Carl Horsley wrote on twitter just the other day…

It’s not about Safety II or even safety, really. It’s bigger than that. It’s about how we work. And it touches on leadership, teams, quality, safety, staff and patient experience.


Over the last five years a small group of us have had the privilege of working on the Sign up to Safety campaign.

Previous campaigns had focused on disseminating interventions related to individual area of harm. In fact we were initially charged with reducing harm by 50% and saving 6000 lives. Interestingly these figures have been bought to life again in the latest national patient safety strategy.

We were adamant that a focus on reducing harm was not the way to go. Our collective experiences in patient safety had taught us that things needed to be done differently.

Our curiosity led us to study psychology, behavioural insights, complexity theory, safety theory, just culture, human factors, safety II and more. We have shared this learning over the last five years on our website, in presentations and in this blog.

Our first realisation was that relationships and how people talk to and listen to each other was at the heart of creating a safety system and culture.

This led us to encourage conversations within and across teams. We called them ‘kitchen tables’ to bring to mind the times people sit round a table and share their day.

We encouraged conversations with respect, humility, curiosity, kindness, and civility.

However over the last two years it has felt like there was something missing, something just over the horizon but we couldn’t yet see it.

This view has just recently become clearer and clearer as we and others have grown in the understanding about really what safety is.

That it is clearly about learning about success as much as failure but so much more.

Our second realisation was that there is an undeniable link between staff health and wellbeing and safety.

For us staff health and wellbeing is not just that they are physically or psychologically cared for or that their basic physical needs are met such as food, hydration and sleep. Staff health and wellbeing is dependent upon the way they are led, the way they are trusted and supported especially when things don’t go as planned.

Staff health and wellbeing is also dependent upon the way people behave towards each other, the way they are kind to each other. It also means building a positive workplace; increasing morale and enjoyment at work.

What is thrilling is that there is not only an evidence base behind all of this thinking but that there is a growing group of people who are coming to the same conclusion.

Patient Safety will be enhanced if we care for the people that care – help staff with their everyday.

Help people work well, be the best they can be, learn, perform, and work together across the different professions and boundaries.

In fact it’s not just about patient safety, as Carl says … it’s bigger than that. Which comes to our third realisation .. thank you Carl.

It is about how we work.

It’s everything.

My work as done

As each placement progressed and as each year passed by I became more and more skilled as a nurse.

I learnt by watching and working with some fantastic role models. I learnt to work with multiple different teams and then to lead them.

I learnt by doing things over and over again, getting better and better at them slowly and incrementally.

I learnt how to do some technical stuff I never imagined I would ever be able to do.

I also learnt how to talk to and listen to patients (even when they couldn’t talk) and their families and my co-workers.

This was my everyday.. my ‘work as done’…

Care for my patients, whether it was one very sick child or the whole ward. Care for them in every way. Their physical and psychological needs. Care as I had been trained to do but also as I grew in experience.

Observe them – really observe them. Through sight, touch, and smell. By listening, watching and counting. By measuring things that could be measured but also noticing things that couldn’t. Sometimes the monitors bleep would change imperceptibly but my brain would register that something was wrong before the numbers changed.

Adjust. Adjust my care to fit the patient need, adjust my choices and actions depending upon what I observed. Adjust my day depending upon the workload and the staff around me.

Inform. Inform patients and families what was happening and when, inform colleagues of status and changes.

Treat. Make sure I (or others) administered the right treatment at the right time in accordance with the individual plans.

Most of the time the basics were the same. Occasionally a new technique or new drug or new practice would be introduced and our skills would be ‘updated’.

We worked hard but we were also cared for. Told to take breaks, urged to eat and drink properly to keep ourselves well. And there always seemed to be someone to go to to ask for help or ask a question or to hear a concern.

This is what I mean when I talk about the fundamentals for patient safety or ‘working safely’.

I don’t recall doing quality improvement projects or filling out incident forms or being constantly scrutinised by investigators or regulators. I don’t recall being constantly aware of failure in fact the opposite. I recall us being constantly focused on success. Not just success in improved outcomes but success in beautifully caring for someone dying.

Does that mean I was any less safe? We will never quite know because the data we collected then and the data we collect now doesn’t really tell us whether we are safer today than 30 years ago .

I worry that we want to progress without doing the time. That years of experience are seen as secondary to promotion. That the experts quickly move on and the role modelling they are so important for is lost.

I worry that we have forgotten to enjoy the everyday and that we think we are making a difference by our obsession with small scale projects.

I worry that we feel we have to focus on the bad and not the good. If we were to believe the safety research we would think that staff are failing constantly when they are in fact doing the opposite.

We need a different conversation. A movement around a shared purpose centred on supporting everyone in healthcare to:

Care with compassion and kindness

Gain and value experience

Observe easily and effectively

Adjust safely

Inform and communicate well

Treat people using the best evidence based practices

Look after those that care by meeting their basic personal health and wellbeing needs and maintain a positive workplace

Ensure there is always someone to turn to

Working safely and competence

Too often I get a question from the audience which goes a little like this …

“It’s all very well all this being kind to one another but what can we do about the people who are useless or lazy or unsafe..”

Now I would argue that it is being kind if we help those people deemed ‘incompetent’ or lazy to find something or somewhere that suits their skill set more.

It is also being kind to figure out what may be behind their perceived incompetence.

Crucially it is vital this exploration does not leave us with the view that safety is purely down to ensuring the workers are competent.

What we actually need to study is how ‘work is done’ and what factors influence success and failure. We need to understand the role that the system and the environment plays (i.e. resources, education, infrastructure, staffing, culture, attending to health and wellbeing, supportive behaviours, relationships and so on) in helping people be the very best they can be.

One of the ways we could explore this further is to understand what psychologists refer to as the four stages of competence, or the conscious competence learning model, and how these stages impact on safety.

How we progress from incompetence to competence in our skills in healthcare is a component of safety.

So let’s explore these stages of competence.

First. Unconscious incompetence

The staff member does not understand or know how to do something and does not recognise that they don’t know.

We are all like this when we start out in life or start a new job. We are that novice who may take risky decisions without knowing how risky we are being.

So we don’t know that we don’t know? And not knowing means we could act unsafely without knowing we are acting unsafely.

Second. Conscious incompetence

The staff member does not understand or know how to do something but they recognise this.

The novice that knows they need expertise and experience to become more expert. This means that we can seek the knowledge to help us act safely. Feels a less risky stage to be.

Third. Conscious competence

The staff member understands or knows how to do something but makes a concerted effort to concentrate on the task in order to get it right.

The novice who is becoming an expert but still makes an effort to really think about it when doing the skill. On the road to being an expert but aware they need to continuously learn.

This feels like the conscious mindset to act safely. To have safety at the forefront of the brain when carrying out a procedure or task.

Is this where we should all try to be?

Fourth. Unconscious competence

The staff member has years of experience or has practiced over a significant time to master a skill. The skill has become second nature and can be performed easily. In fact the skill can be performed while doing other tasks at the same time.

The novice has become the expert and so much so that they can become the educators.

While this seems on the face of it optimal it could also be a risky state to be in. What if this leads to complacency or cutting corners inappropriately.

In healthcare there are around 1.3 million employees. All of whom will exhibit all of these stages at one time or another. In fact most of us exhibit all four stages all of the time. We may be both novice in some areas and expert in others. All of which impacts on the ‘work as done’.

It is too simplistic to say that what we should aim for is everyone being in the third stage (if we consider that to be the safest) when we will be constantly moving between the stages. What we need to do is help people who are in all four stages to work as safely as they can.

There feels a link between system competence and individual competence that may shine a light on ‘work as done’.

So how can truly understand how ‘work is done’ in order to help people work safely.

Collecting and studying incidents will tell us how work is done through the lens of failure.

Investigations and inquiries will provide insight into where there are flaws in our systems and processes.

Quality improvement tends to focus on a problem that needs fixing.

But what of the everyday? The everyday that most of us ignore because it simply just went ok. This we know is the majority of the time yet we fail to study this. What are the factors that help our work simply go ok?

How can we study this?

The research methodology that lends itself to this would be to follow people around and watch what they do (ethnographic methods) or to survey or interview people on the ground. However another way may be for those people to simply share their stories of their everyday. Storytelling is really powerful especially written in the first person.

So if you are interested in sharing your everyday stories I am really interested to listen.

Use the hashtag #workasdone and share on twitter your story or if you have too much to say send me a tweet and you may end up being a guest blogger.