“When staff openly and willingly share their mistakes, you know you have a positive culture.” An interview with medical students Adam Tasker and Julia Jones

Summary

A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated. 

Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research.

About the Author

Julia is a final year graduate medical student. Before studying at Warwick, she completed a Natural Sciences degree at Cambridge University and went on to manage projects for Tesco's Supply Chain. She has always had an interest in organisational culture.

Adam is also a final year graduate medical student at Warwick. Prior to starting his degree, he served in the Royal Navy as a helicopter observer, instructor and aviation specialist within UK, EU and NATO headquarters. He has an interest in safety culture, human factors and team performance and is keen to use his experience to help develop these areas within the NHS.

Questions & Answers

Hi Adam and Julia! Please can you introduce yourselves?

Julia: I'm Julia, and I'm a final year graduate medical student. Before studying at Warwick, I completed a Natural Sciences degree at Cambridge University and went on to manage projects for Tesco's Supply Chain. I've always had an interest in organisational culture and have really enjoyed working with Adam on this research project.

Adam: I’m Adam and I’m also a final year medical student. When I finished my accountancy degree I became an observer in the Royal Navy, which involved operating helicopter radar and weapons systems. After 16 years in the Navy, I decided to pursue a career in medicine and was fortunate to get a place at Warwick Medical School. 

Julia: Adam and I recently found out that we passed our exams so will both be qualified doctors in July!

Where did your interest in creating a Just Culture come from?

Adam: When I was considering a move into medicine, the case of Dr Bawa-Garba was receiving lots of attention. Dr Bawa-Garba was convicted of gross-negligence manslaughter after the death of a young boy from sepsis. It sparked a lot of discussion about the culture within the NHS, how incidents were managed and the need to move towards a Just Culture. 

The culture in military aviation that I was working in was, in contrast, very positive in terms of how the organisation approached incident management. I was concerned about moving from a healthy safety culture to an environment where there was lots of evidence that the culture needed significant improvement. When we were given the opportunity to do a research project as part of our degree, the NHS had recently released guidance on culture change and implementing Just Culture. I thought it would be a good opportunity to take an early look at what the culture was like within one of the trusts where we were doing placements.

Briefly outline your study - what did you want to find out, and how did you do it?

Adam: We conducted our study at a hospital trust in the Midlands. We could only look at one hospital because of timeline constraints, as it would have taken too long to get ethical approvals for a multi-site study. We wanted to try and understand to what extent a Just Culture was being implemented, and decided on a qualitative study as we wanted to understand people’s thoughts, feelings and perspectives on the culture. This would help us assess why things are as they are and what more could be done to facilitate developing a Just Culture. We didn’t have a hypothesis to test; we wanted to focus on building a picture of how both leaders and clinicians on the ground perceived the culture in their trust.

We interviewed 20 people and sat in on five meetings, so the study is only a snapshot of a particular time and place. Our hope was that we could come out of the study really understanding why people of different grades were feeling what they were feeling, and make recommendations that might help with moving the culture forward.

Julia: When we looked into the research that was out there, we found bits and pieces, but nothing had really looked in detail at what had come of the NHS decision to implement Just Culture. For our research we spoke to people on the ground; the other research we found tended to focus on leaders and managers and what they had implemented. The strength of our paper was speaking to doctors at all different levels, so we could give a picture across the medical workforce.

Adam: One of the limitations of our project is that we only spoke to doctors, managers and medical students, we didn’t get to speak to other healthcare professionals. However, we did speak to graduate medical students who had a previous background in those professions, for example, as nurses or physiotherapists. They had unique perspectives as they could share their experiences of culture and how they were treated in their previous profession, and contrast that with their experiences as medical students. We were able to analyse that against the views of students who had come from a non-healthcare background.

What was the most interesting or surprising insight to come out of your research?

Julia: It was refreshing to be able to see the positive culture that seemed to exist in the higher level management meetings. We were only able to go to two, but I was really impressed with the way they dealt with investigations, and they were very clear that their aim was to improve patient safety. They knew the vision of the NHS and they were really trying to implement it. 

However, it was also interesting to see how that had filtered down to lower level meetings—the ones we observed didn’t quite have that same focus. It would be really interesting to find out where the translation between the two had occurred. It struck me as a shame that not many medical students or juniors get to experience those high level meetings.

Adam: I agree with Julia—I realised the importance of communication. Quite often managers set out a policy that sounds reassuring, but if the behaviour being demonstrated and experienced doesn’t align with that, there will be a breakdown in trust and people won’t trust the policy. But we saw within those meetings behaviour very much aligned with a Just Culture, but perhaps lower grades don’t get enough opportunity to see that. When we interviewed junior doctors and medical students, their insecurities were largely based on high profile cases in the media or stories they had heard from other trusts. I don’t think anyone described concerns about culture based on their experience at the trust where they were training.

For me, it highlighted the importance of transparency within the system—one of the recommendations we put to the trust was to consider bringing more junior clinicians into some incident review meetings, as the meetings we saw were largely made up of managers and senior clinicians and nurses. Without that exposure, you’re asking junior clinicians to trust that the process is fair and works without showing them the process. It would also add another important perspective to those meetings; if you’re discussing how an incident involving a junior doctor unfolded, having a junior doctor's perspective might give the room a better appreciation of the pressures they are facing on the ground.

What do you see as the next step in creating a Just Culture in the NHS?

Adam: When we interviewed senior clinicians, they were all fairly familiar with the processes for incident management, but junior doctors seemed much less familiar. As a junior doctor rotating around, you may not have time to look into all the processes in detail as you have to familiarise yourself with a new trust fairly frequently. So another suggestion we made was including incident management in the induction brief, including helping people understand where the boundaries and red lines lie for incident investigation.

I also think it would be really helpful if feedback came directly and in-person from clinicians involved in the incident investigation, so that there is scope for asking questions and making sure that individuals really understand the lessons identified. A movement towards investigation cells, where a core group of clinicians are involved in incident investigations, would help other staff know where to go to find out information about specific incidents.

I think we’re also starting to see a greater appreciation of Human Factors—a lot of junior clinicians had received training on Human Factors at medical school, but fewer senior staff seemed to have a good awareness of it. If you don’t have the full appreciation of Human Factors among the people reviewing incidents, you might be missing out on key factors that are affecting someone’s work and performance.

Julia: Our study was a snapshot of one trust, so there is much more research that can be done to increase our understanding of Just Culture. Hopefully we’ve created a prototype approach to finding out more about culture from the staff working in an organisation—it would be great to see that picked up by other trusts.

Adam: Because junior doctors rotate so much, we discussed the importance of trying to establish a uniform approach within a region. At the moment, different trusts will have different cultures and if a rotating doctor has been burned by a blame culture in one hospital, they can take that with them as they rotate. If they are entering a trust with a more positive culture, their experience will have an impact on the new environment they are entering. That’s why a consistent approach to Just Culture is needed across different NHS organisations.

Julia: What we can’t answer from our research is how easy this regional approach might be to achieve. It underlines the need for further research to get a wider view of culture across different trusts.

How do you think medical training could better prepare doctors for dealing with patient safety Incidents?

Julia: Working with medical students is very important because they are a key part of the future NHS culture. As part of our medical training, we had Human Factors training which was really helpful, but for medical students to challenge what they see, they need to feel safe, and that’s quite a nuanced issue. Having a mentor can really help people feel confident to raise their concerns and put their knowledge of system safety into practice. It’s really important that students and junior doctors are able to keep a positive culture alive, as when they are in senior positions their influence could mark a significant change.

Adam: From the interviews, we picked up that doctors who had trained at different medical schools had received Human Factors training, so it does seem to be becoming more widely adopted.

When I was in the military, no one spoke extensively about Just Culture, it was just something that we did, that was well embedded in the organisation. The NHS is different—you have an organisation that’s trying to adopt a Just Culture, so awareness is really important. Staff need to know about the different cultures that could exist. Only three out of the 20 doctors we interviewed were familiar with the term ‘Just Culture’. At the same time, there are lots of medical students and junior doctors who are quite wary because of how high-profile cases have been handled in the past. So really defining how the culture should be when students and junior doctors join a trust is important. 

The medical curriculum is busy enough as it is, but I think giving students the opportunity to sit in on the incident review process would really help them have confidence in the system. If you tell someone something, they will believe it to an extent, but if you show them how the process works and help them understand what you’re aiming for, their trust and understanding in the process becomes much more solid.

Adam, you spent 16 years in the Royal Navy prior to medical training—what key learning around culture and blame would you like to see applied to the health service?

Adam: I was involved in an incident quite early on in my military aviation career, and my positive experience of how that was handled had a big influence on my career in the Navy. So I think that exposing people in incident reviews early on may give them some reassurance, which will help improve the reporting culture as doctors feel less afraid to admit when they get something wrong.

Something that really helped me in my early years in the Navy was seeing some of my seniors have the humility to land on from a flight and share what had gone wrong. They would share their mistakes and learning, sometimes with the whole squadron or the people within their specialty. Often we want to be seen as perfect, and that makes us not want to admit that we could have done something better. Amongst medical students, I’ve heard a lot of people talking about a sense of imposter syndrome and feeling that they need to be flawless. We need to break the view that we should be perfect, as if we expect people to never get things wrong, we don’t put systems in place to help when they inevitably make mistakes. 

We need to be explicit about showing that we really respect when doctors share what they’ve learned from their mistakes with colleagues to enable them to learn from it too. As a medical student, I’ve encountered some clinicians who have shared what they got wrong with me and outlined the important learning. But I’ve also met many who don’t do that. Part of the culture that I’ve observed within medicine is to show that you know all the right answers and are on top of everything, and that can lead people to want to bury their mistakes, restricting their learning from being shared. It would be great if those open conversations about mistakes and how the system isn’t working could be more encouraged.

Julia: Adam told me that in the Royal Navy there was a flight safety magazine in which people would share their errors alongside their reflections and learning. I think when an organisation can do that, you know that they have a positive culture. I’d love to see the NHS get to that place, where staff feel able to share their mistakes openly and willingly. 

Medicine is all about balancing risks—you could take two different approaches and each has the potential to go wrong. Defensive medicine is costly and can put a patient through a lot of unnecessary investigations. If you are only aware of your own mistakes, you don’t get a clear picture of where different things can go wrong, and that awareness is really important in clinical decision making. To be better clinicians, we all need to be honest about our mistakes, rather than focusing on one horror story that we all go to extreme lengths to avoid, sometimes to the detriment of the patient.

Related reading

• Access Adam and Julia’s research study on the hub: How effectively has a Just Culture been adopted? A qualitative study to analyse the attitudes and behaviours of clinicians and managers to clinical incident management within an NHS Hospital Trust and identify enablers and barriers to achieving a Just Culture
• Adam and Julia’s research poster was also a Poster Category Winner and voted Overall Poster Competition Winner at the HSJ Patient Safety Congress in 2022.
• Read a detailed account of Adam’s experience of culture and incident investigation in the Royal Navy in his article for the BMJ, Naming, shaming and a just culture (paywalled).