Gina Winter-Bates

In my previous blogs, I explored why I developed the model of ‘Safety Chats’ and how they were conducted. The essential elements of these chats are very simple: Talk to staff about safety in the real world of their team. Ask them to explore what is safe and not safe. Engage them in the idea that they are the best people to suggest or lead change in their team. None of this conversational approach is particularly complicated and yet it is so often not undertaken. The exploration of positive experience (what makes you safe/feel safe?) is so often not considered when assessing safety within our healthcare teams. Usually the blunt measures of numbers of incidents reported and complaints are used as an accurate measure of how safe a ward, team and system are. These totally fail in assessing what is actually going on (see the iceberg in blog 3) and where good examples of safety exist. The amount of time and energy used by healthcare organisations looking back at events and investigating them can leave little time to look forward, explore what is worth keeping and how this could be built upon. Energising people to create safer healthcare In his work about 'Rekindling Democracy', Cormac Russel describes Asset Based Community Development and comments that: “You can never know what a community needs until you first know what a community has”. In the NHS each one of our teams is their own small community who make up a series of inter-connected communities. Unless we actively and regularly ask what they 'have' in terms of safety we will not know what they need or can offer to the wider community. We need to ask them, we need to allow them to improve where they can and we need to step in when they cannot make the changes required to make their work place safe for them and their patients. Don Berwick describes how in restoring trust in our staff (and making safe errors in creating improvement) we can restore the ‘joy in work’ for the people who deliver healthcare. This builds resilience and problem solving skills in to the very heart of care and a civic responsibility that underpins why many people entered healthcare in the first place. However, in order to achieve this we must speak to our people and truly hear what they say and allow them to guide us in how to improve their world. Could Safety Chats be the answer? Safety Chats play a small part opening up these conversations with our staff and enabling improvement at such a local level. There is no desire here to underestimate the complexity of creating true psychological safety. It is only in creating this that we will be able to really improve safety in healthcare. This does not mean improving things that improve the measures (reducing incidents/harm free days), but truly creating an environment where staff can: recognise challenges to safety speak up make changes ask for help in those things that they cannot change. Next steps In my organisation we acknowledge how complex this is. We are introducing a whole range of new processes and building on those resources already in place to assist staff in openly discussing issues that concern them. Most are not unique to Solent – Schwartz Rounds, Equality and Diversity groups, Freedom to Speak up Guardians and many other staff support mechanisms exist in many places. We are aiming to recognise what we, the ‘Solent Community’, already have in order to understand what we need. This is how Safety Chats came about and how we will be building more ways of supporting staff to discuss safety, to seek advice and support, and to receive clear assistance when things have gone wrong. To quote Cormac Russel again “…to build on what is strong not what is wrong”. Solent are proud that our staff survey shows that our people rank the organisation highly in aspects of safety and ability to speak up. This means we cannot rest on our laurels though and it drives people from across the organisation to continually strive for even greater improvement. This graphic above is our planned approach to supporting staff. It is a small part in “Making it easy for our staff to do the right thing every time for our patients”, which is the test for any work undertaken by the Quality and Safety team. All of the processes that support staff to be open and safe are being hard wired into our Patient Safety plan. Increasing the ability of staff to improve safety is the key to making patients safe. Safety Chats are now being rolled out across the organisation for all teams to have open and safe conversations about safety in general. We will gather the themes of these whilst ensuring confidentiality. These themes will be our vehicle for change and spread of ‘good’ practice and areas that need further work before an incident happens. It has already proved valuable for supporting some teams who were struggling with finding their voice. This has led to them asking for the support that previously they did not think they could request. It has built trust within the teams and with their managers as it is a safe space to be open. This roll out will carry on over the summer of 2022, as face to face meetings become increasingly possible. The themes and wider outcomes can be shared via similar blogs in the future if you, the audience, would find this useful. However, one community’s themes will not be identical to another communities themes – only by talking to your teams can you truly understand their perspective. I can promise you, it will be worthwhile, it will enlightening and maybe even inspiring. If you would like to discuss Safety Chats further, please email me at: Gina.Winter-Bates@solent.nhs.uk Other blogs in the Safety Chat series Safety Chats blog series: Part 1 Part 2 -Safety as measured Part 3 - Starting the conversation

Previous blogs in this series explored the personal and evidence basis for having honest conversations about safety at the frontline of healthcare. There is often a perception that we are affording staff the opportunities to be open but this can be derailed when there is an unheard consequence in having an open conversation. This could be a for a number of reasons, many of which were identified in the C-LINK Consulting article 'Don't let the 'iceberg of ignorance' sink your company': Staff may be uncomfortable sharing bad news with either their bosses or team (Mum effect). Time – there is so much to communicate and time is limited to share it. We think we know what is going on but only from our own perspective. © C_LINK Consulting This last point is vital in raising questions about the understanding of those who do the work and know the environment and those who plan the work and visit the environment. This is well illustrated in the above graphic. This perfectly describes why I believe that a process of unstructured regular Safety Chats could allow teams an opportunity to discuss things safety. They can be open about the good and the bad, and it will enable them to make changes that could prevent safety incidents occurring in the future. This will not replace Freedom to Speak up processes but will offer an earlier opportunity for change and awareness. How were the Safety Chats conducted? Between July and August 2021 four safety chats were held with two inpatient teams. The original six chats planned for the pilot had to be reduced due to significant system pressures: an important factor in the findings about how staff perceived safety, as it turned out later. Staff were from all grades and a wide range of disciplines, both registrants and non-registrants, clinical and non-clinical. Several did not work for the Trust but were identified as members of the team so were invited to join by colleagues. No further identifying factors were gathered and names were only shared when staff offered them. As previously described, four broad questions were posed and answers either written by the staff or placed on a whiteboard. Staff who were on alternative shifts also requested to join in and in a number of cases left their responses for me to collect. These questions were: What makes you feel safe/the ward feel safe? What makes you feel unsafe/the ward feel unsafe? Can you make changes to improve safety here? What empowers you or stops you? Most staff confirmed that they/their ward felt safe to them. Key themes for staff to feel ‘safe’ None of the themes around feeling safe are a surprise. They exemplify what good looks like for our frontline staff – most of them are about interpersonal or understandable issues. Communication: being able to ask and get information. Teamwork: absolute trust in colleagues, induction and welcome. Time to assess patient and support colleagues. Having time. Being trained and able to give training. Equipment, training, availability and maintenance. They focus on how systems can either support human factors or, as the case of feeling ‘unsafe’, hamper staff in remaining safe. Key themes that made staff feel 'unsafe' Changes to the care model and rapid changes to type of patients on the ward. Communication: not being able to ask (absent leader, lack of authority, being too busy), not being kept informed, mixed messages. Security: environment, job. Staffing: busyness, workload, stress, no time to train or induct staff. Equipment: training, availability and maintenance. Pandemic: rules changing, patients, central decisions, fear and guilt. These findings are characteristic of many areas within the NHS. Changing care models mean that community wards are now having to take sicker patients who are much earlier in their recovery or rehabilitation journey. Covid has made staff wary of visitors due to the perceived harm via infection they can bring to the staff and the patients. Some of these issues are complex and systemic and will take time and work to resolve for staff. The most commonly focused area in feeling unsafe, unsurprisingly, was poor communication, not feeling involved or not being told what is going on. This is entirely within the gift of each of us to improve and this was fed back to the leads in these areas. What empowers and blocks staff in improving safety? 70% of staff said they felt they/their ward was safe and they could make changes. Despite these figures, staff gave many more answers about what prevents them from making changes than what empowers them. Empowering factors, including their core values (patient comes first), communication, being considered or involved in decisions and very visible leadership, were key drivers to empower. Blockers included feeling that they could not communicate with leads, not being considered or involved, central changes over which they had no power or say. Not being listened to when staff reported or raised concerns was an enduring blocker to change. Emerging at the second Safety Chats was the feeling of how system pressures were impacting on staff. They described feeling that they could not speak up and make changes; non-visible management was a key concern as their ward managers were dealing with operational pressures and not clinically on the ward. When speaking about positive elements, staff described support from their ‘leadership’ but when describing negative elements of safety they talked of ‘managers/management’. It is unclear how this distinction was made but it was replicated in all four sessions. The way in which staff talked, in an open and transparent way about safety, meant that they were able to consider, challenge, question and reflect on safety in their environments with each other. Many staff approached us after the session and thanked us for the chance to have time to just talk about safety and the opportunity this presented. If you would like to discuss Safety Chats further, please email me at: Gina.Winter-Bates@solent.nhs.uk In my next blog... In the next blog, I will detail how Safety Chats are being rolled out across the Trust. It will describe how Safety Chats will be the springboard in a range of staff support measures that we are introducing to improve psychological safety, to support Just Culture and to find out the real truth about what safety means to staff delivering care. Other blogs in the Safety Chat series Safety Chats blog series: Part 1 Part 2 -Safety as measured Part 4 - Talking about safety and creating safer environments

How do we know we are safe? This is the Holy Grail that has led to many publications and much research. Authors such as Berwick, Dekker and Syed have written insightful and clear reports that detail that safety is about much more than mere compliance to rules, reporting of incidents and monitoring risk. Local context In my previous blog I shared Solent NHS Trust’s staff survey results, which show high confidence in our staff about safety, having a voice and speaking up. The organisation works hard to define how safe we are and uses a variety of measures for this. Incident reporting is high for a trust of our size and is the highest in our group. The levels of harm are consistently low and the structures for scrutiny and investigation are clean and regularly audited. An active risk register is regularly updated and shared. We still have a long way to go on our journey towards truly triangulated data. There is a real commitment to get there. We seek to learn and have a 'Best in Class' Research and QI Academy. We have regular sharing events – the question on all our lips is often “How do we truly learn?” We monitor safe staffing regularly; even more so at times of significant pressures. A Rapid Quality Impact assessment process, which ensures that rapid change can take place but must be monitored for quality with regular post change follow up. Wider context We are not alone – many trusts share these traits. So what do our staff say about this? Our staff survey (68% participation) shows our staff believe we are safe. We have a larger than normal network of Freedom to Speak Up Guardians and consistently perform well nationally in the annual guardians’ survey. So, what’s the problem – our safety climate is good by all agreed measures? But is it as good as it can be? The key players who can comment on whether we are safe are those delivering care and those receiving it – our community. Our wider community are central to what we do. We have a really ground-breaking community and patient engagement programme. It is the belief of our senior team that complaints are a gift of feedback that help us learn and can shine a light on safety concerns. We take these seriously. When a complaint is made our patient experience team will ask the question “How can we make this it better?” as this will help us learn and improve the experience for other people. Again, it is not perfect but comes from a place of positive intent and partnership. Although staff say the organisation is safe, we have never asked them what that means. We have yet to get them to describe what is safe in their team and what is not safe. It is only from this perspective of safety in the ‘work as done' that an organisation can understand what the real issues are. Through this approach we can support staff to be not just the eyes and ears of safety but the mechanism of making their world safer. The learning across teams could truly drive change across our clinical teams. It was from this position that I decided to undertake a series of “Safety Chats” in clinical areas. A brief outline of them is below but these will be covered in the next blog in this series. If you would like to discuss Safety Chats further, please email me at: Gina.Winter-Bates@solent.nhs.uk Other blogs in the Safety Chat series Safety Chats blog series: Part 1 Part 3 - Starting the conversation Part 4 - Talking about safety and creating safer environments

A personal perspective I was a newly qualified nurse working in cardiac care in the wake of the Kennedy report into deaths at Bristol Royal infirmary between 1984-1995. The response nationally was the introduction of governance frameworks which sought to standardise and monitor safety. It was needed, it brought about improved safety and allowed the NHS organisations to monitor compliance to safety measures. Governance and safety Healthcare, like in many industries, has adopted a large array of, at times, bureaucratic processes attached to this. These can be onerous for clinical staff and can yield little change in actual patient safety. There are still large numbers of serious incidents across the NHS every year. The National Patient Safety Strategy (2019) suggests that as many as 1000 lives a year could be saved if safety was improved. This continues to occur despite the enormous time and effort, including national initiatives in place across the NHS, to comply. This world of governance, safety and compliance is my world. The impact of Covid Like many, I was redeployed to work on the wards. It was a great experience. Staff were caring, kind and working incredibly hard. National guidance changed rapidly and there was significant fear of both infection and of getting the rules wrong. I worked with a number of experienced staff of all grades and noticed that at times their work was hampered by some real or perceived 'rules'. I asked them how they would change things and, do you know what?, they knew the answers. This was their world. I asked them why they didn’t change things and the usual answer was “we wouldn’t be allowed”. I successfully pursued some of their ideas and didn’t meet any of this resistance. Was this a command-and-control issue? Was it about grade? Surely, they were best placed to make the ward safer? They knew it best. I reflected on my years in clinical settings and remembered this scenario: I was a junior staff nurse in acute ward. Kit boxes were introduced so that equipment was available for emergency scenarios. We had them but they were often over-stocked and difficult to grab the right equipment rapidly. So we kept a separate supply that we could get our ‘hands on’ quickly. The ward nurses and doctors all knew where it was but none of us (very junior) staff considered asking the Trust to change the boxes. In our world we knew how to make care safer, but we didn’t share this or try to influence the 'rules' on standardised kit boxes. Why choose to do Safety Chats? It was a revelation to ask the staff on duty questions about how they would make their ward safer and see this reluctance to challenge and make changes was still the case 20 years later. This, despite working in a values based, empowering organisation that wants to learn and make the care safer. The staff survey for Solent has consistently shown that our staff consider the organisation to place a high regard on safety and that they are able to ‘speak up’ when they need to. It occurred to me that we do not spend enough time asking staff how to make things safer in their world and use that innate knowledge to prevent incidents occurring. Staff commented that they had valued my interest and respect of their knowledge. I wanted to continue this when I went back to my role. I am lucky enough to be a Florence Nightingale Foundation Scholar which has led me to explore many aspects of care delivered – mine and others. This project was supported by them and my sponsors from Health Education England (SE). I also work for a Trust that has a great history of encouraging ‘speaking up’ and have a strong safety culture. I was encouraged to ‘get out there’ and ask staff about their work as done and how they thought we could make it safer. With this support, I worked with two clinical teams to talk about safety in their world. I wanted to really understand how safe staff feel, to understand how they may hold the key to truly understanding the issues that affect safety in the work as ‘done’ and how they have the insight and knowledge to make significant changes that can improve safety for the whole organisation. In my next blog... We measure safety via a series of, usually, negative events that have already occurred and in some cases cannot be rectified. It was a revelation that we had failed to ask the staff delivering the care what ‘safe’ looked like in the work as done. Our staff repeatedly report that they feel safe and they are free to speak up about safety concerns, but in the next blog I will describe how conversations with staff reveal how this is not always translated in to staff confidence in making the changes that they know will help. If you would like to discuss Safety Chats further, please email me at: Gina.Winter-Bates@solent.nhs.uk Other blogs in the Safety Chat series Part 2 -Safety as measured Part 3 - Starting the conversation Part 4 - Talking about safety and creating safer environments