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Developed by Agency for Healthcare Research and Quality (AHRQ) and the US Department of Defense, TeamSTEPPS® offers core strategies for use in a variety of healthcare environments coupled with approaches for distinct areas of care such as dental, long term care and office practice. The program collectively offers free training modules, webinars, train the trainer strategies and a bibliography of research describing how the tools have been used.

We attended that Patient Safety Learning conference as this is something I am very interested in. I see my role as (acting) deputy director of nursing, midwifery and AHPs as one who should lead by example and champion high quality care for patients. For the last year, I have been developing a maturing patient safety team who are enthusiastic and willing to make changes for the benefits of our patients. We were looking for ways to innovate our shared learning, learn from others and make contacts with other innovators in this field. Our initiative is using our Trust values ‘We care’ and weaving these into a golden thread for a monthly patient safety newsletter and annual conference for all Trust staff. We are now on edition 16 of our newsletter and our third annual conference is in the planning stage for April 2020. This Christmas we worked with a local school on an alternative 12 days of Christmas. Our hospital singers came from the senor nursing team, midwives, consultants, junior doctors and patient safety team. This video is a good example of how we are slowly engaging staff with the patient safety messages View video We were thrilled to win the Patient Safety Learning award. We shared this on the train home on our staff social media page and referenced how proud we are of our colleagues who strive for patient safety every day. It's extremely motivating to have a little recognition for the continued hard work in keeping patient safety at the top of the Trust agenda. With our prize money we are intending to visiting Homerton, another Patient Safety Learning award winner, to look at how they are implementing their App for policies. The approach and end result was really impressive and I am keen to explore how we could do this in our Trust.

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A flower does not think of competing with the flower next to it. It just blooms. (Zenkei Shibayama) My original presentation of SISOS to the department where I work (theatres) had a huge impact and colleagues recognised the need for it and wanted it. Strong leadership and commitment is essential. I have faced challenges along the way and so far have managed to keep going, but it hasn’t always been easy. I will talk about those challenges as I go. There have been times when I have questioned why I’ve kept going and every so often that question is answered. At a recent conference where I presented a poster, a beautiful human being, kind, intelligent, dedicated to saving lives, looked me in the eyes and said, "How do you support second victims?" and then proceeded to weep uncontrollably. Needless to say I took their willing hand and we shared tea together in a quiet spot. Their incident happened 4 years ago and no blame was attached. This beautiful human being was not an F1 but a consultant. Ironically two days later at work, a consultant suggested that consultants as a group don’t need support because "We have years of experience, we can manage". It’s fair to say that as a group, experienced consultants have challenged the need for this initiative more than other groups and some have been very cynical. However on the whole they have been supportive and welcoming of it. Following my original presentation and the positive feedback from my colleagues, the first thing I did was to form a working group of very senior staff. Nothing would have been possible without their belief and their buy-in. We examined our Trust policy and looked at existing resources; for example, we have an Employee Assistance Programme, which provides professional counselling free of charge to our staff. It was important to see what we as an organisation could provide without incurring additional cost. My experience has been that although support is there in theory, in reality staff were not necessarily accessing it and so one of our roles as Listeners is to improve accessibility. As a group we looked at safety, including the safety of our Listeners and how we support them. Guidelines were produced and training provided. We recognise that we are not experts and that this is still a relatively new initiative for us and one which is evolving. Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration For further information please contact me: carolmenashy@nhs.net

In conclusion, although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

This poster was created by the Royal Free Nursing team on the intensive care unit. It demonstrated how they reduced turnover of staff on the unit by implementing 'Joy in Work'.

Alberta Health Services (AHS) acknowledges that as a group, they are committed and intend to provide safe and healthy care and/or work environments. However, they also know that despite best efforts, things can sometimes go wrong. The AHS recognise that everyone has an important role to play in identifying, reporting and addressing issues or concerns about the health system and/or organisational processes, and to share what they learn, in support of continuous quality and safety improvement. These are Alberta Health Services Guiding principles to a Just Culture.

The results of this study show that poor organisational culture and leadership negatively influences and hinders doctors who make mistakes. Leaders who promote and create environments for open and constructive dialogue following adverse events enable the concept of fallibility and imperfection to be assimilated into new ways of learning. Guilt and fear are the most consistently reported psychological symptoms along with a perception of loss of professional respect and standing. Doctors often carry unresolved trauma for several years causing them to constantly relive an event. Unchecked, this can lead to poor relationships with colleagues and impact greatly on their ability to sleep and performance at work. The review concludes that a prevailing silence, exacerbated by poor organisational culture, inhibits proper disclosure to the first victim, the patient and family. It also impedes a healthy recovery trajectory for the doctor, the second victim. Leaders of organisations have a vital strategic and operational role in creating open, transparent and compassionate cultures where dialogue and understanding takes place for those affected by second victim phenomenon.

The Journey In the changing rooms where I worked as a scrub nurse, I overheard a group of nurses discussing the distressed state of a young doctor. There had been a never event in their theatre that day and the young doctor was the operating surgeon. Moved to tears I wanted to go and put my arms around that doctor but I didn’t feel that I had ‘permission’. ‘It was none of my business, what if I made things worse?’ So I dumped my scrub suit into the laundry bin, put my theatre shoes away and went home. I’m a theatre nurse but more importantly I’m a mother, the mother of a young doctor and that night fearful for the surgeon’s safety I was unable to rest. If it was my daughter I would have wanted someone to be there for her. Galvanised by a mother’s strength, I vowed that nothing could or would hold me back and so the next morning I wasted no time in knocking on my matron’s door. "I was worried about that young doctor last night", I said. "So was I", said my matron. "I rang her and she’s coping’". I was relieved to hear this but as I turned away I realised that there was an urgent need for timely, accessible structured support for when things go wrong. I reflected on an incident that had happened to me and I asked myself this question: What would have helped me, at one o’clock in the morning, all those years ago, when I sat alone in a hospital tea room: devastated, anxious, ashamed, guilty, having flashbacks and feeling like the worst nurse on the planet? I had let my patient down. Two things came out of those reflections. Firstly, I had craved the companionship and compassion of my colleagues because I knew that they above all people would get it. They would understand how this situation could possibly have arisen without attaching blame. Secondly I recognised the need for a safe space, a place where my dignity could have been protected and I could have shared this experience in privacy. As far as I was concerned, my name was in neon lights, I was the failed nurse, there to be gawped at. These two experiences, the young doctor’s and my own were the catalyst for SISOS. Safety Incident Supporting Our Staff. Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model which I’ve developed is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. The care which we can now give our second victims is compassionate, non- judgmental and happens in a dedicated safe space, where experiences are shared in confidence. Empathy, respect and compassion assist in emotional healing. Following a successful audit I’m delighted to say that this model is now being rolled out Trust wide. My passion is that all of our colleagues deserve access to this kind of care. I recognise that it won’t be easy but I will not be deterred, will you? Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration For further information please contact me: carolmenashy@nhs.net Further reading: Hirschinge, LE et al. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare. March/April 2015. Willis D, et al. Lessons for leadership and culture when doctors become second victims: a systematic literature review. BMJ Leader 2019;1–11.

I was invited to attend the Patient Safety Learning Annual Conference as I had been nominated for a Patient Safety Learning Award. Initially I had reservations about attending the conference as my inbox is constantly flooded with a myriad of ‘learning opportunities’ which have often not lived up to expectation. My journey from East Yorkshire to London provided me with time to read Patient Safety Learning's ‘A Blueprint for Action’ safety strategy of which I was very impressed. As a leader in preventing pressure ulcer harms I welcome the drive to change the way we think about patient safety, especially the focus on involving patients and their families/carers to share their experiences and drive the shared learning. The conference was excellent. The agenda was first-rate with the all the speakers showcasing excellent safety improvements. The engagement between speakers and delegates was thought-provoking and the use of interactive technology helped free thought and inquisitive questioning. My nomination for the Patient Safety Learning Culture Award was for the work I had done on Malcolm's Story. Malcolm's Story is a video of Malcolm, his daughter and his wife sharing their experiences of Malcolm being a patient in our Trust and developing a hospital acquired pressure ulcer while in our care. Malcolm and his family gave an honest and frank account of the care and treatment given to Malcolm. Malcolm's Story was shown at the 2018 Trust nursing conferences and hearing their story in an audience of nursing and HEY staff was truly powerful and very emotional, especially as Malcolm and his family were in the audience. We believe the nursing staff in the audience really felt the message about how what may be seen as small failures in care can build up to cause significant harm, and long delays in a patient's recovery. In addition to this piece of work, the nomination also featured my passion to create a lessons learned attitude towards all serious incidents. Over two years ago I wanted to 'do something different' to investigate why tissue viability serious incidents occurred as the usual investigation methods didn't always allow staff to feel safe to be open and honest. Along with the Organisational Development team we looked at new investigation techniques using the Yorkshire Contributory Factors Framework (YCFF) involving staff members to engage and learn about pressure ulcer harms differently. I hold team sessions which focuses on allowing individuals within a team to see what happened to the care the patient received with a wide-angled lens versus their individual memories of the patient and incident. It also allows us to explore issues that are wider than just clinical and process issues for patients and understand what the wider contributory factors are. I am extremely proud to have won the Patient Safety Learning Award in the category for culture. Involving Malcolm and his family and changing the way pressure ulcer harms are investigated has been pivotal in improving the culture around pressure ulcer prevention within ward teams and I extend my heartfelt thanks to all involved. It is also the start in showcasing the excellent patient safety journey Hull University Teaching Hospitals are on. Next steps include embedding this style of safety investigations across primary and secondary care boundaries to challenge organisations to share YCFF learning events and to involve the patient and their families early on in the investigation. I will use the prize money to visit exemplar organisations who are already demonstrating this collective safety strategy.