Getting to Safe: Resilience Strategies for Healthcare Teams

By Denys Court

For patient safety to flourish, those who provide care must also be flourishing. That is what this book is about. It is people working in mutually supportive professional relationships and who are supported by safe systems who are best enabled to provide safe care. The goal of this book is to enable reflection on how to achieve that shared concept of safety. Some suggest that health should be more like the aviation industry, which is properly considered safe because its accident rate is so very low. But if an aircraft is ‘understaffed’, it simply does not fly. An understaffed hospital ward is never told it can’t fly; its staff is more likely to be asked to do more with less. For this and many other reasons, there is a limit to the extent that systems can provide safe environments in the health sector. There is so much unpredictability that it is frequently not the rules and guidelines that determine safety but the actions of individuals and the teams in which they work, and their ability to work around the unexpected that determine it. For that to be possible and effective, these teams and individuals need to be supported, safe and resilient also. This book examines how healthcare professionals can get to a safer place in their workplace and, by doing so, keep their patients safer.

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Jan 8, 2021
• ISBN: 9781528993609

Denys Court

Denys Court is an obstetrician-gynaecologist who has worked in New Zealand, Canada and the United States. His experience includes many years in health leadership. He is also qualified in law and has extensive experience as an advisor in a medical indemnity organisation, as well as a facilitator of communication skills workshops for health professionals. He chairs a clinical ethics advisory group for a District Health Board and is a credentialed mediator and conflict management coach.

Book preview

Getting to Safe

Resilience Strategies for

Healthcare Teams

Denys Court

Austin Macauley Publishers

Getting to Safe

About the Author

Dedication

Copyright Information©

Acknowledgement

Introduction: Why This Book?

Chapter 1: Setting the Scene for Safety

A Comprehensive Understanding of Safety

Aspiring to Resilience in Healthcare

Safety for Clinicians

Bringing Resilience Principles to Healthcare

Chapter 2: Mind the Gap

Assessing Resilience in Healthcare

Personalities in Healthcare and Aviation

Learning Safety Strategies from Aviation

Chapter 3: Managing the Gap

The Good and Bad of Workarounds

Chapter 4: It’s Just Culture

Organisational Culture Necessary for Teams

Inadvertence, Recklessness and Reality

A Just Culture

Accountability

Standard of Care Revisited

Chapter 5: Sharing Leadership

Chapter 6: Effective Teams

Introducing the Challenge

Creating Effective Team Functioning

Trust and Psychological Safety; the Essence of Effective Teamwork

A Shared Mental Model; the Framework of Effective Teamwork

Distributed Cognition

Effective Teams Can Learn Together

Little-C Coaching and the Art of Feedback

Professionalism

Chapter 7: Why Things Go Wrong

Expecting Perfection, but Getting Less

Defining the Problem

Why Things Go Wrong – In Health Organisations, All Cheese is Swiss

Caught Between Slices of Cheese

Supporting a Learning Environment

When Learning Fails

Chapter 8: Supporting Open Communication

The Relationship Between Adverse Events and Litigation

Open Communication After Adverse Events

The First AE Meeting with the Patient

Chapter 9: When Things Have Gone Wrong

Managing the Effects of Adverse Events on Staff

Critical Incident Debriefing: lessons for Healthcare

Schwartz Rounds

Chapter 10: Making Things Go Right

Speaking Up for Safety

The Deteriorating Patient

Handover/Handoff

Checklists

Briefings

Debrief

Chapter 11: Conflict Competence

Values, Identity, Interests, Needs and Triggers⁵

Communication During Conflict

Developing Conflict Competence

The Challenges in Conflict Resolution

Emotions and Rationality

The Conflict Management Process

Chapter 12: Challenging Conversations

Preparing for Challenging Conversations

Suggestions for Starting Challenging Conversations with Those Superior to You in the Organisation

Suggestions for Starting Challenging Conversations with Peers Where There Is No or Moderate Power Differential

Suggestions for Starting Challenging Conversations with Staff Where You Have the Greater Power

Chapter 13: Career Positivity

Stress and Burnout

Satisfaction and Happiness

Positivity (Positive Psychology)

Gratitude, Savouring and Flow

Mindfulness

Chapter 14: The Resilience Habit

Explanatory Styles; Optimism, Realism, Pessimism

Willpower and Habits

Your Resilience Toolbox

Epilogue: Planning Your Strategies

360° Resilience

Notes and References

Chapter 1: Setting the Scene for Safety

Chapter 2: Minding the Gap

Chapter 3: Managing the Gap

Chapter 4: It’s Just Culture

Chapter 5: Shared Leadership

Chapter 6: Effective Teams

Chapter 7: Why Things Go Wrong

Chapter 8: Supporting Open Communication

Chapter 9: When Things Have Gone Wrong

Chapter 10: Making Things Go Right

Chapter 11: Conflict Competence

Chapter 12: Challenging Conversations

Chapter 13: Career Positivity

Chapter 14: The Resilience Habit

About the Author

Denys Court is an obstetrician-gynaecologist who has worked in New Zealand, Canada and the United States. His experience includes many years in health leadership. He is also qualified in law and has extensive experience as an advisor in a medical indemnity organisation, as well as a facilitator of communication skills workshops for health professionals. He chairs a clinical ethics advisory group for a District Health Board and is a credentialed mediator and conflict management coach.

Dedication

To the many excellent teams that I have been so lucky to work with and the team members within them who have seeded my passion and inspiration.

Copyright Information©

Copyright © Denys Court (2021)

The right of Denys Court to be identified as author of this work has been asserted by the author in accordance with section 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publishers.

Any person who commits any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

A CIP catalogue record for this title is available from the British Library.

ISBN 9781528993593 (Paperback)

ISBN 9781528993609 (ePub e-book)

www.austinmacauley.com

First Published (2021)

Austin Macauley Publishers Ltd

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Canary Wharf

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E14 5LQ

Acknowledgement

I always start any book I read with the acknowledgments section to understand the context in which it has been written. I’ve been impressed that so many authors have a plethora of colleagues and friends who seem to write much of the book for them; I’d love to understand how they have harnessed such contribution. Although I don’t have that particular kind of collegial plethora, I have certainly benefited from the many friends and colleagues who have encouraged me along the way, especially those who have read a chapter or two and given me constructive feedback.

I’d like to thank Sue Fleming who, after my first shot at writing a chapter, said something along the lines of there is probably a book within you, but this isn’t it. Or at least, that is how I heard it. And indeed, Sue did not recognise this book but did indirectly set me on the right track. The other friend and colleague who provided me with the wherewithal to write was Neil Pattison, who agreed to job-share to allow me to free up big aliquots of uninterrupted time for this project.

That uninterrupted time meant that my family were at times short-changed. My wonderful and tolerant partner, Shirley, my delightful four children, both humorous and humouring, and my delicious seven grandchildren who show me more respect than I deserve and relish the time I do manage to find for them. I’ll make up for that now.

Having sketched out the idea of the book, it was Joy Marriott who did the research for me, to free me from that irksome responsibility and to ensure that my thoughts and ideas were evidence-based. At times, my enthusiasm meant that I put Joy under pressure to deliver in unreasonably short timeframes but she always did so uncomplainingly.

I’d like to thank the Hawaii sunsets. Much of my most productive writing was done in the hours that followed them.

And now for two very special people. A big thank you to my daughter, Bridget, who allowed me to use a part of her personal story in the book. You are one of the bravest and most resilient people I have ever known. The second is Mike Roberts, who mentored me through this whole adventure. Mike is surely the most constructive yet self-effacing mentor one could ever be lucky enough to benefit from. There were a number of times when I wondered whether this project was too big a bite. It was at those times that Mike provided me with the thoughts and comments that rebuilt my writing resilience. He believed this book needed to be written; so, Mike, it has been.

Introduction

Why This Book?

This is a book about people. It is a book which looks at the ways in which people involved in healthcare can keep people they are caring for, and thereby themselves, safe. For patient safety to flourish, those who provide safe care must also be flourishing. It is people, working in mutually supportive professional relationships, and who are supported by safe systems, who are best enabled to provide safe care. My goal is to enable reflection on how you may achieve that shared safety.

If I were to ask you right now about safety in your healthcare workplace, what would immediately spring to your mind? It would probably depend on your most recent experiences. It could be that you had a colleague who stepped in and supported you when you were overworked and made you feel safe and cared about – that you felt safe. Or was it that you spoke up when you were concerned that a patient allergy was about to be overlooked and thus kept a patient safe? And of course, in the process of doing so, kept a colleague safe too. That interwoven view of safety is what this book is about. It is an inclusive look at how to do things right more often, as individuals, and in the context of team-based relationships. As much as anything else, it is about self-care, staying safe ourselves, because if we do not, we are less able to care safely for our patients.

***

For healthcare to be safe for our patients and ourselves, the organisations in which we work must be safe and resilient. In my first two chapters, I will assess in which areas of healthcare we can largely rely on our organisations’ systems to provide a reliable backbone to safety; and in contrast, where does safety depend more on the mindfulness and actions of clinicians simply because our systems are not resilient enough? I refer to this as ‘identifying the gap’. I use the term clinician throughout the book to include all professionals involved in providing clinical care: nurses, doctors, midwives and allied health professionals. Identifying the gap is about clinicians being mindful of where the systems under which we work are least able to keep us and our patients safe and therefore where, as clinicians, like it or not we carry the greatest safety burden. By doing so, I hope to develop insight into the possibilities for, and limits of, safety in our organisations.

To develop that tension, I will explore in Chapter 3 the reality that where our organisation’s systems provide us with the most fragile safety framework is where the work our leaders and system-designers envisage we will do – ‘work as intended’ (WAI) – is not accurately able to reflect the work we actually do – ‘work as done’ (WAD). This occurs, for example, when because of resource constraints such as time, skill-match or staffing and equipment issues, we find that to achieve organisational goals as best we can, we have to do things differently from what our leaders or systems envisage; we ‘work around’ the problem. The more WAD can be moved to approximate WAI, the safer an organisation will be because WAD will then have a higher degree of predictability. When circumstances make us deviate from WAI, we need to be mindful that safety may be compromised. It is largely us as health professionals that can improve safety in such circumstances by identifying, reporting and suggesting cures for unsafe work-arounds. I will therefore develop the concept that there is much we can do as individual clinicians to increase healthcare safety. Because we increasingly provide patient care in multidisciplinary teams; it is within those teams that safety can best be enhanced. To be champions for safety in the ways I will suggest, we need to feel psychologically safe in the teams we work in, that if we wish to challenge a team norm or habit, that will not only be tolerated without derision, but actively encouraged in the belief that the free expression of ideas is a vector to improvement.

Therefore, I will examine in Chapters 4 through 6 what characteristics of teams promote psychological safety for team-members. What leadership structures are best? How do we develop a shared mental understanding of team goals and team strengths? How can we help each other as team-mates? For which of our actions are we accountable and what are reasonable systems of accountability?

All that said, we also need to accept that being as safe as (say) aviation, is a distant dream unlikely to be achieved in our lifetimes. Aircraft are usually healthy; patients are frequently unwell so will have more complications in care than will aircraft in flight. It is one of the frailties of humanity that when things do go wrong, all too frequently we look to blame others, or fear we will be blamed by others. This can be the case for patients who may look for a clinician to blame for a poor outcome, or between clinicians who out of fear wish to responsibility-shift. It is part of our in-built ‘fight or flight’ neurohumoral response to things we fear. Sadly, the consequences of this are that relationships can be damaged, both between patients and professionals, and between various professionals, with care quality thereby suffering. Furthermore, a fear to report adverse outcomes then develops such that we may lose the opportunity for individual and team learning from things that do go wrong. To my mind, one of the greatest inhibitors to learning from things that go wrong is the poor understanding, even amongst our leaders, of the concept of a ‘Just Culture’. I will, therefore, expound that and related concepts in considerable detail in Chapter 4. We also need to understand on the one hand the relationship between adverse events and litigation, yet on the other we need to feel able to, and supported to, safely communicate openly with those patients who suffer harm in order that they continue to value the professional relationship, increasing the chance they will adhere to clinical plans intended to return them to good health, including the importance of open communication. Even by substantially improving healthcare safety, things will sometimes go wrong with the care we provide, even when that care is provided to the best of our ability. So, in Chapters 7 through 9, I will explore why things go wrong and how we should deal with adverse outcomes so that patients will be more likely to recover, and continue to value their relationship with us; improving their safety and ours. If a patient suffers an adverse outcome, perhaps from a complication, and we support them during that time of their vulnerability, they may well become amongst our more grateful patients. How should we also best support our staff when things do go wrong so that both patient and staff outcomes are best protected?

We also need to flip that coin and explore what we can do that will more often make things we do go right. Why did this task work well? What does that tell me about how we can make it go even better in future? Where are the risks that may in future result in harm, where if I am mindful, we can recognise and mitigate those risks? Although I have indicated that some of the resilience in health care safety sheets home to clinicians and their teams, there are resilience tools that can be of great assistance. Such things as speaking up for safety, handover methods and checklists will be amongst methods discussed in Chapter 10.

Even from the above preliminary discussion, it should not surprise us that there are many tensions in day to day clinical practice. It is my experience in healthcare that some conflict between individuals in our complex structures will be inevitable. Conflict is an unfortunate manifestation of the human condition. It is one of my greatest disappointments that such conflict is too rarely resolved. Some of us swallow it silently and some of us act it out overtly or covertly. Either way, it risks patient and professional safety. I therefore provide thoughts in Chapter 11 as to how one can become ‘conflict competent’, obviously with an accent on conflict resolution. If we are to take opportunities to avoid conflict, we also need to be capable of difficult conversations which can resolve that potential before conflict manifests. The first few sentences of such conversations will likely determine their success. I provide some practical examples with explanation in Chapter 12.

Finally, in Chapters 13 and 14, I examine what we can consider self-care strategies; the need for us to maintain our personal resilience if we are to be able to be members of resilient teams. Sadly, burnout is an ever-present risk in healthcare and those who are suffering such stress are not personally safe, nor are they as able to protect the safety of their patients. Doing what we can to ensure our own resilience is an important component of safety in healthcare.

Finally, in my final few pages (Chapter 15) I will invite you to reflect on what you have read, to consider what may have tempted you to do something differently, either in your workplace or for yourself which will increase safety resilience. I hope you find this book useful.

***

In the journey through my chapters, I will have gone full circle in my logical belief that there is mutuality between patient safety and clinician safety. Clinicians who feel supported and safe are in a better position to keep their patients safe. In turn, when patients feel clinicians are doing all they reasonably can to keep them safe, the safety of clinicians is better protected.

As health professionals, what makes us feel good at the end of a working day is the belief that we have provided ‘good’ care to our patients and have a sense, not always expressed, that such care has been appreciated; by our patients, the colleagues we work with, and the organisations in which we work. Our feelings as to what constitutes ‘good’ will be subjective but will probably include that we provided care with the effectiveness, safety and (perhaps most importantly) humanity that we would wish to receive if we were in our patients’ circumstances. I hope this book will increase how often you feel ‘good’ at the end of a working day.

Chapter 1: Setting the Scene for Safety

The safety of the people shall be the highest law.

Marcus Tullius Cicero,

Roman philosopher born in 106 BC

Let’s start this chapter with an undeniable truth: the ideals and goals of healthcare as set out by leaders, mission statements, policies, best practice guidelines, and even our own desires to do good, are not always realised. We just need to consider the fact that the results demonstrated by RCAs (randomised controlled trials) are often not as well achieved in everyday practice. RCAs are done under tightly controlled and monitored circumstances with special funding to maintain those ideal circumstances. Where the protocol is breached, that individual’s outcome may be discarded from the study. This clearly differs from everyday practice. Despite best intentions throughout our organisations, we do not practice healthcare in ideal environments.

For us to agree how our work occurs in reality, I need to discuss the concepts of ‘work as imagined’ (WAI) and ‘work as done’ (WAD), as developed by resilience engineers and other authors.¹ Through understanding this we will be better able to determine where systems will provide a strong backbone for safety, and where maintaining safety will fall to clinicians.

WAI is what the leadership and management of our organisations (at the ‘blunt end’) expect will be done as well as what clinicians plan to do. It is the work we are expected to complete, and the way we are expected to complete it, whether that is the triage of acutely admitted patients, provision of post-operative care, or whatever. It is established by policy and training and supported by systems designed (sometimes imperfectly) to achieve the WAI. But WAI reflects what is intended to happen in a perfect clinical world. It would be naïve to assume we are always able to complete our work exactly as the organisation imagines. Sometimes because of a nomadic workforce (for example, residents changing clinical attachments every few months) we are not even sure we know what it is that is imagined! There is variance between WAI and WAD, the latter being what we actually do in the clinical arena (at the ‘sharp end’ of the organisation). But here’s the rub: when WAI and WAD vary significantly it is not that one or other must be ‘wrong’; it is simply that it is impossible for clinicians to follow all the instructions, policies, procedures and rules that are specified for them regardless of circumstance or even what we expect of ourselves. Variance between WAI and WAD occurs for two reasons. Firstly, let’s not bag our leadership; it is impossible for those who determine WAI to predict all circumstances to which WAI will apply (or misapply). Secondly, WAI usually does not take into consideration unpredicted challenges to resources; staff being ill, equipment being unavailable, skill-mix in a clinical workplace not being ideal. The more closely WAD can resemble WAI, the more resilient will be the organisation; where high resilience is a characteristic of very safe organisations, such as aviation and the nuclear industry. By methods we will later discuss, WAD has been brought to almost exactly replicate WAI in such industries.

The most resilient organisations will usually also have high stability of performance. This refers to a system’s capacity to return quickly to an equilibrium state after a temporary disturbance, perhaps in above-mentioned circumstances. I represent the relationship between resilience, stability, WAI, and WAD in Figure 1. At the midpoint of the stability range is a dotted line which reflects WAI. The variability in the way we perform that work (WAD) is represented by the sinusoidal line which for most of the time fluctuates from moment to moment but for extended periods does not become unstable; that is, it does not fall into the zone of heightened risk. On a good day, well established systems and competent people working within those systems will create that stable though oscillating state, the oscillations created by such things as the variability of acuity where WAD does vary moderately from WAI but not at the cost of safety and not creating instability. A normal day in the real clinical world.

Figure 1:

However, if the strain of circumstances (either unpredicted, not responded to, or where clinicians are not sufficiently supported) create excessive variability, the WAD strays into the zone of risk with loss of safety. This can be human factors such as exhaustion, compromised inter-professional relationships, or systems that are not robust enough to meet variances in circumstance; predictable or not. In such situations, it is a combination of clinicians being supported by systems (a safe method for escalating a problem for example) and personal resilience (mindfulness, coping through understanding one’s strengths for example) that guides the return of WAD to stability. Without resilience, systems may be destabilised long-term or permanently. Where resilience fails, and a slip/lapse/mistake occurs without rescue, an adverse outcome or near miss may result.

The WAD oscillating line in Figure 1 may also show a positive variance above the zone of stability. This represents an organisational opportunity. For example, what if a task is completed in a way that seems forced by circumstance and is far from ideal yet there is a sense there is a better, safer and more stable way of doing things? A ‘light-bulb’ moment may occur, where a mindful team member devises a safer way to achieve a particular task without loss of efficiency and escalates that idea to leaders. A resilient and learning organisation with resilient and learning individuals will see the opportunity and communicate it to those who may enable the organisation to benefit from it. We’ll return to resilience but first let’s look at how organisations consider or measure safety.

A Comprehensive Understanding of Safety

The WAI/WAD concept provides us with a model by which we can consider risk and safety in healthcare. However, asking the simple question ‘what is safety?’ does not lead to a simple answer. The word safety is both ubiquitous and contextual²; we are unlikely to pause to define it. In our personal lives we will often say to each other ‘stay safe’ or ‘have a safe trip’ and assume that the outcome will almost surely be safe. The understanding is a combination of ‘don’t take unreasonable risks’ (put your seatbelt on) and ‘watch out for the unsafe acts or omissions of others’ (the red-light runner). The aspiration reflects our own efforts as well as acknowledging that safety may at times be in the hands of other influences – that we do not always have control over unforeseen circumstances that impact on safety.

All humans naturally want to feel protected from harm. Traditionally, measuring safety in healthcare has aligned with this desire by measuring the incidence and severity of harm and assuming that safety is the absence of harm. As James Reason has pointed out, we have come to consider safety as ‘defined and measured more by its absence [harm] than by its presence’.³ This is not to say that the retrospective assessment of harm through mechanisms such as root cause analysis; finding its causes, making recommendations, and improving performance, is misplaced. It remains very important, can lead to considerable organisational learning and care improvement and can be more formally taught within an organisation.

However, we should not be tempted to assume simplistically that a safe outcome equates with safe care delivery. Even when harm has not occurred it cannot be automatically inferred that our systems are inherently safe. We only need to think about the last time we drove, cycled, walked, or took a bus home without being harmed, despite seeing several episodes of driving on the way that were somewhere on a spectrum for ‘whoops’ to ‘crazy’ and may have put us or others at risk, to know that considering only actual harm done is insufficient in determining safety.

Our continuing focus on harm as an inverse measure of safety is in part because we do not have the resources to formally investigate all adverse outcomes, let alone be thinking about what it is we do that more frequently makes things go right. We need to expand our view of safety to consider it from the perspective of patients on the one hand³ and on significantly improving what can be done to support those who provide care, on the other.

The single greatest challenge, in my view, to maximise gains from investigating adverse outcomes is to overcome the anxiety and vulnerability we naturally feel when care with which we have had some involvement has gone wrong and may be analysed by others. We feel the risk to us. However, if we do not manage that anxiety, we lose the opportunity to learn and improve. Sadly, I have found that at all levels of health organisations, the concept of a Just Culture which I discuss in detail in Chapter 4, is poorly understood; yet without that understanding, learning from adverse outcomes will always be truncated. Without this understanding, we are more likely to think twice as to whether we should support adverse outcome reporting and cooperate with their investigation.

To balance such concerns, it is now generally accepted in investigating adverse events endeavours should be made to accent systems rather than be focussed on individuals; if something goes wrong, it is that the systems have not effectively supported those who work within them. However, this does not absolve us as clinicians from the obligation to act safely within our systems as best we can.

The more complex our environments are, the more a stand-alone adverse events approach is insufficient. The complexity of modern healthcare demands that we work in increasingly large multi-disciplinary teams. Where only two people work together there is only one interpersonal interaction. By the time we get to six team members, there are potentially 15 interactions (={6x5/2}), 10 clinicians equal 45 (={10x9/2}) possible interactions and so on. An example of the risks this creates is shown by the Medical Protection Society, the world’s largest professional indemnity organisation, which has noted it is increasingly seeing examples of the passing of patient care from one clinician to another, or clinicians disagreeing over the best care for a patient, leading to risk for all parties involved; poor outcomes for patients, dissatisfaction with the care provided, and risk for clinicians all being possible consequences.⁵ Well-functioning relationships are so important.

The approach centred on investigating what goes wrong has been classified by Erik Hollnagel⁶ as Safety–I, defined as a condition where the number of things that go wrong (accidents/incidents/near misses) is as low as possible. As Hollnagel states: In well-tested and well-behaved systems equipment is highly reliable (because it has been designed well and is perfectly maintained); workers and managers alike are ever-vigilant in their testing, observations, procedures, training and operations; the staff are competent, alert, and well trained; the management is enlightened; and good operating procedures are always available in the right form and at the right time.⁷ Obviously a very conditional statement – who amongst us would assert those features are always perfectly in tune in our organisations and that we act accordingly? What is perhaps astonishing is how often outcomes are good despite imperfect systems or circumstances. As Hollnagel asserts, need to acknowledge that Safety-I can only give us snapshots of what goes wrong in an organisation⁸. Being vigilant to see what may go wrong as well as how we may increase the chances of things going right deserves our attention also. Hollnagel has therefore moved to define Safety–II as a condition where as much as possible goes right (preferably everything).⁹

As I see it, the challenge for Safety-II, is the need for us to maintain mindfulness in our day to day clinical activities, living in the clinical moment as best we can to consider what will make what we do go right. Why did this work well? Where are the risks that may in future result in harm; where if I am mindful, I can recognise it so we can mitigate those risks? The challenge is to turn that from aspiration to reality, and the challenge to that is time pressure. The more we can achieve such mindfulness and apply it to WAD, the less potential there is for an adverse outcome. The safer it is for patients, and the safer we will feel as professionals.

For example, I briefly precis a maternity case, the analysis of which I was involved in a few years ago. A woman in labour was reaching full cervical dilatation and was about to commence ‘pushing’ (expulsive effort) anticipating a normal birth. Because she had spontaneously ruptured her membranes many hours prior to labour being induced, she had been on antibiotics in labour. Her second dose of antibiotic would be due soon after pushing was to commence. The midwife caring for her had realised she was going to be very busy administering the antibiotic intravenously, coaching the patient through second stage labour, conducting the birth, and providing intravenous oxytocin around the time of the birth of the placenta to minimise the chance for haemorrhage. Therefore, under pressure, she had drawn up the oxytocin into a syringe. It was not labelled. The syringe was a different size but in the same ‘kidney dish’ as the antibiotic which had also been drawn up prior. It also was not labelled. You can see where this is heading. At the time the second dose of antibiotics was due, the supposed antibiotic syringe was connected to the intravenous cannula and administered by slow push. However, it was actually the oxytocin. A tetanic uterine contraction occurred followed by foetal bradycardia. By lucky happenstance a senior obstetric resident was nearby and in the space of five minutes performed a safe instrumental birth. The mother was physically unharmed. The neonate had no apparent resulting harm. It would be possible to say there was no adverse outcome as there was objectively no harm. That however would be absurd. The mother was aware of the crisis and was panicked by it so from a patient perspective, of course there was an adverse outcome. Professional stress or distress was also obvious; so there was a professional adverse outcome. Obviously, a Safety-I investigation occurred. Changes to practice, some of which are obvious and I will not enlarge on here, were made to prevent a recurrence. In the five years since, there has indeed been no recurrence. I stated above ‘you can see where this is heading’ because the scenario as I was developing it on a written page would have made you mindful of the unacceptable risk. But would you have been as alert to it in real time with real clinical stressors? What was necessary at the time of this incident was a Safety-II type of mindfulness which could have avoided the risky practice, thereby avoiding all harm. Safety-II is a focus on everyday clinical work and why it usually goes well. It explicitly assumes that systems work best when people are enabled to adjust what they do in order to best match the conditions of their work. But safe systems alone do not mean that a patient journey in healthcare will be safe. Clinical vigilance and mindfulness are significant components of this approach – we can never rest and say ‘what we do is safe’ – we need to constantly and mindfully monitor and adjust what we do to improve safety. I would be very surprised if there wasn’t a little voice in your head saying something like, Well, that’s easy to say, but clearly you (I, that is) don’t understand the stress that sometimes happens in my workplace. Yes, that’s the challenge for me and I hope you will come to see that though I have obviously not experienced your work circumstances, we can come to understand it.

Safety-I and Safety-II are compatible and complementary and even sometimes not distinctly differentiated. But Safety-II provides us with the opportunity to avoid harm. Human performance is always variable. We need to learn from what goes wrong and what goes right.

If only it were enough for us to expect health leadership alone to provide us with continually improving and safer systems. However, systems, being also a product of imperfect humans, will never be perfect, nor able to predict all the circumstances of our work. All of us working in health systems have a responsibility for ensuring as much as possible goes right. Those who develop systems have a responsibility to ensure they, and the leadership that creates them, are sufficiently supportive of professionals that mindfulness can become an entrenched norm. For things to go well and be safe we all need to be actively engaged in trying to make them go right, understanding how our systems work and trying to ensure the best possible conditions. We need to be mindful in what we do; to remain sensitive to the possibility of failure or to have a constant if subliminal sense of unease, aware that safety is a brittle thing, because it truly is. We should not let our inevitable familiarity with risk numb us to its importance, to accepting it without question. I challenge you to think of a (hopefully) small list of things in your daily clinical activities that you consider unsafe. Record them and keep them in mind as you read through the book. You may well find ways to ‘treat’ those risks.

As individual care providers, we need to maintain a focus on the interactions between health professionals in the teams in which we work. There is good evidence that effective communication is linked with patient safety.¹⁰ It is also linked to professional safety. The need for skilled communication strategies has never been greater. I am neither thinking simply of ‘send → receive → understand’ communication, nor of only professional-patient communication, but also of communication skills that enhance relationships between individual health professionals and within their teams. I intend to address those later, because a significant part of supporting clinicians to support their patients is about enhancing inter-professional relationships; the structures that support and the skills that build.

Aspiring to Resilience in Healthcare

In industries, systems that evidence the best levels of safety are referred to as having ‘high resilience’. Resilience engineering developed following the realisation in industry that previous approaches to safety were ineffective. It is about ensuring that an organisation is able to cope with more unusual and unexpected situations – not only those which may disturb usual or safe functioning (threats and risks) but also those which have the potential to improve everyday performance (opportunities). Though the initial accent was on technological systems; with time, human reliability factors became accepted as a necessary component.¹¹ However, reliability is relatively opaque in that when things go well it is neither transparently evident, nor do we necessarily apply thought as to why. Resilience engineering is about what an organisation does, not what it is; about how organisations perform, not just about how they remain safe.¹² Hollnagel’s concept of Safety-II is about introducing us to the potential to improve resilience in healthcare.

Eric Hollnagel defines health care resilience as ‘the ability of the health care system (a clinic, a ward, a hospital…) to adjust its functioning prior to, during or following events (changes, disturbances, opportunities) and thereby sustain required operations under both expected and unexpected conditions’.¹³ Resilient healthcare (RHC) is in its relative infancy. Examples of its development are provided in the book ‘Delivering Resilient Health Care’ by Hollnagel, Braithwaite et al.¹ Developing data on RHC will be a challenge because our systems involve not only technology, but people, these together creating a complex and somewhat unpredictable environment which will defy complete description. The focus will need to involve how care was planned, co-ordinated and delivered, how and why decisions were made, and how people adapted to the pressured clinical environment.¹⁴ We need a way to understand RHC in a way that will assist us in our everyday clinical work.

Healthcare organisations have no way of objectively measuring the frequency of, or extent to which, WAD falls below stability into risk but is then recovered by the clinical resilience of individuals. They can only predict the probability of falling below the adverse outcome line in Fig 1; and even then, only based on historical statistics. For example, an organisation may know the rate of serious adverse outcome in a particular clinical activity is 1:104 but not be able to foresee which patient will suffer the harm. For health organisations to be resilient, they rely on resilient people to rescue safety when WAD falls below the stability range; at least for the 50% or more of adverse outcomes which are generally held to be avoidable. When rescue does not occur, and adverse outcome occurs, reporting of that adverse outcome must occur in order for analysis and learning to occur. For that to occur, clinicians need to feel safe too.

Therefore, in healthcare, resilience is not about policy and systems as much as it is about people; especially clinicians. It is the ability to dynamically anticipate and avoid risk of harm. For individuals it involves not only anticipating risk in the workplace, but also assessing one’s own risk factors and moving to reduce one’s own risk of harm – self-care. Resilience in clinicians is essential because WAI cannot envisage the ways in which the act of completing a task is shaped by the constantly changing real-time conditions of work or the vagaries of patient response, and therefore at times the systems that are intended to support us are insufficient alone. An analogy could be that Google Maps may predict your time to destination but if an accident or flash-flood occurs, Google needs real time feedback for everyone to learn what is happening on that route right now and the best alternate route to take. The unpredictability, and at times the instability, of our workflow may mean that WAD may vary considerably from WAI. That is why the idea that systems can be polished to the point of flawlessness and can therefore be depended upon in all circumstances and totally responsible for supporting the right people to do the right thing, the right way, at the right time, is flawed. Systems are designed for predicted ranges of conditions (the stability range); not the unpredictable. It is sharp-end clinicians who are in the best position to detect when systems become inadequate. WAD can be complex and variable; task and activity may not be a perfect match. The importance of this distinction for our purposes is that the WAI-WAD gap is where much of safety is determined or compromised and where mindful monitoring is required. Those of us who work at the WAD sharp end know we can only be effective when we continually adjust what we do to fit the situation. It is impossible for those at the blunt end to anticipate all the possible conditions that can exist at the sharp end. In leadership positions I am too frequently embarrassed by my own admissions that start with, Oh I didn’t realise that was happening.

Safety for Clinicians

We can only mindfully keep a watchful eye out for patient safety