Undermining in the ED

Authors: Dan Darbyshire / Editor: Charlotte Davies / Codes: CC15, CC7, CC8, SLO2, SLO7, SLO9 / Published: 08/03/2022

To follow on from the RCEM Learning blog on Bullying in the ED we will move on to an unwanted behaviour that, while it shares some characteristics with bullying, is distinct.

In their review of undermining and bullying of medical trainees, published in 2015, the GMC defined undermining as “behaviour that subverts, weakens or wears away confidence.”

Unlike bullying, undermining does not have to be repetitive, intentional or involve an imbalance of power. This difference means that undermining is a far more common experience. The 2020 EMTA survey found that over one-in-four trainees had experienced undermining in the four weeks before the survey, significantly more than had experienced bullying (10%) or harassment (7%).

The EMTA survey data, along with similar data from the GMC annual training survey, suggests undermining is very common. Before we work through a couple of examples of what undermining is, it is worth spending a minute clarifying what it is not.

Negative feedback isn’t undermining.

Being a healthcare professional is about lifelong learning, and occasionally getting things wrong. We have a duty to provide feedback to colleagues about this and take on board feedback ourselves. Sometimes when feedback is given, with the intention of improving competence and confidence over the long term, confidence can take a hit in the short term. I know I have experienced this when I have made a mistake. And if someone’s feedback doesn’t land right, it may have the effect of accidentally undermining someone. This becomes a problem when it is deliberate or repetitive.

Example 1

You are in handover at the end of your shift. The supervising consultant makes comments about the management plan you have instigated for every patient. The comments are all negative though you can’t identify anything in particular that you have done wrong.

The consultant here may think they are providing feedback, but the public space and lack of any constructive criticism mean that it is unlikely to be interpreted in these terms. The timing is also poor, unless something is safety critical it is rarely helpful or necessary to provide this information when someone is exhausted at the end of their shift.

Every time you are in handover with this particular consultant you experience similar things. You begin to dread these shifts and avoid picking up patients for fear of the criticism you will inevitably receive.

The behaviour in the first instance is now more clearly undermining, and because of the imbalance in power and, in the second part of example, repetitive nature of the behaviour, may be considered bullying. This is one reason why undermining is potentially so harmful for those who experience it. The example also shows a major concern with all of these unwanted workplace behaviours; the impact they can have on the care we deliver and patient outcomes (see the civility saves lives campaign for more information).

Learning how to give effective feedback is one way to try and stop yourself from lapsing into something resembling the start of the first example (there is a RCEM Learning blog around this).

Example 2

You are coordinating the department and one of the more junior doctors presents a case to gain some help with the management plan. You listen intently and suggest some changes to the proposed management. Your colleague asks you the rationale for the changes so you explain the problems the initial management might cause and the advantages of the revised plan.

This scenario will sound very familiar from the perspective presented and seems to represent many elements of good practice. However, the experience of being on the receiving end may on occasion not match the intended experience.

You are a few weeks into your emergency medicine placement and are not sure of the process for managing a particular diagnosis. You present the case to the senior coordinating the department who makes suggestions and proceeds to tell you why every part of the initial plan was wrong. You know what to do for the patient now but feel overwhelmed with the volume of criticism and are still not sure why the suggested plan is better.

Undermining is a common experience. One of the free-text response to the 2020 EMTA Survey highlights one reason why this might be the case:

“Sometimes people do undermining, not even realising, when under stress. Managing stress on the shop floor is skill, especially when understaffed.”

The scenario in example 2 does not mention stress or service pressure, but it is easy to imagine how these might lead someone to not take the required time when providing feedback and delivering it in a way that undermines someone’s confidence.

There is a huge amount of grey area between these two examples. This really highlights the difficulties faced trying to eradicate undermining. The GMC report really emphasises the importance of a positive departmental culture; changing culture is notoriously difficult but the EM Leaders module on changing culture is a good place to start.

Another resource is the workplace behaviours toolkit produced by the RCOG. While not EM specific the content is well produced, free to access, and the principles are all relevant.

Summary

Undermining can be unintentional. It can even occur despite our best intentions. So, how do you stop yourself from undermining a colleague? Reading this was a great start, but you can do more. Your site’s annual GMC survey results will not be specific to you. Still, they might give you insight that such behaviours are present in your department. Next time you have your practice of running the shop-floor observed, ask the person watching to look for signs of undermining. Ask yourself if people are reluctant to come to you for advice? Ask people to who you have provided feedback to complete your MSF.

If you identify that you have undermined, what can you do to improve? Try and check how your feedback has landed. Stop thinking you are giving feedback to the nightshift team—thanks and encouragement are all that is appropriate. A WPBA at a more appropriate time is a better option. But perhaps most importantly, being guilty of undermining someone does not make you a bad person or a lousy emergency physician. But ignoring the problem and failing to try and improve it may very well be a red flag that you are struggling.

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3 Comments

  1. Sunil Gopisetty says:

    Realistic

  2. Ms. Jacqueline Toovey says:

    Thank you for this

  3. lords says:

    Good highlight of when we may inadvertently be seen as undermining.

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