I have just uploaded a post related to a just culture. That was describing the culture that is for the vast vast majority of incidents and staff. I purposefully left it at that because I didn’t want it confused with this post which is asking some difficult questions that I don’t know the answer to.
Let’s go with the fact that the vast majority of staff do not intend to harm in any way shape or form.
Let’s also go to the very hard place that we find inconceivable, shocking and extremely uncomfortable. There have been and will be the very rare cases where an individual does intend to harm in some way.
How therefore do we ask the very difficult question about whether the incident is a case of intentional harm without completely destroying the culture that we want. How do we do this so that we don’t create the blame and shame culture that we are striving to get away from. How do we do it so that people are not fearful of saying anything in case the accusatory finger is pointed at them?
Given the very rare cases that have been in the news in the past decade what can we do to help us detect these people earlier.
I ask all of these questions because I don’t have the answer but I think we need the conversation and it would be great if we could create the perfect balance of…seeking to create the supportive, fair and open culture that is just while at the same time asking the right questions to ensure we are not blind to what might be going on. The very last thing I would want is for us to swing back to full on blame, which sadly exists in some areas or always thinking that people are purposefully harming when they most definitely are not.
Some of you will be thinking that all we need to do is ask the questions in the just culture algorithms – I am not sure this is the answer. I think it might help if we can use something that acknowledges our biases such as:
- Confirmation Bias: Favouring information that confirms preexisting beliefs or values.
2. Optimism Bias: Believing that one is less likely to experience negative events compared to others
3. Halo Effect: Letting an overall impression of a person influence thoughts about their specific traits.
4. Groupthink: Prioritising harmony and conformity within a group over realistic appraisal of alternatives.
5. Implicit Bias: Holding unconscious associations about certain groups of people.
In the coming weeks, colleagues and I will be thinking more on this and would welcome any thoughts you might have.
PATIENT SAFETY NOW 
2 responses
Suzette – the subject of sustaining an open learning culture, and trust of staff who are involved in, and report occurrences of unexpected harm, is a good topic especially in the wake of the LL case which has left one Trust reeling, and picking up the pieces, as a small number of organisations have been required to do over the last 40-50 years. There are a range of practical information analysis approaches that can support a Trust/team/service in taking a measured approach, that enables exploration without finger pointing, is evidence based and not opinion loaded and enables a Trust/Team or Service to demonstrate reasonable best, and that they have fulfilled their duty under the health and social care act to deliver a safe service.
The first grounded and pragmatic approach is: Pattern analysis. Thinking through what needs to be understood – what information do you already have, how much of it do you have and does it reveal ‘patterns’ in terms of identifiable staff, time of day, similarly in ‘co-workers’, similarity in patient type, diagnosis and prognosis to suggest a few. If No – such information is not available can a well designed case notes audit tool be devised to capture this retrospectively and also to look at key issues in real time?
Exploring important issues of concern such as ‘deliberate harm’ can be done in a measured way, and in a way that does not segregate or isolate or judge before there is firm triangulated evidence that means to do otherwise would be a dereliction of duty. I, as a HCP, expect people who set out to harm, to be weeded out. I don’t think this is a threat to a safe learning culture. The way we go about it might pose a threat, and this is why auditable, grounded, data driven techniques alongside softer more qualitative approaches such as staff testimonies must be at the table.
Another tool is structured and scheduled participant and non-participant observation practice over several weeks and across the 24hr clock, involving all shifts, and all staff. Where possible a comparative service is useful. It’s hard to sustain purposeful changes in behaviour where observation practice is sustained and routinised. What is revealed – does it support concerns raised, does it not. Does it add weight to any pattern analysis work ?
My third go to tool in this type of circumstance is semi-structured surveys and questionnaires is MS Forms, or smaller focus groups again using QR codes an forms to provide all participants to the privacy to say what they want/need to say without influence from anyone else. I have seem and experience powerful results from this type of activity including groups of people from the most junior to the most senior.
My advice to anyone catching a concern about a team member who may be harming others is to think through what information is accessible to robustly test out the concern and if there is none, what is needed, and how can it be gathered without pointing a finger at a member of staff. A just fair and equitable culture demands an evidence based, and consistent approach. Therefore tools that support and enable this are to be embraced especially when they have been tired and tested over decades.
To Finish:
In the Beverly Allit case 30 years ago – an event/staff map was created by the Police to try and discern commonalities between the cases of concern. There was a common denominator – Allit. These tools have no personality, what they do, is make the process objective and then allow us to act from a firmer footing.
Just a few thoughts
Maria
Dear Maria
Thank you so much for this. Really helpful.
Hope you are well.
Best wishes Suzette