How the little things can have a big impact on well-being and care

We all know how surprisingly annoying, even painful, a small stone in the shoe can be – how it can irritate us and occupy our minds when we can not get to it and shake it out.

In the workplace, there can be many different types of “pebble in our shoe” – things that do not work as well as they should and make it harder for us to work as well as we can.

These pebbles are rarely a priority to sort out, particularly in current conditions, but they can fester or combine to affect our well-being and even the quality of care we provide.

Stopping to deal with the pebbles in your shoe is, therefore, time well-spent, according to the Institute for Healthcare Improvement (IHI), a US-based not-for-profit that aims to improve the lives of patients, the health of communities, and the joy of the health-care workforce around the world, based on improvement science.

In fact, addressing these niggles can be so beneficial to our mood and performance that it forms the second step in the framework developed by the IHI for improving joy in work.

Experiencing joy in work might seem beyond reach for many of us right now, but it’s not about feeling elated all the time – the IHI’s definition of joy encompasses feeling pride, satisfaction, confidence, safety and hope, as well as the occasional excitement or buzz .

Furthermore, the IHI’s scientific approach is particularly relevant in these challenging times as it provides practical steps to improve our systems of work, which in turn helps to reduce burnout. It helps strengthen team connections, which is especially important as our world has become increasingly isolated. It’s also been shown to improve team engagement, satisfaction and productivity, as well as patients’ experience.

So, while we may not be able to solve the larger issues currently beleaguering the industry, there’s a strong business case for working together to resolve some of the irritations in daily practice life once and for all.

To get the most out of tackling the things that bug us at work, it ‘s vital to understand what really matters to our team – our colleagues’ motivations and values ​​- and why these particular issues vex us as a result. This is step one of the IHI’s framework and is vital to building the trust the team needs to talk up about what bothers them at work. Read more about this in part one of this series (VT51.49).

Pebbles in your shoe

“Pebbles in your shoe” have been formally described as the processes, issues or circumstances that get in the way of meeting our professional, social and psychological needs.

This is a broad definition that caters for the wide variety of life’s imperfections and how we, as individuals, all react differently to them.

As we well know, we all have our own particular bugbears. What’s more, no two workplaces are identical, so there are impediments to joy unique to every practice.

It’s important to note that there are “pebbles” – things that get under our skin that the team can work together to resolve – and then there are “boulders”, or major issues at an organizational level, such as workload and staffing levels, that require senior support to address effectively.

Identifying what’s under our control, what we’re able to influence, and what’s beyond our control is key to making this a satisfying and effective endeavor.

To set the scene for productive conversations, preparation is essential. There’s the format and timing to think through, who will facilitate, and how to broach the subject with colleagues, among other considerations (the same groundwork for the “what matters to you” conversations in step one of the IHI framework applies here).

It’s crucial the whole team is clear about the overall goal of these discussions, and that achieving joy in work is a shared effort that can take time to accomplish.

As mentioned earlier, trust is the cornerstone of valuable conversations and this entails a feeling of psychological safety. Team members need to be confident they will not be punished for speaking up with comments, questions or mistakes and need to feel comfortable being themselves, in order to share private concerns and constructive critisms.

Simple, direct questions can help get thoughts flowing. What obstacles are there to what matters to you (the “pebbles in your shoes”)? What gets in the way of a good day?

Colleagues may be forthcoming given their experience of the conversations in step one and especially in light of the immense difficulties confronting the industry at present. Generalities or extremes sometimes crop up when people have the opportunity to exorcise long-held frustrations. In these cases, follow-up questions can help clarify specifics, for example: “What happened yesterday that would be an example of that?” or “The thing that frustrates you is… – is that right?”

With the best will in the world, there will always be those who are less keen to speak up even though they will informally discuss their views with colleagues.

Seeing less-reserved colleagues air concerns without interruption and, furthermore, seeing these concerns acknowledged and recorded as a basis for action, can go a long way towards overcoming cynicism.

When the conversation leader encourages the team to start thinking about tangible measures that could be put in place to address impediments that have been raised, this gives out a signal that contributions are being taken seriously, which can also convince reluctant colleagues to take part.

If necessary, a conversation leader gently invites all team members who have not contributed up to that point to share an idea. This can reassure shy or nervous colleagues that it’s genuinely okay to express an annoyance.

It also serves to demonstrate equal respect for all practice members and helps build camaraderie.

Part to play for everyone

There’s a part for everyone to play in building a more joyful workplace. Regardless of role, any team member can be a conversation facilitator or scribe, as long as they have the relevant strengths.

A trusted colleague can help the facilitator practice and build their confidence. Others can work together to review the pebbles that emerge during the conversations and to identify common themes. Others again can start to determine priorities.

The team as a whole needs to agree which issues to work on first to ensure everyone is on board with the project and process. Essentially, creating an environment in which everyone can take more joy in their work is a collaboration, not a task that is given to a team or done for them.

It is critical to note down all the pebbles that are mentioned and display them in full somewhere prominent in the practice, even if they will be dealt with further down the line or escalated to management as “boulders”.

Ideas for changes can also be included (the next step in the framework focuses on how to tackle pebbles as a team). A complete and visible list of pebbles underscores the structure of the process, illustrates an ongoing commitment to the project, and confirms there is value in everyone’s views.

Do make it clear that the list isn’t set in stone – people can always add pebbles and ideas at any time.

For those concerned about embarking on a new undertaking given current pressures, lessons learned from human health may be reassuring: just start.

Don’t waste time overthinking conversations or second-guessing points that might be raised. Start small and go slowly if necessary, to be sure that change is going to be effective in tackling an issue.

Firm foundations at the beginning may allow the pace of change to snowball as time goes on and confidence in the project grows.

Sustained commitment

Restoring joy requires sustained commitment from the whole team. Colleagues need to work together to monitor and update one another on the effectiveness of measures put in place, and to change tack if required.

To do this, teams need to draw on a range of tools including those used in quality improvement, which involves a systematic and coordinated approach to solving problems, using specific methods and tools to bring about measurable improvements.

Experience shows that working on pebbles periodically can focus attention on them and ensure this work has not been forgotten in this busiest of times. It is recommended to involve different people at different stages or on different pebbles to maintain momentum and energy.

Above all, be sure to communicate progress to keep colleagues engaged. Why not use a wallchart, moving the pebbles through different columns representing each stage of improvement?

The team will then be able to discern overall progress at a glance and can add fresh pebbles and ideas for improvements at any time, strengthening the living nature of the project. A visual reminder of improvements that have been made and work to be done also serves as proof of the spent combined and ongoing dedication to making work smoother and more satisfying for all.

It’s helpful for one person – it could be anyone in the team – to be responsible for keeping an eye on the chart, and organizing times for the team to consider new additions and agree on priorities and actions.

However, to make headway on boulders and make the drive for joy a permanent part of working life, it is essential to have consistent support at a senior level.

Using data from clinical audits to evidence the need for change – or the value of changes already made – can be a powerful way to attract managers’ interest and support.

When teams make and celebrate progress, this generates energy, happiness and productivity, which all appeal to leaders.

Sustained leadership engagement is irreplaceable in tackling the bigger issues that stand in the way of achieving joy in work. In smaller practices, this can be as simple as a manager having regular, informal conversations with team members over a coffee about what bothers them on a day-to-day basis and whether they feel safe.

In larger practices, it is sensible to schedule in these conversations, especially when senior leaders are based elsewhere or are new to the framework. Regular, informal walkrounds can help leaders acquire an up-to-date grasp of issues at the coalface and the current joy in work activity, as well as demonstrate commitment to the drive towards joy.

Leaders can quickly gain a sense of the work to be done by simply asking: “Do you feel prepared to succeed today?”, “When you do your work do you feel it is appreciated by someone else?” or “Does the work you do add value to your life?”

Sometimes, leaders are hesitant to get involved as they simply do not know where to start.

The IHI has a resource on human health walkrounds that can be useful here, including aims, conversation starters and measures of success.

Problems or “pebbles” can’t always be shaken out overnight, but shaking up the status quo by truly listening to one another, strengthening human connections and empowering colleagues to solve problems together can put the team on the path to greater joy from day one .

Useful free resources

What’s the pebble in your shoe? conversation guide:

Video: Introduction to quality improvement in veterinary practice:

Free CPD: Getting started with Quality Improvement:

Root cause analysis in action and the cause-and-effect template:

Feature: Human factors for safer care and a better cup of tea:

Podcast: Getting your team on board to deliver quality improvement:

IHI Patient Safety Leadership Walkrounds tool (register to access):

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