off the medical director for such a wanton cultural infringement.

There are many wonderful things about the culture of Emergency Medicine. But we also have our problems.

The Emergency Department is a pressure cooker of pain, uncertainty, and emotional distress. It’s no wonder we aren’t our best selves at work. That means there’s plenty of inappropriate behaviour on display, which sadly contributes to our culture.

The ways we harm each other at work have many names. Sexism, racism, and incivility just scratch the surface. Each of these has their own history, deserves their own attention, and needs to be tackled in their own way. But each is also a facet of our culture.

The Royal College of Emergency Medicine has recently formed an “Improving Culture in Emergency Medicine” working group. So, what is culture and how do we improve it?

Culture is what we accept as normal

Culture is enacted. We learn it from our day-to-day experiences of interacting with each other. In any group, the sum total of our behaviours forms our culture. We are shaped by culture. It influences the behaviours we choose. And in turn we shape culture. Our behaviours contribute to it. Culture is something we are constantly creating together.

Culture is the informal set of rules that tell us what is, and is not, acceptable. Every time we witness a behaviour that someone “gets away with”, we learn it is acceptable in our culture. Every time we allow an inappropriate behaviour to go unchallenged, we teach everyone it is acceptable. We are always learning. We are always teaching. We are always influencing culture, even when we’re silent.

What can I do about it?

There is nothing inevitable about our culture. We make it. We can change it.

I directly and indirectly contribute to cultural problems. The solution to both issues starts with self-work. Change begins with me.

In the first case, I can change my behaviour so I stop directly contributing to cultural problems. In the second case, I can learn to treat myself with kindness and compassion so that I have the capacity to challenge inappropriate behaviour with care, calm, and curiosity.

I directly contribute to cultural problems

Some of my behaviours are unintentionally racist, sexist, and transphobic. I choose to do better. I will need to educate myself, sensitively seek feedback on the impact of my behaviours, and be prepared to change. This is vital self-work.

As well as increasing my self-awareness, I need to increase my self-acceptance. If I can learn to like myself a little more then I will become less reliant on those around me for validation. If I am at home with myself then I can navigate a broader array of situations without perceiving threat. I can come into contact with behaviours or lifestyles I don’t understand and approach them with curiosity rather than fear. A more centred version of myself will less readily feel threatened by things I don’t understand.

Action for me: Learn about the experiences of marginalised groups to better understand other perspectives on the world. Learn about common microaggressions marginalised groups experience and reflect on which of these behaviours I still engage in. Get a coach and focus specifically on my workplace behaviours.

I indirectly contribute to cultural problems

I indirectly contribute to cultural problems when I stand by in silence. Every unchallenged example of inappropriate behaviour adds to our existing culture. My silence is an endorsement.

I can start by separating the behaviour from the person. Behaviours need to be challenged. But people need to be treated with kindness.

Inappropriate behaviour can be a manifestation of fear. People express their most challenging sides when they feel threatened, afraid, and unsupported. But inappropriate behaviour doesn’t typically invite care, compassion, and curiosity. Only if I am engaged in my own self-work will I have the capacity to sit with my colleague, whose behaviour has done harm, and show them kindness rather than anger, judgement, and blame. I need to be rested, calm, and peaceful.

Rather than “calling out” the behaviour, I can “call in” the person. Maybe we get a coffee together. I can ask them to help me understand what the world looks like from their point of view and what is driving their behaviour. I can invite them to see the world from a different perspective. I can let them know, in non-violent terms,4 about the impact of their behaviour. And together we can consider what we could do differently next time.

To be very clear, I’m not suggesting policing behaviour to virtue signal and bring shame on a colleague. I’m talking about the importance of using moments of inappropriate behaviour as opportunities to build connection and understanding. To bring people closer together rather than drive them further apart.

I have talked about challenging inappropriate behaviour, but it is vital to prioritise the needs of the person who has been on the receiving end of that behaviour. We must ensure their safety and wellbeing in the first instance.

Action for me: Practise using non-violent communication to describe how I feel in response to a behaviour. Normalise coffee breaks with colleagues where we talk about the impact of our behaviour in the workplace. Seek out Active Bystander training.

Why is culture so hard to change?

Culture rewards and punishes

Acting in accordance with the existing culture is socially rewarded. It shows everyone that we know the rules. We belong to the “in group”. Our shared culture is how we signal our collective identity and meet our need to belong to a group.

Deviating from the existing culture is socially risky. We might be identified as someone who doesn’t know the rules and is an unwelcome outsider, or we might be seen as an agitator, someone who is deliberately trying to rock the boat.

Policing the existing culture is socially rewarded. Pointing out where the behaviour of others deviates from established expectations signals our knowledge of the cultural norms and entrenches our “in group” status.

We find familiarity comforting, even if it is harmful to us. We simultaneously feel at home in our ED whilst also acknowledging the harm we suffer from the racism, sexism, and incivility that we experience there. Change itself can feel threatening or destabilising.

Culture is normative. Our sense of what is normal, is based on our experience of what is common. A single counter-cultural act doesn’t establish a new normal. It takes a lot of repetition to make a significant shift.

Culture arises from the interactions of everyone with everyone else. So, whilst each of us is instrumental in establishing culture, no single person can change it entirely on their own. We all need to behave in accordance with a new culture for it to take hold.

The higher and more secure our social status is, the more cultural influence our actions have. However, social hierarchies, which offer cultural influence, are culturally determined. Those best placed to change culture are those who benefit most from the existing culture.

Action for me: Reflect on the cultural influence I have due to my place in our social hierarchy. Reflect on the cultural impact of my actions and inactions. Reflect on why it might feel risky for other people to defy our current culture.

Culture doesn’t exist in a vacuum

Each of us grew up in a national and global cultural context. We have taken onboard ideas about how society works and is structured. We reproduce those ideas in the workplace because they feel “natural”.

It’s easy to have an ingrained sense that: Senior roles are naturally filled by White people. Certain tasks suit men better than women. Heterosexuality is normal. If you have come from abroad to work in the UK then you should be grateful for the opportunity. If you work hard you can achieve anything. The “best” candidate should be offered the job. A person of colour is rarely the “best” candidate.

We can label these ideas with words like racism, sexism, and homophobia. We can also spot ideologies such as neoliberalism, neocolonialism, and White supremacy showing up. We may not be consciously aware of these influences, but they define our sense of what is “normal” in society. These are the cultural templates we follow in our Emergency Departments.

If I want to change culture I will need to unlearn some of what I have been socialised to believe is normal.

Action for me: Educate myself on the ideas and ideologies which shape our society and how they show up specifically in Emergency Medicine. How does structural racism influence who receives rapid tranquilisation? How does recruitment of international medical graduates to my Emergency Department reinforce neocolonialism?

Conclusion

For me, the starting point for improving culture is reflection and self-work. I need to be able to show kindness to myself and my colleagues even in the most challenging situations. That requires an inner peace that only comes with practice. It will require thoughtful, proactive, and sustained effort.

This blog is a call to embrace the difficult and never-ending task of enacting the culture we want to see. I hope you’ll join me on the journey.

RCEMLearning blogs try to subtly change culture – how many of the blogs below emphasising the importance of communication have you seen?

What about the blog on Supporting Overseas Doctors (IMGs)? 

And finally, have you read our series of blogs on unwanted behaviour?

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References

  1. Johnson G. The Q**** Study – basic randomised evaluation of attendance at a children’s emergency department. Emergency Medicine Journal, 2010;27:A11.
  2. Calling In and Calling Out Guide. Harvard, Diversity Inclusion & Belonging.
  3. Hickson, Gerald B. MD; Pichert, et al. A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors. Academic Medicine 82(11):p 1040-1048, November 2007.
  4. Rosenberg MB. Nonviolent communication: a language of life. 3rd edition. Encinitas, CA, PuddleDancer Press. 2015.

Further reading