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 video, Neal Jones, Director of Patient Safety at Liverpool University Hospitals, discusses the challenges staff are currently facing and the support that they need.
A transcript of the video is also included below.
Questions & Answers
How did you first get involved in patient safety?
Neal: I started my career working in intensive care, clinically. Then I moved into education and specifically simulation-based education. And, in around 2004, was lucky enough to be trained as a Human Factors instructor under a British aviation training company. And that really sparked my enthusiasm and special interest in utilising the principles of safety science to redesign healthcare systems and processes to create generative, just, open learning cultures, and to deliver meaningful and sustainable change.
Why is staff safety important and what does it look like?
Neal: Staff safety is absolutely essential to patient safety. Fundamentally, if our staff don’t feel safe and they’re not working within safe systems and within a safe culture within which they recognise that, whilst mistakes happen, those mistakes are often driven by the systems within which staff work. And the treatment of those staff obviously has implications in regards to accumulative fatigue, in regards to stress levels, and a lot of the elements and aspects of the… science of Human Factors, in regards to the principles of error causation.
Keeping our staff safe is challenging at times, especially in recent months as we’ve gone through the COVID-19 pandemic. Obviously, our staff are fearful and frightened; they recognise that they have a significant role to play in the protection and survival of our patient base. And it is our job as an organisation to create the conditions for success; to support them, to work with them and to reassure them that we are taking every possible step and every possible measure to keep them safe so they can deliver safe and effective care to their patients.
How does staff safety make a difference to patient safety?
Neal: Staff safety makes a difference because if you don’t feel psychologically safe in the workplace, and you come into work feeling anxious, feeling nervous, then you are likely to be internally distracted, and distraction leads to a… total loss of potential control, it’s at the forefront of many errors that we review in healthcare. And it’s quite simplistic to see distractions within the clinical environment, to be able to spot other people… interjecting and distracting, and noise and environmental distractions. But, actually, what we don’t necessarily see so obviously is the stress-related internal distractions. People are preoccupied, fearful of harm to self as a result of errors that they’ve made, and the consequences of not getting and sustaining an appropriate, just and supportive culture.
As an organisation, we have to be accountable for those conditions. It’s something that we have the power to influence and to develop. And I guess the staff that work for us come to work each and every day, wanting to do their best. And if the reality for those staff is that errors are recurring as a result of inadequate environments or equipment, or systems and processes that aren’t necessarily designed to support human function and human performance and optimise the performance of staff within the workplace, then the task is ours as an organisation to initiate effective change. Some examples of that… you could say that some of the project work we’ve done about staff working hours, looking about how we protect staff from errors associated with fatigue. So we’ve piloted projects such as providing a 48-hour enforced rest period between night shifts and day shifts, so it gives staff a chance for their circadian rhythm to normalise, and therefore their performance to normalise. There’s been quite widely published evidence over the last few years, looking at an error rate of somewhere between 25 – 30%, where staff are unnecessarily fatigued, either working 12-hour shifts or longer or not having adequate periods of recovery before they come back into the workplace. And these aspects, these kinds of issues that are fundamental to the performance of our staff and therefore their safety and the safety of their patients, have to be the responsibility of the organisation. And it’s our responsibility to think differently about how we support staff and whether that’s within the way that they work or within the systems and environments within which they work – that is ultimately the responsibility of the organisation to… pioneer and improve upon, and do everything that we can to keep our staff safe so, in turn, they can keep our patients safe.
Can you provide an example where you’ve seen this to be the case in your own line of work?
Neal: Examples where I’ve seen distressed staff and staff not being kept safe? It’s difficult because the examples are relatively common. I think it’s fair to say that the approach to incident investigation hasn’t yet found its balance; the balance that is required to create the conditions where staff would be more likely to feel like second victims; that there’s an instant organisational accountability for the failures that potentially put those staff in a position… within which error becomes inevitable. And whilst we’re undertaking a significant programme of work at the moment to create a really fundamental change in how staff feel when mistakes are made. It’s not a short or quick process. This is a programme of cultural transformation.
And I think my position, reflecting on my past clinical working life within which I, like every human being on the planet, although my mistakes didn’t lead to… patient harm… they were mistakes. We spend more time punishing ourselves for those errors than anybody else can do. And there’s also the concept that a person who’s made a mistake and immediately recognises that, potentially instantly becomes the safest person in the room. So I think challenging that concept and applying a more punitive approach and making staff feel as though they’ve failed in some way… is unhelpful at best. It’s going to stifle learning; it’s going to stifle innovation; it’s not going to help with recruitment; it’s going to impact upon staff-related sickness absence; and it’s something that, as a healthcare organisation, we need to look at very differently going forward in the future. It’s our staff that keep our patients safe and we absolutely have to recognise that as being fundamental to the organisation’s success.
What advice do you have for staff, themselves, to ensure they are safe at work?
Neal: I think we’re quickly moving towards the point where we will require our workforce to be cognisant of their own, and their team’s, performance limitations. That there will be some concepts, such as peer mentoring, where different team members will start to think more carefully about the behaviours of their colleagues and whether or not those behaviours are indicative of stress response or fatigue-related failures, and to start to look to collaboratively and collectively work to… eradicate the risks that they pose.
Everybody is in a position, I guess, where we’re tired. We’ve just come out of – we haven’t actually come out of it yet, we’re still in the midst of – a global pandemic. And it’s challenging, not only because of the impact it’s had upon staffing levels, through isolation and sickness, and leaving the staff that are here and are giving the 110% each and every day to deliver optimised care. And recognising that that is a challenge for staff, and that level of fatigue and stress. And especially because we’re not in a position at this point to lead normal lives. Most of us would like to disappear off on a plane and spend some time in the sun, completely decompressing from our day-to-day work lives. And unfortunately, as I’m sure everybody’s aware, that that isn’t necessarily as simple and straightforward. And especially if you’re working within a healthcare environment and you’re frontline staff, then the potential [of] going abroad and returning, having fully relaxed and recovered, leading to a 14-day period of isolation, isn’t necessarily practical or deliverable at this stage.
I think foresight support for staff. I think if staff are educated and informed and have high levels of self-awareness around the potential risks that they face, and they can utilise the principles of foresight to identify those risks, and to act rapidly and collectively with colleagues to attempt to mitigate in real-time; trapping risks is essential in something as dynamic as healthcare. Of course there needs to be balance within that; we shouldn’t be expecting our workforce to compensate for the inadequacies in the systems within which they work, but by the same effect, this is going to be a long process of transformational change. And as technology advances, as the environments within which we’re able to deliver healthcare and the reliability of those systems and processes advances, the requirements of staff to compensate will diminish over time. But, for the time being, there needs to be a combination of system redesign, of staff engagement, support, and giving those staff the opportunity – and the ability, capacity and capability – to be able to recognise and trap errors as part of their daily function.
How can Patient Safety Learning help?
Neal: I guess we’ve been looking at safety science and its application in healthcare for probably 20 years now since ‘To err is human’. And, certainly within the NHS, since around 2013, the publication of the Human Factors Concordat. There’s been an appetite to investigate the application of safety science into the industry of healthcare, to create enhanced reliability, to reduce episodes of avoidable harm, to protect staff from being involved in those areas, both psychologically and fundamentally. And Patient Safety Learning offers us an opportunity to share learning nationally. It gives us the opportunity that we don’t have to repeat the mistakes of others, and if we become more open and more transparent and more active in sharing and supporting and creating… lessons learned at a national level – not just a regional or even a local inter-departmental level – then we should start to see advances in patient safety.
From a staffing perspective, you can’t defend against what you don’t know. So anything that acts as a resource for our workforce to access lessons learned from other organisations is absolutely critical and essential. To trap something, you’ve got to be able to spot it first. And, as we move through developments in healthcare, new error types will emerge. And if we could get to the stage that the first organisation that spots or suffers as result of these error traps is able to share what happened and what action they’ve taken, with some immediacy into a national learning and sharing hub, then it would potentially provide each and every other organisation in the country with the ability and opportunity to put those mitigation strategies into place and avoid the repetition of harm.