When we fail, we do three things:
Personalisation – we think it is all our fault
Pervasiveness – we think it is going to affect every bit of our lives
Permanence – we think we are going to feel this bad forever
In 2016 I came across a radio interview with Bob Ebeling. Bob was one of the engineers working on the shuttle Challenger 30 years ago – since the radio interview Bob has since died. This was his story.
On 27 January 1986, Bob, the engineer had joined four of his colleagues in trying to keep the space shuttle Challenger grounded. They argued for hours that the launch the next morning would be the coldest ever. Freezing temperatures, (their data showed), stiffened rubber O-rings that keep burning rocket fuel from leaking out of the joints in the shuttle’s boosters. For more than 30 years, Bob carried the guilt of the Challenger explosion. He was an engineer and he knew the shuttle couldn’t sustain the freezing temperatures. He warned his supervisors. He told his wife it was going to blow up. The next morning it did, just as he said it would, and seven astronauts died.
Bob was simply not listened to.
Since that tragic day, Bob blamed himself. He always wondered whether he could have done more. That day changed him. He became steeped in his own grief, despondent and withdrawn. He quit his job. Bob at 89 spoke on National Public Radio (NPR) a radio station in the US on the 30th anniversary of the Challenger explosion. If you listen to the recording, you can hear his voice; it is low, quiet and heavy with sadness as recalled the day and described his three decades of guilt. “I think that was one of the mistakes that God made,” he said “He (God) shouldn’t have picked me for the job. But next time I talk to him, I’m gonna ask him…‘Why me? You picked a loser”.
The listeners were so moved by this they sent hundreds of e-mails and letters of support to Bob. Engineering teachers said they would use him as an example of good ethical practice and other professionals wrote that because of his example they are more vigilant in their jobs. Allan McDonald, who was Bob’s boss at the time contacted him and told him that he had done everything he could have done to warn them; “The decision was a collective decision made by all of us. You should not torture yourself with any assumed blame.” And NASA issued a statement commending courageous people like Bob who they said “speak up so that our astronauts can safely carry out their missions.”
If Bob had been listened to, he may have been able to prevent the death of seven astronauts.
While this story relates to space travel, there are strong synergies with the way healthcare practitioners have across the centuries tried to speak out and not been listened to. The similarities are also with the way those affected by error live with the guilt and shame for the rest of their lives, profoundly and forever affected by these events. For staff there is a fear like no other. Shock that can deeply affect the people involved. It becomes a whole world of blame.
We need to help all of those people like Bob Ebeling. The people who are living with the guilt and shame and the people who are profoundly and forever affected by these events. It is my belief that they need to be cared for, that they need kindness not punishment and supported to come to terms with what went on.
We know that healthcare staff can experience guilt, anxiety, depression, and more. They find themselves reliving the event days, weeks, months and sometimes years later. They are often devastated and it can lead to their lives unravelling. Anecdotal evidence suggests that unsupported health workers may also change their place of work or leave and even some leave the career altogether. Well-trained, caring, experienced nurses and doctors are moving on, either to another hospital or another career altogether.
Every healthcare facility should provide an after-event duty of care to all; a function that supports patients and their relatives and staff when things go wrong.
If people could talk to each other about these experiences, it would allow others to come forward to share with the rest of the group. That active communication should be encouraged but we lack the appropriate forums for this kind of discussion and there are no institutional mechanisms (and we have eroded the spaces for people to come together) for helping the grieving process that all clinicians go through. Even if they are talked about at morbidity and mortality meetings it is usually just to examine the facts and not the feelings of the people involved.
An aspect of personalisation is that of personal competence.
Because of our attitude to error there is a fear about it but also a feeling that it could be controlled in some way. Most of us think that if we have loads of experience and have practiced something a lot or we really pay attention then we won’t make a mistake. So, it is a shock when we do. We have the notion that we failed because we are or were incompetent. That all we need to do is improve ourselves. And in doing so we make it all about ourselves.
This onus of responsibility on the individual perpetuates the blame culture. Personal competence also fails to distinguish between the broader assessment of how we perform in general versus how we perform in the moment, thereby narrowing our judgement.
We have been consumed with the idea of competence or incompetence for decades. Mistakes are thing you can prevent through being competent, experienced, skilful and diligent. The problem with focusing on individual incompetence is that it misses a whole heap of learning about individual competence, collective competence of the team and the competence of the system.
Let us consider competence in a bit more detail. Healthcare staff are trained for significant lengths of time to move from novices to experts. This training is a mixture of academia and experiential. Our competence is routinely assessed and our progress is dependent upon that competence. Our competence is directly related to the conditions in which we are working. It is directly related to the personal factors, our ability to function, our physical health, our mental health and to the system factors such as staffing levels, access to expertise and support, the right resources and equipment.
It really isn’t straight forward. We can be individually competent but incompetent within a team. We can be individually incompetent but competent within a team.
Dr Lorelei Lingard (2021) states:
- Competent individuals can come together to form an incompetent team
- Individuals who perform competently in one team may not in another team
- One incompetent member functionally impairs some teams, but not others
She asserts that in healthcare there are many individual members of the team who are competent but when they come together as a team it does not guarantee a competent team. The factors that might relate to this include are our ability or inability to communicate with others, our ability to speak up or our deference to hierarchy.
Collective competence is impacted by the complex system of activity in which people interact each other and processes. Through methods such as briefing and debriefing, or huddles or handovers or interdisciplinary rounds teams build competence and collective knowledge about how to work together.
Healthcare is a complex adaptive system. Therefore, our understanding of what helps us develop both individual and collective competence is vital for the success. We definitely need to move away from personalisation and perhaps we need to move away from the goal or reliance on individual competence and recognise that healthcare today is far too complex to achieve this.
PATIENT SAFETY NOW 