Balancing "Me" and "We": ProSocial cultures of perinatal care

How can we explore better ways to work together in perinatal care?

How do we strive for a shared vision and purpose across perinatal teams?

Can we create a strong, safe foundation for these changes?

Perinatal care is a complex beast. It comprises many interconnected parts: maternity, fetal medicine, neonatal and paediatric care, transport, palliative care, mental and physical health services and local and regional networks. These systems are themselves made up of finely tuned, complex interactions.  At the heart of it all lies the experience of families, many of whom face very frightening times with babies born early or needing hospital care. For these babies and families to feel (and be) safe, this whole complex system needs to pull in the same direction. This is hard and fraught with challenges, many of which have been repeatedly highlighted by recent public enquiries into perinatal services.

Perinatal care is a complex beast.

Insights from evolutionary and psychological theory, under the umbrella of the “Prosocial” approach, can help us understand how we can shape perinatal services to bring about collaborative cultures of care in this sometimes bewildering landscape.

As with any complex system, a key factor shaping perinatal culture is the tension between two levels: the “Me” and the “We.” On the one hand there are the needs and actions of individual people, with their unique identities. On the other hand there are the needs and actions of the multiple groups to which those individuals belong (professions, specialties, teams, organisations, regions).

On the whole, all these individuals and groups are working in service of “the best outcomes for babies and families.” But inevitably, there are different ideas about what this means and how to get there. Both within and between teams there are different needs, ends and means: a way of working that fits for one group (e.g. the maternity team) might not fit for another (e.g. the neonatal team); a particular team approach might conflict with the individual interests of some team members.

People usually find a way to navigate and balance all this, but a number of factors can make that difficult:

1. Threat

   The balance becomes more fragile when the background context is threatening. Our inbuilt human self-protective neural responses to threat make it harder for us to engage in pro-social patterns of interaction. We become more self-focused, more rigid and more tribal: connecting more with people with whom we identify, and disconnecting with others where we perceive difference.

2. Scarcity

   When there are limited resources: time, funding, space, equipment, our natural human response is to flip from a collaborative mindset to a more competitive one. Individual self interest comes more to the fore: any split between “us” and “them” is strengthened and our focus shifts to prioritise “me” over “we”.

A perinatal system that is shaped by self-interest will not function well.

A key factor shaping perinatal culture is the tension between two levels: the “Me” and the “We.”

Eleanor Ostrom, in her Nobel prize-winning economic research, helpfully identified the common features of groups and systems that foster collaboration in the face of the undermining influence of self-interest.

This is not about removing self-interest in service of ‘the greater good’. An imbalance towards the collective-interest causes problems too: it may lead to individuals not having their needs met or valued. This can result in exclusion, burnout and resentment, and result in a rebound of self-interest within the group.

Ostrom studied diverse groups who cooperated to share a limited resource. These groups were governed by a number of common “core design principles”:

1. Shared values, purpose and group identity

What does it mean to belong in this group?

2. Inclusive decision making

Do the people who will be impacted by a decision have a voice in how the decision is made?

3. Fair balance of effort and reward

Do those who contribute to this team also gain in equal measure?

4. Transparency

Is everyone in the team clear what everyone else is doing?

5. Proportionate responses for desirable and undesirable behaviour

What happens when someone breaks a shared agreement? Are the consequences fair and effective?

6. Fast and fair conflict resolution

How do we resolve conflict and repair ruptures with each other?

7. Authority to self-govern

Do we have the autonomy to govern our own team without undue influence from outside?

8. Cooperative relationships with other groups

Can we apply these principles not only within our team, but also to our relationships with other teams and groups?

One reason that these principles are so helpful is that they not only describe how cooperative relationships can be organised within a group, they can be applied to collaboration between groups too.

Evolutionary theorists have argued that groups and systems who are able to apply these principles, and in doing so balance self- and group-interest, are better able to adapt to scarcity and other challenges. It is this adaptability that is key – applying any group principle as a rigid rule is unlikely to be an effective means of organising a team.

So how can teams hold onto these core design principles lightly as guides for shared agreements? David Sloan Wilson, Steve Hayes and colleagues explore this in illuminating detail in their book ProSocial. For us, this is an opportunity to put the compassionate mind to work. A lot of the training that we offer at The Relational Practice is about developing the ‘compassionate mind’ – the skills, motivation and commitment needed by healthcare professionals to connect with - and offer care for - their own struggles and those of their patients, families, colleagues and teams.

Applying our compassionate minds to create a team culture that is shaped by the core design principles requires that we:

• Understand what we are striving for in our work, as individuals and teams. What is our shared purpose? How do we make decisions together? How do we want to address conflict when it arises? How do we want to behave with each other?

• Recognise what happens to these efforts when threat shows up and gets in the way. When we are facing threat, how do we react (as individuals and as a team)? How do these threat-based reactions undermine our valued team principles?

• Safely connect with each other and ourselves to restore balance and repair. How can we reconnect with safeness and make wise choices about what is needed?

This is hard work. Shaping ProSocial cultures within your team takes time, commitment, and courage. It is likely to benefit from some external facilitation, too. This is a service we offer, so if you would like to explore that with us, please do get in touch. For now, with your team in mind, consider these questions:

• Which of the core design principles is working best in your team at the moment?

• Which principle would make the biggest difference to your team if you made a change?

• When your team meets with a challenge, which of the core design principles gets derailed most easily?

• What helps you to feel the connection, courage and wisdom needed to safely talk about these difficult patterns in your team?

In future blogs we will look at the individual principles in more depth. If you would like to find out more, check out our upcoming webinar series, and this specific webinar where we discuss the ProSocial approach.

Thanks for reading!