• it asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive 
• it helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background. This has similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black and minority ethnic staff.

This guide should not be used routinely. It should only be used when there is already suspicion that a member of staff requires some support or management to work safely, or as part of an individual practitioner performance/case investigation. Remember, you have moved into individual practitioner performance investigation when it is suggested a single individual needs support to work safely (including training, supervision, reflective practice, or disciplinary action), as opposed to where a whole cohort of staff has been identified, which would be examined as part of a safety investigation.

The guide does not replace the need for patient safety investigation and should not be used as a routine or integral part of a patient safety investigation. This is because the aim of those investigations is system learning and improvement. As a result decisions on avoidability, blame, or the management of individual staff are excluded from safety investigations to limit the adverse effect this can have on opportunities for system learning and improvement.

This guide reflects our best current understanding on how to apply the principles of a just culture in practice, in what is a live area of both academic and practical debate.

In this article, Richard discusses the origins of Schwartz rounds and his experience of attending two Schwartz rounds, one in a hospice and one in an acute trust.

The analysis highlights the necessary conditions for rounds to work.

“The After Action Review has democratised the Army. It has instilled a discipline of relentlessly questioning everything we do. Above all, it has re-socialised many generations of officers to move away from a command and control style of leadership to one that takes advantage of distributed intelligence.” Pascale, Millemann  and Gioja, 2000¹

We can learn much from the military’s use of AAR. The problems created by its hierarchical structure are similar to ours in medicine, especially the fear of the consequences of speaking out and voicing a different opinion to your superiors. Research confirms that junior staff are often reluctant to question the direction or decisions of their seniors, even when they feared patients were at risk of harm.² Fear of the consequences also limits open and honest reporting of incidents, restricting the potential gains of learning at the system-wide level and at the local level. Yet consistent and widespread use of AAR in battlefield and training environments has reduced the fear of blame and retribution and increased effective communication through the ranks and transformed the speed and value gained from learning. 

It has done this in part because every AAR creates a safe environment for learning due to the actions of the AAR Conductor and the organisational commitment to using AAR. Professor Amy Edmondson has spent over 20 years researching the components of effective 'work groups' and summarises what increases team performance as "psychological safety". It can be defined as "being able to show and employ one's self without fear of negative consequences of self-image, status or career".³ High levels of psychological safety in clinical teams have numerous benefits for safe and effective care.⁴

My experience has taught me that with repeated and regular use of AAR, the psychological safety experienced during them, shapes and influences behaviour positively outside of them. 

Another reason AAR works to improve patient safety is the quality of the learning and changes in behaviour coming out of them. Here the research is also very clear. A meta-analysis of research into AARs⁵ demonstrated that the learning coming out of AARs can improve team and individual performance as much as 25% when compared to control groups. This analysis of research in a wide variety of settings showed that participants learnt so effectively through the AARs, that they were able to perform and deliver up to 25% more effectively afterwards. This is because the participants in the AAR are fully involved in their own learning so instead of being talked at, they are being asked to make sense of the shared picture of the event that has been generated in the AAR. The responsibility for learning and change in an AAR, therefore, rests with the participants and is directly relevant to them.  In a clinical setting this means that improvements in safety and behaviour can start the minute the AAR ends. Contrast this with an investigation, where the learning is owned by the investigator and the organisation that employs him or her, and the responsibility for change rests far away from those involved in the action.  

The quality of the shared mental model that is created in the best AARs directly supports learning about patient safety matters as the individual participants access other people’s experiences to gain an overview of an issue. The skilled facilitation by the AAR Conductors is a vital part of this, as once a safe learning environment is established, cognitive biases and prejudices are reduced and clearer thinking is possible. Patient safety learning is also greatly enhanced through AAR because of both its 'learn as you do' approach and the fit with effective adult learning theory models. AARs do not require clinical staff to leave the ward for days at a time for traditional teaching about patient safety. Instead AAR  practice makes it possible for learning about patient safety to become an everyday habit and, therefore, more effective. Since the AAR process allows individuals to learn for themselves what happened and what got in the way or enhanced safe, effective care, it is mapped onto the individuals own knowledge base and makes a more lasting impact.

The last feature of the issues highlighted in the NHS Long Term Plan concerning patient safety was the workforce. My experience of facilitating hundreds of AARs in clinical settings has highlighted its potential to reduce the stress levels of staff as the supportive no-blame environment encourages greater clarity and less personal blame. Lower stress levels will have an indirect but valuable effect on staffing levels as sickness absence may be reduced and retention boosted.

This is just a summary of some of the features of the AAR approach  which I know will enhance patient safety. Other AAR Conductors will have more insights to share, and the academic researchers in the US and Israel universities many more. 

I would love to discuss AARs further with you, contact me at: judy.walker@its-leadership.co.uk

References

1. Pascale RT, Millemann M, Gioja L. Surfing the Edge of Chaos: The Laws of Nature and the New Laws of Business. Three Rivers Press; 2000.
2. Crowe S, Clarke N, Brugha R. ‘You do not cross them’: Hierarchy and emotion in doctors' narratives of power relations in specialist training. Social Science & Medicine 2017; 186: 70–77.
3. Kahn WA. (1990-12-01). Psychological Conditions of Personal Engagement and Disengagement at Work". Academy of Management Journal 1990; 33(4): 692–24. doi:10.2307/256287.
4. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines : Team Learning and New Technology Implementation in Hospitals. Harvard University Administrative Science Quarterly 2001; 46: 685–716.
5. Tannenbaum SI, Cerasoli CP; the Group for Organizational Effectiveness. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors 2013; 55(No. 1): 231–245.

With this in mind, we brainstormed ideas for the reasons behind this ‘divide' and decided a regular newsletter might help us.

The initial benefits would be:

• To keep CCU/HDU staff up to date with our current projects - this was a problem identified during recruitment into the outreach team as CCU staff suggested that they had limited opportunity to become involved in the work of the outreach team. Having the CCU staff become more involved and aware of the ‘extra’ work we do has helped to improve our working relationships; various nurses are now more involved with some of our projects, and others are looking to help with the view of progressing into a future outreach role.
• To explain our role as it not always widely understood by some colleagues on CCU.
• To offer our support to any individual wanting to work on a QI, but was not sure how to proceed.
• To highlight our achievements and hard work and to introduce staff to some of our ‘behind the scenes’ work.
• To involve all staff - we regularly asked staff for suggested content that they would find most useful.

The success of the newsletter quickly led us to adapt it to all hospital staff of any discipline or grade:

• The above benefits were similar, but now pertinent to a larger audience, including healthcare assistants, students, physios, occupational therapists, speech and language therapists, doctors and management.
• Some of our team are relatively new and it is a good tool to introduce them, using photographs to help improve our visibility and approachability within the hospital.
• We wanted an ‘educational hot topic’ to be a regular feature to help maintain high quality care and standards amongst staff. We asked readers what topics they wanted to engage with. We now have a number of ‘guest writers’ for this section, from various specialties, to help share their knowledge and expertise. It is encouraging to hear how healthcare assistants, students and associate practitioners have found our newsletter content so educational and helped them to provide better care to the patients (and feel more engaged with the care they are providing).
• Every time a new edition of the newsletter is sent out, I have received personal feedback of how useful and interesting it has been. Staff have often personally thanked me on the wards and in the corridor. There is a lot of effort and time that goes into these newsletters, but I feel it is definitely worthwhile. I am a great believer in valuing staff and this has really helped me to keep going, despite the difficulties encountered.
• The newsletter is now jointly written with our Hospital Out of Hours (HOOH) team. Although we are two separate teams, our lead, Rhona, is shared. We all work very closely, supporting each other and preach many of the same messaged, so this just made sense.

Challenges and lessons learnt:

• Team engagement – not all team members wish to be involved in the newsletter and feel there is little extra time to engage with this extra workload.
• The time spent writing and editing is significant and cannot be done within my working hours, so much of this work has been in my own unpaid time.
• I have to rely on some sections being written by other professionals. It is difficult to quickly replace sections if deadlines are missed or not already within a requested word limit.
• I initially edited the newsletter in Word, but found formatting was very difficult. I discovered Publisher and taught myself to use this. I am sure I can learn much more, but have so far found this much easier to work with.
• We wanted to send to ‘All email users’ within the hospital, but were told this was not possible. Instead, I use various groups of staff set up on our work email system.
• My first Ward newsletter was only sent out to CCU staff and Ward Managers. This was not always shared with other staff; inboxes were frequently full and therefore emails could not be received; and this method missed vital teams such as physiotherapists, speech and language, doctors, students.
• Following my distribution issues, I have since compiled a ‘mailing list’ which I add to regularly (this includes professionals in other trusts who enjoy our newsletter too). The hospital librarian team and individual keen students have personally asked to be added to this list which is encouraging.

Perhaps we could all share our newsletters and stories within our trusts and on the hub and support each other in this patient safety initiative. I’d love to hear from others on ideas for newsletters and how they have overcome some of the challenges I describe above.

CCOT Newsletter to WARDS FEB 2019 Edition 1.pdf

CCOT Newsletter for ITU Staff Edition 1. Feb 2019.pdf

Joint CCOT and HOOH Newsletter 2nd Edition June 2019.pdf

• Acute: Leeds Teaching Hospitals NHS Trust
• Mental Health and Community Trust: Tees, Esk & Wear Valley
• District General Hospital: Kettering

What will I learn?

• What does employee engagement mean in the NHS?
• How is engagement measured?
• Why is employee engagement important in the NHS?
• What are the enablers and barriers to good staff engagement in the NHS?
• What interventions are effective in improving employee engagement in the NHS?