The view from the corridor

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The following blog is from LfE fellow, Alison Jones.  Alison’s professional role has changed significantly during the pandemic, and here are her reflections on her recent experiences:

 

One of the central tenets of Appreciative Inquiry is the importance of storytelling or the power of narrative. MariaSirois said in her DLCCenterforAI webinar that if we talk authentically about how we have lived events, our story will resonate with someone, somewhere and as a consequence meaning will be added to both experiences. This story was part of my #COVID19 experience:

I have a background in adult ICU nursing but haven’t been registered with the NMC for many years. With the onset of the pandemic my greatest wish was to regain registration and join my colleagues on the ‘front line’ to help ‘fight’ this dreadful virus (the language of war we so easily adopt in these scenarios). It soon became clear that I had been away from the bedside too long to qualify for expedited re-registration; I was deeply disappointed and also experienced a strong sense of guilt at not contributing in the way I felt I should.

And so my role during COVID19 became that of ‘clean runner’ outside the intensive care unit at the children’s hospital where a new zone was created: an area made necessary by COVID19 isolation procedures. In this space, along with numerous hand sanitizers and the sequential PPE donning stations (first a gown, next a mask, then goggles, visor and finally gloves) a new team convened whom I shall call the Corridor Crew!

Once a nurse is in PPE and through the unit doors, s/he cannot come and go from the patient’s bedside out to store rooms and facilities beyond the isolation area. So they need ‘runners’. Runners for supplies – linen and IV fluids, blood products and medicines, ventilators and feed pumps; send swabs and specimens, bring tubes and wires.

In my role as a clean corridor runner I have been struck by the variety of people and emotions and responses passing through and gained a new perspective on this COVID experience: the view from the corridor:

Mums

Some in wheelchairs hours after an emergency C-section, some beginning to establish a routine – new normal. Post-partum people trying to heal and bear milk (often difficult enough at home with a healthy baby) now having to navigate the land of critical care, separation from baby, family, other children maybe … and carers in full PPE another type of separateness. I see in them dependency, vulnerability, shock and disbelief – how on earth did I get here? 3 weeks ago I was a chief exec/happy-go-lucky 17 year old/ran my own business/had all my ducks in a row.

But the thing I remember most is what they said to me in that corridor: ‘I have never met so many lovely people in one place’ and, tearfully, ‘you are all so kind, I can’t thank you enough’

Dads

Red-eyed dads displaying anguish, fear and frustration. Not in an aggressive way, although I know that happens too, but in a keyed-up, dumbed down sort of desperation. Through no fault of their own they are facing their greatest challenge; not only does their child require intensive care, but the world is in lockdown, global pandemic. Visiting is restricted, medical teams are cloaked in PPE and of all things, touch is prohibited. We witnessed brave but ever so slightly broken young dads walk past whilst we simultaneously adhered to social distancing and resisted the most natural instinct to give physical reassurance. Caring at arms length takes its toll on all of us.

Seeing, thinking, feeling these things emboldened me to enquire – how are things today? (eye contact, be brave, the answer might be tough to hear but it’s his answer and this is how we must express our love in the time of COVID).

The Day Shift

Mindful, rehearsed, #weareinthistogether. As they calmly progress through the donning stations I hear breathing exercises, the odd mantra and, whenever I ask ‘Are you hydrated? Feeling OK? Ready?’, ‘As I’ll ever be! Oh yes! Absolutely!’ come the replies. Thanks to stellar leadership from the ICUnurse management team we are as prepared as we can be for the daily evolution of the COVID19 response.

Throughout the shift they appear at the unit entrance often with gloved hands folded, steady eye contact and clear articulation through the mask: ‘Could I please have the special feed for Sally Morris, the blue thingy that adds a neb to the vent, some Micropore and a small sharps bin. The nurse next to me needs a temp module for the Philips monitor and 2 Weetabix cos her patient has kept free fluids down for 4 hours. I’ll come back for them, thank you so much’. They turn on their heels, speed walking back to their patient so they don’t waste a minute of care-giving time.

Short, frequently interrupted conversations punctuate the clean corridor day. Full of intimate details shared now like they never would be on a normal office day. Brief exchanges spanning the whole of our current existence: the grey roots showing in our hair (reframe: appreciation of hairdressing as a craft), supermarket queues (reframe: how lucky are we to live in a land of plenty), Generation C19 – adolescents with no exams and no motivation, the death of a neighbour (oh god, I’m so sorry) and dad’s had surgery so urgent not even COVID19 could stop it …nurses have lives too.

To The Corridor Crew:

27,000 steps today. We bring our whole selves to the job at hand – manning the corridor can be a fetch and carry task or an observing, serving, providing, learning experience

I know more about you now than I did before [Simon/Esther/John/Jen]

More unites us than divides us [tech/stores/pharmacy/labs/housekeepers/admin]

(Corridor) Music soothes, lightens, connects and heals

Thanks for the opportunity

So often we dismiss the value of our own stories and dwell on what we are not.We must cultivate an appreciation of who we are and the stories we have lived; show up to the situation as we can and bring our whole selves to the task. And the best stories end with an invitation into the next chapter so, when you tell your stories of what happened during COVID19, enrich them with how it made you feel, who or what inspired you and what good has or could come of the experience.

Alison Jones

Hawks and Doves

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I just spoke about LfE to some laboratory staff. There was an excellent question from the audience (paraphrased):

“I perceive excellence as rare and exceptional. As a ‘hawk’ this makes sense to me. Is LfE about capturing this stuff, or more about the everyday ‘good’ activities?”

In my answer I tried to articulate that excellence is subjective. It doesn’t come with a priori definitions. It also doesn’t have to be intimidating. We have thousands of LfE reports from our institution and the vast majority describe a simple episode of non-technical activity involving one or more colleagues. On the face of it these reports often seem to be descriptions of ‘people just doing their jobs. But in every case, there was something excellent about the episode, in the eyes of the reporter.

That is all that is required to trigger an excellence report. The positive feedback is powerful and informs the recipient about the impact of their actions, the extent of which is often not known by the recipient until the report arrives.

Hawk or dove, you can use LfE to show appreciation to colleagues, based on your own definition of excellence.

 

Adrian

Show me the “learning”

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Questions from the sceptics: 2. Show me the “learning”.  This is the second in a series of short blogs about common questions we receive about LfE.

I’m sometimes asked to demonstrate the “learning” from learning from excellence.  Often, LfE is regarded as a mere “pat on the back” for a job well done:  a harmless initiative, but not of any tangible utility.  What is the actionable intelligence?  Where is the “learning” which can be transferred from one situation to another?  This view of LfE is missing the effect of feedback on performance.

The core of LfE is a simple, formal positive feedback tool, which allows peers to show appreciation to each other.  Recipients of excellence reports are made aware of the positive effects of their actions.  This gives them the opportunity to reflect and think about why their actions were so well received.  This may prompt comments like “I was just doing my job”, yet staff members often go on to make changes in their future behaviours based on the new awareness they have of their positive actions.

So the principle type of “learning” in LfE is the same as the learning we experience from any type of feedback.  The main difference is that LfE is exclusively positive feedback – an extremely rare phenomenon in today’s NHS.

Adrian

Could Learning from Excellence be enabling compassion to flow?

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I’m delighted to introduce a guest blog from Andy Bradley from Frameworks 4 Change.  Andy’s blog starts with his thoughts on a recent LfE event in London:

 

Could Learning from Excellence be enabling compassion to flow?

To change an organisation, change its stories

Gary Hamel, London Business School

I spent four minutes in total listening to an orthopaedic surgeon at a workshop on Learning from Excellence at a national patient safety conference. I did not find out the surgeon’s name but here is what I did discover:-

He had received some positive feedback in writing from a patient who had felt anxious about her planned surgery. The feedback thanked the surgeon for his calm, caring demeanour and the patience he showed in answering the patient’s questions and allaying her fears. As a result of receiving this feedback I discovered that the surgeon felt happy and proud. As a result of our conversation, in which he spoke and I listened, the surgeon had decided to go back to the team he works in to suggest that they start gathering data specific to how well prepared patients feel for surgery – he was thinking about a likert scale with space for a qualitative comment – he was thinking that the importance of preparation in terms of the patient experience could be overlooked and that by focusing on this area a range of improvements were possible.

We had been asked in our pair to think about:-

A story of excellence in care

How the story made the story teller feel

What could be done to create more of the moments shared in the story

The Learning from Excellence Philosophy

Safety in healthcare has traditionally focused on avoiding harm by learning from error.  This approach may miss opportunities to learn from excellent practice.  Excellence in healthcare is highly prevalent, but there is no formal system to capture it.  We tend to regard excellence as something to gratefully accept, rather than something to study and understand.  Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation.  It is time to redress the balance.  We believe that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale

Does pride helps us to deal with shame and release compassion?

Your mind is like a garden, whatever you focus on grows

Matthieu Ricard, Bhuddist Monk

The fear referred to in the Learning from Excellence philosophy drives the dominant narrative in health care – the rules and rigidity increase in relation to the fear which often manifests in the individual as guilt (I have done something bad), internal shame (I am bad) or both.

In their book the Archaeology of Mind: Neuroevolutionary Origins of Human Emotion Jaak Pansepp and Lucy Biven throw light on the neural sources of our human values and basic emotional feelings. The ‘primary processes’ which are located in deep areas of the brain include fear, rage, grief and care. The secondary process in which we make sense of these primal feelings and begin to integrate our experiences are empathy, trust, pride, blame, guilt, and shame.

Primary processing in medicine is complex – when culture and practice is healthy care is clearly central but when things go wrong fear and panic can set in and cultures can become toxic In these circumstances secondary processing in healthcare is dominated by blame, guilt and shame – which may help to explain why the system is experienced by many as institutionally defensive.

Learning from Excellence fosters pride in accomplishment and is grounded by noticing and giving voice to appreciation this may help practitioners to come to terms with guilt and shame. Paul Gilbert OBE, the founder of the Compassionate Mind foundation has concluded from research that the number one block to the flow of compassion (self to self, self to other, other to self) is shame.

So, here is what I am thinking now….

by generating pride and making appreciation explicit could Learning from Excellence help to balance the health care system by enabling the flow of compassion?

Andy Bradley

Frameworks 4 Change

Isn’t this all just a bit “touchy-feely”?

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Questions from the sceptics:  1.  Isn’t this all a bit touchy-feely?

This is the first in a series of blog posts, reflecting on some of the comments we hear about Learning from Excellence.  This one is from Emma Plunkett

I talk about Learning from Excellence (LfE) a lot these days. I’ve presented the concept and the practicalities of the initiative at many different local, regional and national meetings and am generally met with a positive response. People can usually see the value in having a system for acknowledging and appreciating the work of colleagues. In addition, more people are becoming aware of the concept of safety-2 and understand the importance of learning from when things go right.

But naturally, as with any new idea, there are sceptics. Some people just don’t get it. Or maybe they can’t. One of the recent questions I have had from people struggling to understand the point of the initiative has been, “Isn’t this all just a bit touchy-feely?” When people have a really different perspective from mine, I try to understand their paradigm. I’ve found it hard this time, perhaps because the question came after a presentation describing all the uses of LfE (that’s another blog in itself). I find it hard to understand why someone wouldn’t agree that excellent work is to be appreciated, valued and investigated, so we can make more of it happen.

I’ve been thinking about how I should answer this if it comes up again and I’ve realised that my problem with the question is twofold. Firstly it’s the negative connotations associated with the phrase “touchy-feely”, which is often used to belittle the importance of emotional connections. It’s strange how a positive initiative can be “touchy-feely” in a somewhat undesirable way, whereas something with negative emotional consequences would never be described like that (or at least I hope it wouldn’t). Why can’t we equally value positive interactions? And not dismiss them as something sentimental that carries less value. It also implies that the praise is unrestrained or overstated. Importantly, this is not the case with LfE. The honest and sincere nature of the reports we see is key to their value; exaggerated or artificial praise becomes patronising and does not work, and LfE is not about this.

My second problem is with the word “just”. There are elements to the initiative which are deliberately and importantly emotional. But there is much more to it. “Just” in this context represents an excuse to dismiss LfE as something trivial and although some reports are about small events, all of them have made a difference to the people involved, and none of them should be rejected as inconsequential. LfE can’t be pigeon-holed into being “just” one thing – it is about reflection, appreciation, improving morale, improving quality, service development and creating a culture of learning.

For me, work is made worthwhile through connecting with others, be they patients, relatives, or colleagues, and making a difference to their lives. LfE involves showing genuine gratitude for the work of others, enabling a positive connection to form. Success at work also relies upon constantly learning, developing and improving and helping others to do the same. Learning from what we have done and using it to inform our future decisions. These are the key principles behind LfE.

So how will I answer the question next time? I think I will try to explore what is meant by “touchy-feely”. If it means insincere or inappropriate, effusive sentimentality , then that is not what LfE is about. But I’m not going to pretend that LfE doesn’t involve expressing positive emotions. It’s one of the keys to its success. And if that’s what being touchy-feely is, then yes it is a bit, and that’s why it works.

 

Dr Emma Plunkett

On celebration

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I’m all for celebrating fantastic achievements and well-earned successes. But if we celebrate something (or someone) everyday, we devalue that which we are celebrating. Whenever we create winners, we also create losers. For every award-winner, there are countless colleagues going un-rewarded; under the radar.

The Learning from Excellence movement is not concerned with celebrating success. In fact a key feature of the initiative is that the positive feedback from each report is privately shared with the staff member who has been reported for excellence. There is no overt celebration. No league-tables or performance charting. Learning from Excellence is a way to show appreciation. Appreciation is more subtle than celebration. It is not a reward. It is not a prize. It is noticing the good. Showing our colleagues that we have noticed their good work is a powerful motivator, because it shows that they are valued in their work.

Intangibles and ‘ordinary excellence’

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I recently received an excellence report (IR2) from one of our nurses. The report detailed how I had supported the nurse after she had been involved in a medication error. Within the report was a description of what I had done, and why it was helpful. The final words were ‘he probably doesn’t know how helpful this was. Thank you.’  This was true, I hadn’t realised that I had done anything out of the ordinary. I considered my actions to be normal and I felt that I was ‘just doing my job’.

A common criticism of excellence reporting is that we have created a system which serves to ‘reward’ staff for simply doing their job. A brief review of the reports would suggest there might be some truth in this – many of the reports describe normal activities and tasks.  But this view is missing an important point: excellence is defined by the reporter. Objectively defined outliers of high performance are rare, by definition. Whilst these are occasionally captured in excellence reports, they are a relatively infrequent theme. Much more common is ‘ordinary excellence’: a description of what would be considered a normal activity, but there is something intangibly ‘good’ about it. This intangible quality is the trigger for writing the report.

Why is important to capture and report these events? To answer that, you have to speak to the recipients of the reports. In the majority of cases they will tell you that they didn’t realise how appreciated their action was and that they will make small changes to their practice as a result. I write this as a recipient of such a report: I now conduct myself differently as a result of this simple act of appreciation. I am also more confident that this aspect of my practice will benefit staff and patients.

The story of LfE from the National Maternity Hospital, Dublin

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This guest blog post is from Associate Professor Mary Higgins, Consultant Obstetrician and Gynaecologist:

 

In October 2016, inspired by the work of the LfE group, we decided we had to run a LfE pilot within our unit. The National Maternity Hospital, Dublin, is a tertiary level standalone maternity unit in Dublin with more than 9000 births per year. To say we are busy is an understatement, but we wished to remind ourselves that the “majority of healthcare interactions result in positive outcomes” and, that we needed to study high quality practice.

The last few years have not been easy for those working in maternity care. The high profile media coverage of adverse outcomes, reduction in public confidence and increasing complexity has provided many, daily, ongoing challenges for staff. On the ground it has resulted in increased frustration and burnout amongst both clinical and non-clinical staff. There is a real and heartfelt wish to continue to provide high quality evidence based care to women and their children, but the demands on the service and the expectation of perfection makes this a real challenge.

In common with others, our approach to clinical risk and safety is largely focused on a reactive approach to safety. In addition, we have seen the toll taken on staff after an adverse event. While the patient is, and always be, the primary focus of concern, staff involved may also be affected (the “second victim”) as well as the healthcare organization (the “third victim”) – we have chosen to call this the “Domino effect”.  Second victims have been shown to have increased rates of anxiety, depression, post-traumatic stress, lack of clinical confidence and suicidal ideation.

The idea of “Safety II” being based on the concept of resilience caught our attention – the ability of an organisation to adapt to changes in conditions. Anyone who works in clinical care is familiar with “work around” – we do it on a daily basis to deal with our work. Maybe it was time to recognize that this workaround is ok, and should be applauded?

Research

We decided to run a whole hospital LfE pilot within one calendar month (October, 2016).  Following an intensive review of the literature on “Safety II”, appreciative inquiry and the impact of second victims, as well as reviewing advice from the PICU team (which, in retrospect, probably should have included rereading the advice to start small), the project began with a hospital wide information campaign and included both clinical and non clinical members of staff. Email and face-to-face contact was made with all departments in order to inform them of the pilot, the evidence base supporting it and how to report examples of excellence. Forms were circulated requesting examples of both individuals and team excellence and there were weekly reminders during the month encouraging reporting.

As individuals and groups were identified, a “Gold Star” award was presented to the nominee(s) – these were both given directly to the nominee(s) and publicly published on a notice-board on the hospital canteen. If appropriate each nominated team/individual received a copy of the nomination form so that they could identify what were the circumstances of the specific area of excellence. Themes were identified by content analysis of forms. A hospital wide presentation was made at Grand Rounds in November, when all nominated teams and individuals were identified, and a short video on this presentation was made and uploaded to the hospital intranet for those who could not attend. Possible patient identifiers were removed in order to protect confidentiality.

Effect on the organization

Eighteen teams and 27 individuals received nominations for LfE; four LfE themes were identified.  The first, “Excellence in Daily work”, was illustrated by examples from the operating theatre team, neonatal intensive care, Human Resources, postnatal wards, pharmacy and diabetes team amongst others. These examples illustrated the importance of high quality care every day – what is done every day makes a positive difference to women and their children.

The second theme “Identifying problems, proactively solving them” illustrated staff led initiatives to combat issues of importance to patients and staff – education for women on early labour, coverage of Cariban, morning antenatal classes, staff planning in Community midwifery.

The third theme “Emergency Care” used real life clinical scenarios where good communication and team work made a difference – staff were described as “excellent” and “calm, unflappable”, handover as “seamless”, care was “compassionate” and “supportive”.

The final theme of the LfE pilot reviewed “Educational Initiatives” where opportunities were taken to teach on the ground – use of epilepsy medications, care with urinary retention and a Medical Social Work conference on Domestic Violence. One of the most poignant examples was that of Chaplaincy running a debriefing session for staff – ten staff were anticipated, 35 arrived.  There was minimal time to adapt to larger groups needs so ground rules had to be established. Guided meditation was used to “appropriately express emotions and confidently support each other, bringing session to dignified close”. Afterwards, a reflection by facilitators established that they had a common desire to provide the best possible understanding and professional support to their colleagues, in order to provide a good solid debriefing session based on collaboration and cooperation. Staff came away feeling understood, supported and minded

The effect of the LfE programme on staff has been incredibly valuable, resulting in increased discussion of positive outcomes, and a commitment to recognize what has been done well and to continue as well as improve our high quality care.

Having completed the pilot, the organizing group now plans to continue “LfE” into the future, in order to use appreciative inquiry and Safety II principles to balance teaching, learning and clinical care. In order to succeed an organisation needs a “Goldilocks” level of positive to negative feedback – too much positivity may become insincere, too little and there may be burnout.  The LfE pilot and programme aims to return this feedback to a healthier balance in this maternity unit in order to continue to be able to provide high quality, evidence based patient centered care.

FERF UP YOUR LIFE!

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The following guest blog post is from Dr Clarissa Chase , an ST5 trainee in paediatrics, at Southampton General Hospital.  Clarissa conceived a positive reporting system called “FERF”. The story of FERF is below:

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It seems almost every day that a negative healthcare story makes its way into the headlines; missed diagnoses; missed opportunities; repeated failings that suggest a lack of learning from previous serious incidents.

While the issues raised by these stories may be significant, the articles rarely present a balanced account. The distorted information is presented for maximum impact and consequently effects public perception of us all.

As healthcare professionals, we have no right to reply or publicly defend these cases. As we are in the business of preventing harm and striving for clinical excellence it is difficult to know how to manage such misrepresentation. Not least because the barrage of negative press stories and distorted perceptions of NHS care must be having a negative effect on the morale of our workforce.

I don’t think anyone would deny that learning from mistakes is essential.

Reviewing failings, whether in the form of a formal inquiry or simply personal reflection, is necessary to identify hazards or risks and target improvements to address these and prevent any recurrence. Patient safety is paramount and we have a myriad processes to direct our focus at this; adverse incident reporting forms; patient complaint processes; the National Reporting and Learning System to name but a few. All these processes have been designed around identifying adverse events. Perhaps we are guilty ourselves of propagating this endless focus on the negatives, thus further perpetuating dwindling morale.

A 2007 survey for Hospital Doctor suggested 69% of doctors in the UK reported falling morale. The reasons for this are likely to be complex and varied, but might at least in part be a result of a relentless attention on adversity, both within the NHS and in the wider public forum.

So what if we turned that on its head? Redress the balance and recognise that it is as important to learn from the things that go well; the good things we all do every day that get little or no recognition: instead of learning from an example of incorrect care of a post-operative patient resulting from poor handover of information on arrival to the ward, identify the cases where the handover is exemplary and evaluate what makes it so, in order to encourage the process to happen in this way each time. Identify the details of specific positive examples, use them to educate and we will all learn from good practice.

Positive reinforcement is a well-recognised concept first described by psychologist BF Skinner that describes the reinforcement of a specific desired behaviour using a reward; a positive event that follows a particular action will reinforce it and make it more likely to happen again.

Putting this into context within the NHS would seem simple: if the reinforcement takes the form of specific positive feedback, for example: ‘I think you managed that consultation well – you involved the patient in the decision making and summarised all the information clearly’ then we will start to recognise all the things that we all do well every day, while we emphasise what works well and, in so doing, ensure continued good practice. The side effect of this process might be to increase morale and confidence. It will change the way people think about one another and build a stronger team.

I remember an incident as a junior registrar in 2012 when one of my consultants was admitting someone unexpectedly to the ward after clinic. As I was the registrar covering the evening shift she came and found me and took me to the clinic room to meet the parents and their baby. While we were in the clinic room she explained the reason for admission to me, in front of the parents and explained her proposed plan for overnight. I was then able to accompany the parents to the ward and introduce them to the ward staff. It struck me that her actions had a big impact on the very anxious parents. They clearly felt reassured that the discussions had both happened in their presence, and involving them.

Two other things struck me that day: 1) did my consultant realise the positive impact of her actions and 2) what a shame that I was the only person around to learn from her brilliant practice. I wanted to find a way to recognise, emphasise and learn from positive events.

And so the idea of Favourable Event Reporting Forms (FERF) was born. The concept was simple: a paper reporting form to identify positive practice and the individuals involved that could be filled in by any member of the team. A multidisciplinary team would then review the forms monthly and the learning points for each of the events drawn out. These learning points would then provide feedback both to the individuals involved, and to the rest of the team. The individual would receive a letter from the clinical leads of the team. The event and learning point would also be summarised and displayed on a noticeboard for staff, patients and visitors to see, as well as being discussed in Mortality and Morbidity meetings and education sessions.

The FERF initiative has been extremely well received in many different clinical areas. As well as enabling learning from positive practice, FERF provides a mechanism for individual professional development and has increased morale among all members of the multidisciplinary team. In addition to being used by patients and relatives and for patients and relatives, many have commented on how pleased and reassured they are to see both examples of positive practice and learning from positive practice.

While striving for clinical excellence we should recognise and celebrate our successes, learn from one other and from the hundreds of brilliant things we all do every day. If we change the way we value each other perhaps we will change the way others view us too.