A key part of my job is to explore what it takes to create a safety culture. I spend a lot of my time thoroughly enjoying reading research, opinion pieces, blogs and books on safety culture and just culture.
No aspect of either a safety culture or just culture is delightfully black or white, one thing or another. There are blurred boundaries and nuances to every aspect of each. Some aspects lend themselves to clearer boundaries such as error or criminal intent but its the middle that causes concern or confusion. What to do with people who take risks or people who are considered reckless but not intentional? What do we even mean by risky behaviour or reckless behaviour?
In safety II – the experts talk about (healthcare) workers having:
- The ability for people to adjust what they do to match the conditions of work
- The ability to succeed under expected and unexpected conditions alike
- The ability to take actions to help create a state where as much as possible goes right
But in patient safety this behaviour is often described as violating best practice or violations or risky behaviour. Is it really risky behaviour to do your very best, given the circumstances you are faced, to provide safe and effective care by adapting what you do and even adapting the written policies and procedures? Even the words violating or violation have strong connotations of ‘disgraceful behaviour’; the tone is already set for those who are found to have not adhered to a set procedure.
However, violation (or risky behaviour) comes in many forms…
- Erroneous – an individual did not understand the policy or was not aware of it. Given the amount of stuff people have to be aware of in this information rich world together with the limited time and pressures in today’s healthcare – its a wonder anyone has time to read a policy or procedure
- Routine — when the policy or procedure is routinely bypassed or ‘worked around’ – this is the stuff that human factors experts talk about in terms of ‘work as imagined versus work as done’
- Situational – usually related to the on-going and insidious circumstances, situation, environment or resources including time, effort, money and people – all of which impact or can make it difficult to take the right steps
- Exceptional – extreme circumstances which result in the clinician making a purposeful choice to bypass the normal procedure (linked to situational)
- Optimising —when in fact there is a better way of doing things i.e. people on the ground know better or the policy is out of date, unworkable (linked to routine)
Ken Catchpole (1) sums it all up for me when he wrote in the BMJ Quality and Safety Journal, ‘violations and non-adherence are common, not always conscious, not always planned, are frequently well meaning, and in many cases allow the system to run smoothly’.
However, importantly, as Rene Amalberti (2) states, a resilient system requires flexibility to help it become safer, efficient and adaptive to changing circumstances.
It is therefore important to understand why this happens first before simply judging people and disproportionally blaming people when they are considered to have violated a policy or procedure.
(1) Catchpole, K. BMJ Qual Saf 2013;22:705-709 doi:10.1136/bmjqs-2012-001604
(2) Amalberti, R, Vincent C, Auroy, Y et al BMJ Qual Saf Health Care 2006;15:i66-i71 doi:10.1136/qshc.2005.015982