How learning from narratives can help improve patient safety: a blog by Rosanna Hunt

Summary

Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision.

Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team.

This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. 

Content

We believe that it cannot be assumed that merely reaching an understanding of the causes of past incidents will lead to improvements in future practice. Improving the safety of healthcare provision is firstly dependent on the particular approach taken to understanding why patient safety incidents occur. Although current approaches may shed light on why an incident occurs, they do not always do so in a way that accounts for the context in which the practice under review is delivered. This links to the second influence on improving patient safety: most practitioners cannot reliably predict in which case a patient safety incident will occur.

Unless learning can be presented in a form that makes sense to practitioners, then its impact will be limited. Thus, explicit attention needs to be given to the extent to which learning can be operationalised in day-to-day practice.

SenseMaker® is a tool that allows staff to tackle complex problems that they experience on a day-to-day basis but for which there doesn’t seem to be a space for unravelling the complexity involved in the problem within the busyness of the working day. Therefore, it is often used as a reflective journal; a space to capture a story at the end of a work shift, and discover, through later workshops, whether it aligns with the experiences of others and where to focus leadership efforts in taking action.

Of course, there often simply isn’t time to write down a reflective journal entry, so protected time provided by the organisation for this is essential to get representative data to fuel the future change.

Why SenseMaker?

Traditional staff surveys are limited in their scope to provide data relating to challenging problems because they ask staff to reflect on how the current system is working based on what is known about the current system. Although they provide valuable feedback on how systems are currently working, they lack the capacity to extract phenomena that can provide insights into what possible future systems might look like and how they might operate.

Unlike those traditional surveys where a third party interprets a respondent’s data and assigns meaning to it, SenseMaker is designed to mimic the ways that information is shared implicitly through conversation and informal networks, takes an approach of self-signification; giving the story-teller ownership of their narrative within their own context, evaluating their own data, which places them at the intersection between statistics and storytelling.

Often researchers, leaders and/or senior decision-makers (although acting out of the best intent) are often not privy to the perspectives of those working in the change context itself. The narratives can reveal biases and hidden assumptions about how the so-called 'other' is making decisions or going about their role. The SenseMaker tool therefore prioritises the lived experiences of individuals to create a richer, descriptive picture at scale.

Previously, we have used SenseMaker to extract and workshop experiences of system leadership development, equality diversity and inclusion, staff wellbeing, development of new roles, international staff retention and recruitment, and change agency in the NHS. We prompt respondents with a question asking them to share a story of a recent experience, which they label by adding a title or a hashtag for the story. A prompt question for a study looking to extract patient safety experiences might look like this:

“Please use this space to tell us a story about a patient or a group of patients, that you recently were involved in, were told about, or observed, that you think the organisation should know about.”

How does it work?

The prompt question should provide opportunities for staff to offer both negative and positive stories and the framework always asks respondents to indicate the 'emotional tone' of their story using a closed multiple choice question. The platform provides quantitative interpretations of the qualitative data using triads, dyads and stones. These tools use 'signifiers' that are used to enable participants to say what was significant about their story for them. Signifiers are designed with a co-design team and aim to produce data that reveals clusters, patterns, outliers and longitudinal shifts. 

An example of a triad:

My journal entry is about…

(move the pentagon to a spot within the triangle that represents your experience)

 An example of a dyad:

Acting on this journal entry would make…

(move the pentagon to a spot on the line that represents your experience)

How can we use the stories?

These questions enable us to monitor change over time, thus deploying the tool as an evaluation tool that collects baseline and follow-up data.

By collecting stories and monitoring shifts in the meaning attached to those stories over time, we can evaluate whether any intervention (or unexpected event) has an impact on experience.

It is, however, critical that skilled strategic facilitators help to complete the learning loop offered by the data by presenting it back to the participants in a digestible format and facilitating conversations about the stories with those participants. These sense-making sessions often use 'futures thinking' methodologies where the stories are, for example, sorted into two piles – 'stories we want more of' and 'stories we want less of' – as a means of discovering the actionable steps to achieve the desired future state.

The recent introduction by NHS England of the Patient Safety Incident Response Framework (PSIRF) encourages a positive change of direction. The system-based approach to learning as recommended within the PSIRF is likely (i) to lead to a more nuanced causal explanation for patient safety incidents (than merely focusing on index cases), and (ii) to encourage a ‘just culture’. However, we believe there is further to go as this shift may not address the factors that interfere with the operationalisability of learning for everyday practice.

We can, of course, learn from both staff and patient perspectives and can even cast the net much wider, to gather broader systems perspective on the problem. Here is an example, from the education sector, of how mass collection of different perspectives, plotted on one triad can reveal insights that are of benefit to share and learn from: 

What’s the impact?

SenseMaker was recently used to evaluate 'Stay & Thrive' – a cross-regional NHS programme that used 'positive deviance' as an approach to accelerating the retention and recruitment of international staff. The analysis generated by SenseMaker demonstrated a proportional increase in the percentage of positive experiences of retention and recruitment in the North East and Yorkshire and the South West regions, which correlated with the length of individuals’ involvement in the programme.

The narratives were also used in workshops, where facilitated conversations about the data revealed insights as to what contextual factors were associated with positive experiences; these included, amongst other factors, attention to professional growth, opportunity to innovate and building a sense of belonging. The actionable insights from these workshops help to inform local strategies for enhancing retention and recruitment in a wide variety of contexts and professions.

For further information, please contact Rosanna Hunt and Lizzy MacNamara.

We would love to hear if your organisation is using SenseMaker or similar tools. Add your comments in the comments field at the end of the page. You need to be a hub member and signed in to comment.  If you're not a hub member, it's free and easy to Sign up.

About the Author

Rosanna Hunt

Rosanna has been helping teams, leaders, organisations and systems achieve large-scale change in the NHS and wider public sector as part of the Horizons team in the NHS since 2014. She is a qualified ILM5 coach and provides 1:1 mentoring and team development to many different organisations, often using the 'Energy for Change framework' to help teams refresh their approaches to change.

She has a Ph.D. in Psychology and Learning Theory and has convened stakeholders to build shared purpose and share learning across many programmes of work, including the 'Stay & Thrive' programme as a means to gather intelligence, distil insights and mobilise action for change. At the NHS Institute for Innovation and Improvement between 2006 and 2014, she contributed to the development of the 'Change Model', 'NHS Model for Large Scale Change' and 'Spread and Scale' Frameworks, all of which she applies routinely in building active learning networks for change.

Rosanna is a qualified SenseMaker practitioner and works closely with the Cynefin Centre to gather narratives for the purpose of research, intelligence and insight generation in healthcare. SenseMaker is based on the application of the Cynefin Framework, a tool rooted in complexity science, which has been used in strategy, police work, international development, public policy, military, counterterrorism, safety, energy, healthcare, sales and education. 

Taj Nathan

Taj is a practicing forensic psychiatrist within the NHS who also holds honorary academic roles at the Universities of Liverpool and Chester, and at Liverpool John Moores University. Having qualified in medicine at the University of Wales College of Medicine, he went on to undertake postgraduate studies at the Universities of Oxford, Liverpool and Leeds. His clinical role as a forensic psychiatrist has informed his academic work in the field of risk assessment and management. In recent years, Taj’s scope of interest has widened to take account of the complex system in which risk-related practice occurs, including safety systems. Alongside his clinical and academic roles, Taj has been involved in the public dissemination of his specialist areas by authoring a non-fiction book, publishing in The Guardian and The Spectator, and contributing to radio/TV programmes.

Lizzy MacNamara

Lizzy has recently graduated from King’s College London with an MSc in Global Health after completing her BSc in Psychology at the University of Bristol. Lizzy first joined the Cynefin Co as an intern in 2021 working with colleagues to develop the Health programme, during which time she supported clients in building SenseMaker project designs for the healthcare workforce. After completing her Master’s and specialising in health misinformation and international health policy processes, she worked with a non-governmental organisation at King’s to support operational processes in strengthening health systems across Africa; in Sierra Leone, Zambia, Somaliland and the Democratic Republic of Congo, with particular focus on maternal health services. As of January 2023, Lizzy has re-joined the Cynefin Co as a Junior Research Consultant working primarily in the Health Programme and supporting the team with learning and training methods.