The potential of safer safety conversations
By Catherine Ede
As a junior staff nurse I worked in a busy district general A&E. Frequently at age 22 I was left in charge overnight. I had on a regular basis up to 15 patients to my name as well as the responsibility of the department itself. I was told I was an excellent nurse and that my patients were lucky to have me as I had excellent knowledge. But the thing is, I often went home unable to sleep knowing that despite all my learning I was not preventing harm to those patients and in fact, sometimes I was causing it.
During my training I had been tested on my knowledge of conditions and care and, perhaps the most important skill, of reflection. The problem was that I would reflect continuously on the care – or as it was in my head – the lack of care I was providing to my patients. Despite all my learning from university I did not have the skills, power or energy to change anything. I coped with this by running away to Australia and whilst initially effective, the same problems began to occur there as they had in the UK.
Not long after arriving in Australia they introduced the idea of a national incident reporting scheme. This became a new outlet for nurses who felt their patient had been harmed or potentially harmed and it meant that you would complete a form and somehow you had solved the problem, or at least made it someone else’s problem. The management would investigate and sort this problem out for you and you were absolved from responsibility. The problem came when I progressed to management and found that the same incidents I had been reporting were still happening and happening to a lot of patients and staff, and now it was my turn as Matron to be the management and ‘solve’ the problem.
As a Matron I was studying for my MSc and learning about patient safety & quality. This was expected to help me assess the harms occurring and to put solutions in place to stop reoccurrence. And yet, I had a manager who, when I tried to think outside the box would demand a one size fits all approach; that all reports contained staff member counselling regardless of the incident. They would take pencil to my report and almost grade me on the standard of the report itself without knowledge of circumstance or the incident other than the four lines that had been provided in the initial report. He had seen so many of these types of report that he thought he knew all the answers already.
So why was I bothering to investigate if we had the answers already, and if the answers were correct, why were we all still making the same “mistakes”?
When I returned to the UK I was privileged to be able to work on the Patient Safety First campaign and meet some of the incredible people working within our NHS. It was a time when people were encouraging staff to report more incidents to demonstrate a good safety culture. Hospitals were using the Datix system to capture incidents in a computerised system which enabled easier analysis of types of reports. The National Patient Safety Agency (NPSA) had the National Reporting & Learning System (NRLS) and safety alerts were issued by the NPSA to help share and prevent high level harm. I would speak to Safety Leads about safety improvement work which was more often than not guided by reported incidents, but quite often found them swamped in the investigations of all these reported incidents and having to put off the safety improvement work as their time was limited and incident reports were expected to completed before all other work. This was guided by the high level system rather than individual choice and to me seemed a very disconnected situation.
Now working for Sign up to Safety as regional lead for London, when visiting organisations I find a similar situation but now as well as trying to complete all the investigations the safety leads are trying to demonstrate for the CQC among others that learning has actually happened post incident. Staff are expected to tell inspectors about the last or major incidents that have occurred in their areas and what was learned from them. Different organisations try different methods of disseminating this information, for example, safety message of the week at handovers, newsletters, and safety forums. This, however, has still not solved the problem, as the main question I’m asked is whether I can share work from other organisations of how they have successfully demonstrated learning from incidents.
First we must consider how incidents are investigated. These are done after the time sometimes within days but more often than not after a week or more and this leads to hindsight bias. Discussions with frontline are nearly always limited and whether it was me answering the questions or others, the responses are normally defensive. We rarely gain insights into how the incident happened as whoever is involved is already feeling bad, as no health professional ever wants to harm someone. After an “incident” and even that term has connotations of badness about it, you are interviewed; is there anyone out there who actually enjoys interviews? I certainly do not, in fact I am rubbish at them and repeatedly find myself walking away thinking I wish I had thought of this or said that. I am sure this is the same in a lot of incident investigation interviews, do we remember what actually happened or do we sometimes say what we think we should say to protect ourselves?
Perhaps if we were to use the idea of a conversation that is two-way and held without fear of reprisal then everyone involved could work together to actually listen and to actually learn what has taken place.
Instead of imposing a set of recommendations, get all involved immediately and get to work, looking at what happened, plan together and actively change the situation to prevent it happening again. If we provide support to those involved and share what learning we have to support the frontline then perhaps we will gain some understanding into what is actually happening when harm occurs and what needs to change.
Most importantly though we, as healthcare professionals, should encourage responsibility and reflection in our roles about potential harm to patients and most importantly provide a just culture where compassion and encouragement are shown to staff. Reflection, if the appropriate support and guidance is available, is a very powerful tool. It can enable us the insight of changes that need to be made to improve our lives and that of our patients. Conversations which enable us to reflect back on not only what didn’t go to plan but also allow us to reflect on what went well have the potential to improve learning and care but these need to be commonplace, not just rolled out after an incident. Let us take up the role in senior positions of being the team coach where reflections are spoken about on a regular basis and not left to the individual alone and instead of being the judge of success or failure, be the toolkit to support our frontline to make the difference to their patients they have always wanted.
About the author
Catherine is a critical care nurse specialising in Emergency and major trauma with 18 years’ experience. In the last 10 years an interest then passion developed in improving the safety of care for patients which stemmed from not only be involved as a junior nurse in incidents to then investigating harm as a senior nurse. Catherine worked on both the Patient Safety First Campaign and the Matching Michigan Project in the capacity of field manager and improvement facilitator where she was energised by the amount of work being done in the arena. After completing her MSc in Patient Safety and becoming mother to two boys she joined Sign up to Safety as Regional Lead for London.