The NHS needs to look across the waters to learn from the Navy – which does better at making employees feel valued, write Nishma Manek and Richard Jones
I gave you my heart
But the very next day you gave it away.
To save me from tears
I’ll give it to someone special.
These lyrics might resonate more than usual with junior doctors this Christmas. A year ago, it would have been hard to imagine what was to come: the incendiary placards, the data tossed into the arena with fingers in ears to silence the aftershocks, the gut wrenching withdrawals of care whilst linguistic warfare like “imposition”, “nuclear options” and “militancy” filtered into vocabulary.
Six interrelated elements that underpin morale were identified: a clear sense of mission, leadership, communication, care for people, safety, and training
On the frontline, morale has been sapped. The Nuffield Trust’s survey of 100 health leaders found almost 60 per cent thought that morale had deteriorated at their organisation. For a system that’s propped up by the goodwill of its staff going the extra mile, restoring the psychological contract with the workforce should be top of the Christmas list for most.
Can we learn from other fields and their expertise in navigating such choppy waters?
As part of an MSc in leadership, consultant cardiologist Richard Jones spent 10 days with the Royal Navy on a type 42 destroyer with 280 crew members. The warship is a hugely complex organism, and to be effective it is essential that disparate tribes work collaboratively to produce a fighting ship. The similarities with our hospitals are patent.
In the Royal Navy, the Captain is acutely aware of the need for high morale if the ship is to “fight” with a crew that goes the extra mile, and works tirelessly to guard against threats to it. A commanding officer will weigh every important decision against two outcomes: firstly, how will this decision affect operational capability (performance), and secondly, how will it affect morale?
This seems a world away from healthcare: do we give morale that degree of prominence to our decisions?
Having observed the crew on board and conducted interviews with senior naval officers, his thematic analysis identified six interrelated elements that underpin morale: a clear sense of mission, leadership, communication, care for people, safety, and training.
Clear sense of mission
The Navy ensures that every member of the crew understands its mission and has clarity over their goals.
Perhaps one of the problems is that, for junior doctors, the mission itself has become foggy, exacerbated by travelling the system merry-go-round so frequently. The relative weight clinicians are meant to give to targets of time, quality, safety, cost and efficiency seems to shift shape too often to remain meaningful.
The single most important factor in promoting high morale in the Royal Navy is leadership.
Every interaction, by every leader, at every level, shapes the culture of the organisation
Specific leadership behaviours observed include the use of respectful language, creating a culture of constant feedback, and an awareness that the leader sets the mood. The capacity for low mood and irritability to spread like wildfire throughout the ship was undeniable.
Rekindling morale amongst junior doctors will no doubt be the responsibility of our leaders. Teams sailing solidly on a wave of high morale, withstanding buffeting from external threats, frequently have at the helm a compassionate leader who embodies the behaviours they wish their juniors to exhibit. Prof Michael West says: ”every interaction, by every leader, at every level, shapes the culture of the organisation”.
But how much training are clinical leaders given in leading people?
Multiple routes were used to inform the ship’s company of what was happening, with careful thought behind the tone of the message.
Finding the time to make human connections, remembering names, and simply understanding the person behind the name badge can breed empathy
How often do junior doctors lament the lack of communication from their employers? Receiving rotas that dictate the pattern of our lives for the coming months just a week in advance, for example, should be unacceptable.
And moreover, do we hide behind emails and bleeps too often? Finding the time to make human connections, remembering names, and simply understanding the person behind the name badge can breed empathy, which forms the foundation for increasing morale.
Care for people
The Royal Navy has developed a culture of constant feedback and high quality appraisal, with a recognition that the lives of crew members extend beyond the work environment. For example, the Captain personally takes responsibility for writing frequent letters to family members back home, explaining their activities.
The two most important questions a leader should ask at an appraisal are simply, “how are you?”, and “how can I help?”
For junior doctors, too often formal meetings with supervisors are spent huddled side by side looking at a computer screen, precious time being eaten up trying to tick the right boxes of an archaic portfolio system. These are wasted interactions to reinforce that regimental spirit that faded with the longer working weeks.
Can we reassess the role of appraisal and the meaningful opportunities they might provide? As Nick Harding, a founding partner of the Modality GP partnership, says, the two most important questions a leader should ask at an appraisal are simply, “how are you?”, and “how can I help?”
Senior ratings take a personal interest in the safety of the younger members of the ship’s company, often at sea for the first time.
The Navy are not the only organisation to prioritise creating a safe culture. Google, for example, identified the most important factor for the success of its teams to be the presence of “psychological safety”.
Physical safety might be a given in a hospital environment, but a culture of psychological safety is far from guarenteed. This is a prerequisite for junior doctors to truly engage with quality improvement. These opportunities can be a potential boost to morale.
The Navy ensures sailors are thoroughly prepared for leadership and life-threatening events through simulation.
Could a stronger emphasis on simulation of clinical emergencies for junior doctors have a similar effect? Practising for rare but life-threatening emergencies builds stronger team relationships, reduces anxiety, and gives confidence that any threat can be managed.
Like sailors working away from home for many months in an uncomfortable environment, junior doctors in the NHS can endure a great deal.
In the Royal Navy, morale is viewed as the indispensable glue that ties its tribes together in their mission. There is a clear understanding of the principles which promote it, and an active strategy to guard against threats which may undermine it
However, the junior doctors dispute was the consequence of removing the last brick of a precarious Jenga tower; a skeletal foundation that no longer signalled our professionalism and our value to the system. It marked a long period of the NHS simply not doing the ‘H’ in HR very well. In fact, sometimes the ‘R’ too, as we felt less and less like resources or assets to be harnessed, and more like commodities to be moved around at whim.
In the Royal Navy, morale is viewed as the indispensable glue that ties its tribes together in their mission. There is a clear understanding of the principles which promote it, and an active strategy to guard against threats which may undermine it.
Resetting the psychological contract with junior doctors and restoring morale will involve navigating tricky and unfamiliar terrain. But for as long as we expect our workforce to give much of themselves to their jobs each day, a look across the waters to learn from organisations faring better may well be a worthwhile investment.
Nishma Manek, national medical director’s clinical fellow at NHS England; and Richard Jones, consultant cardiologist, Queen Alexandra Hospital, Portsmouth