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  • “Evidence shows that when staff feel psychologically safe, they are more likely to speak out in the patient’s best interest” (WPSD 2020)

    Patient Safety Learning
    • UK
    • Interviews and reflections
    • New
    • Health and care staff, Patient safety leads


    17 September 2020 marks the second annual World Patient Safety Day. The theme this year is 'Health Worker Safety: A Priority for Patient Safety'.

    In the run up to this special event, Patient Safety Learning are publishing a series of interviews with staff from across the health and care system to highlight key issues in staff safety and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe. 

    In this joint interview, Patient Safety Learning speaks to Rob Tomlinson, a nurse in the operating theatres at East Lancashire Hospitals Trust, and Peter Smith, now retired after enjoying a thirty-year career in operating theatre nursing.

    Rob and Pete discuss why staff need to feel both physically and psychologically safe in the operating theatre and empowered to speak up, and  how the Below Ten Thousand language tool has made a huge difference in creating a safer operating environment.

    About the Author

    Pete is author of The Below Ten Thousand Way and Rob has been championing the Below 10,000 concept from the UK to Australia. 

    Rob tells us: 

    “Operating theatres have become increasingly loud, partly due to technological advancements and surgical advancements. This noise and distraction leads to a loss of situational awareness – now a leading cause of surgical error and a major cause of Never Events.

    Inspired by the aviation industry, ‘Below 10,000’ is a simple language tool, which can be used by any member of the operative team when they feel there is too much noise or distraction on the patient’s surgical journey. When someone calls “Below 10,000” what results is reduced noise and distractions, allowing the team to refocus on the task in hand.”

    For more information about Rob and Pete’s work, please see www.tenthousandfeet.co.uk.

    Questions & Answers

    Why is staff safety important to you?

    Pete: During my work as an occupational health and safety representative on the theatre floor, I became aware of a serious gap in our interpretation of the workplace safety act. I saw that we focused on physical injury, but when I looked at the definitions within the Act, wherever ‘health’ was written, physical and psychological health was explicitly implied. And yet I could see stress all around me that affected how people worked together. It was then that I decided I would try to do something about it, even if it killed me.

    Why is staff safety important for patient safety?

    Rob: Staff need to feel both physically and psychologically safe. As well as increased noise and distractions in the operating theatre, another leading cause of Never Events in the UK is a failure of staff to speak out even when they notice that a patient could be under increased risk of harm. Evidence shows that when staff feel psychologically safe, they are more likely to speak out in the patient’s best interest. Unfortunately, when staff work in environments where there is a steep hierarchical gradient present, staff are scared and less likely to speak out for their patients’ best interest.

    This was a problem in aviation, where we have seen co-pilots die rather than speak out against the pilot.

    How have you seen Below Ten Thousand make a difference to staff safety and patient safety?

    Rob: I, and many others, have used the Below Ten Thousand language tool a lot and have witnessed the positive impact it has had upon patient safety and staff performance. The problem in the operating theatre is that, during an operating list, we all concentrate at different points. The anesthetist will obviously be at peak concentration at intubation and extubation, whereas the surgeon has dipped here and peaks at various points during surgery. It is at these points, when our concentration levels decrease, that noise and distraction creeps into the room.

    One example was when a student nurse was attempting to implement the ‘sign out’ just before a patient was extubated. There were several pockets of conversations in theatre with staff mental workloads were dipping as hers was peaking. The student nurse asked for quiet and was simply disregarded. Then the theatre support worker simply called “10,000 feet”. What resulted was complete staff focus and a quiet environment during the ‘sign out’ by the full operative team. Two of the most junior members of the operative team collaborated to bring the team back together for a critical point on the patient’s pathway. The hierarchy was instantly flattened. It was either ‘10,000 feet’ being called or something very uncivil!

    Pete: Even on the first day of Below Ten Thousand on the floor at Geelong, I was inundated with happy faces. A junior anesthetic registrar shook my hand. A senior consultant beamed “it worked!” There is no doubt that even such a simple solution can make a huge difference to creating a safer operating environment at key and pivotal times, but it takes the whole team to willingly comply. And that’s where authenticity is the art and science of healthcare, and emotional intelligence becomes a key influencer in affirmative team behaviours.

    Do you feel safe?

    Pete: There is so much work to do, and Below Ten Thousand is just the beginning. My immediate thoughts are to imagine a trip down any Australian highway. The two signs you see, over and over again, are ‘speed kills’ and ‘fatigue kills’. And yet, in healthcare, we insist on nurses working at a relentless full throttle whilst as tired as a zombie.

    The interesting thing about the CQC report into the need for a transformative safety culture was that there was not a single mention of the need to transform safety by negating fatigue in our clinical workforce, which is like trying to avoid radiation whilst standing as close to the image intensifier as possible wearing nothing but a plastic apron.

    I think I will feel safer once we start to take serious action to address this chasm in healthcare’s safety culture.

    What have you seen organisations do to keep their staff safe?

    Rob: The trust where I work is effectively declaring that they don’t want steep hierarchies and want staff to feel empowered to speak out if they feel the environment is not focused on the patient as it should be. By doing this, they are also implementing a Just Culture. The ugly face of blame can creep in when things go wrong in healthcare. The trust is employing the Below Ten Thousand language tool. No longer can surgeons or nurses blame each other for too much noise or distraction when things go wrong, as we all have the environment in our control. Sadly, this is quite common with investigations finding out how and why patients are harmed.

    What advice can you give organisations to keep their staff safe?

    Rob: Many organisations declare that they want staff to feel able or empowered to speak up. Unfortunately, they do this with no extra training or systems in place to accommodate this. Research tells us that any language tools or systems to reduce distraction needs to be encouraged. Unfortunately, as clinicians, we can misperceive and overestimate our non-technical skills, so we dismiss concepts such as Below Ten Thousand or Rob Hackett’s Theatre Hat Challenge.

    We often work within unfamiliar surgical teams at very unsociable hours of the day or night. I can assure you that we need help communicating at these times more than any other. It is so obvious that having your name and job role visible on your hat would help improve communication. The hat challenge, like Below Ten Thousand, promotes horizontal communication and attempts to reduce steep hierarchies. The crazy comparison is that my uncle works on a building site and having your name and job role visible on your hard hat is a compulsory safety requirement. We work in one of the most safety critical environments and yet identifying each other, particularly when we wear a lot of PPE, can be a guessing game. Many staff say they would feel silly wearing a hat like this; that is coming from a department of staff who walk around in their pyjamas all day!

    There is a lot of good work in this area going on all over the world. In our opinion, more needs to be done to help ‘ground up’ concepts, like Below Ten Thousand and the Theatre Hat Challenge. A recent national survey revealed that 83% of theatre nurses and ODP’s believe the NHS is not doing enough to facilitate clinician/ground up change.

    We are the people who work with patients on a daily basis, so if we want to wear a hat with our name and job role or use the Below Ten Thousand concept, don’t make us take it off and don’t turn a ‘ground up’ concept into a ‘top down’ concept!

    Pete: Rob, I agree. Ultimately, the people working at the clinical interface are the ones with knowledge of the true problems and opportunities arising from these problems. The truth is that the solutions these people come up with are often subtle, hugely effective at solving unidentified problems and practically free in terms of healthcare dollars. They make such a huge difference to engaging and inspiring the workforce, and yet we do our best to crush the proponents because the idea hasn’t come from people in positions of authority who see themselves as the chief dictators of order.

    I see it as a measure of the industry’s insecurity, and it gets in the way of us being the architects of world class teams in clinical practice.

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