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The current consultation by the Department of Health and Social Care, ‘Leading the NHS: proposals to regulate NHS managers’ defines professional standards as “…the values, behaviours and competencies that managers will be expected to demonstrate.” In this blog, Lesley Parkinson, Executive Director at Restorative Thinking, and author of 'Restorative Practice at Work', explains what restorative and relational practice is and why this needs to be explicitly written into the professional standards being developed to improve relationships and accountability. There is currently not a set of recognised professional standards for NHS managers and I understand that NHS England is in the process of developing these. My hope is that restorative and relational practice will be included. This consists of a set of principles, processes and skills that guide our thinking, language and behaviours, and help us to continually build and improve our relationship skills. The graphic below gives a little more detail about what restorative and relational practice offers: If these behaviours and processes can be coherently and explicitly written into the professional standards being developed, they will go some way to improving relationships and accountability. This will have a positive impact on patient safety, as there will be less likelihood of people carrying grudges, feeling that things aren’t fair and other emotional distractions that prevent us from giving our full attention to the patients in front of us. There is already some guidance around workplace behaviours in the NHS; ‘compassionate leadership’ and ‘civility and respect’ spring to mind. Restorative and relational practice adds the detail of processes and language to deliberately foster equality of voice and respectfully challenge each other when we see, hear or feel something that isn’t right; this could be the way someone speaks to us or something we observe taking place that looks wrong or unsafe. Approaching someone in order to challenge them is a key relationship skill that needs deliberate and specific attention. If our approach is accusatory, we will likely meet a defensive or argumentative response; this interaction could damage a relationship immediately and in the long term. Restorative and relational practice helps us to navigate this tricky territory so that we learn how to respectfully challenge each other: to pause judgement; invite perspectives; discuss feelings and expectations; end with a solution in which there’s clear accountability and agreement. The Restorative Thinking team is currently delivering workshops with NHS trusts to develop these particular skills, but I’m afraid there’s no quick fix. The language and processes we use are based on a group of psychological and behavioural sciences and it’s key that we understand and grasp these before putting the theory into practice. New research from the Imperial College Business School shows how leaders can make constructive challenge not just possible but an integral part of a thriving organisational culture. In terms of the current Department of Health and Social Care consultation, I’ve observed the most effective regulation is done within teams and departments, person to person. It's clear that too many leaders, managers and staff lack the relationship skills to regulate each other; this is what needs to be addressed so that all NHS staff (whatever their role) can give their full attention to patient care and patient safety. The good news is that the Restorative Thinking team is developing learning options: podcasts, videos and paper resources, to help facilitate this ‘relationships education’ and we are building a self-guided learning page on our website to be launched in 2025. We already offer a short e-learning course and we've started to publish freely available podcasts on this theme. We are also partnering with the organisation AQUA to help NHS organisations to design and deliver safer care for patients by including restorative and relational practice into staff inductions, staff training, organisational development and Board development sessions.

'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.

The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management.  Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making. Fatigue The chart below shows pilot fatigue measured using the Samn-Perelli Scale (S-PS).[1] The S-PS has 7 intervals and a score of 4 indicates the onset of fatigue. The data shows how fatigue increases across the first and second sectors of the day, but, also, that fatigue is significantly higher during night-time operations. A study[2] of urology surgeons using the S-PS, reported that fatigue, as measured pre- and post-operation, increased by 67.95% across the four procedures undertaken in the day. Another study[3] looking at 29 ICU doctors found that the median S-PS score at the start of a day shift was 3 and 4 at the end; however, at the start of a night shift the median was 3 and at the end it was 5. Pilots with less than 6 hours of sleep before a duty started the day with an S-PS score of 4. In a risk assessment of night flights to Queenstown Airport, New Zealand, it was suggested that pilots with an S-PS of 4 or greater should be prohibited from flying.[4] Fatigue affects error rates. The Line Operations Safety Audit (LOSA)[5] shows that crew that slept for 6 hours or less before a duty committed more errors. In a study[6] of crew flying night cargo operations, crew acclimatised to the local day but flying during their local night had an error rate of 13.18/sector. However, crews who were flying at night in a different time zone but operating on their home daytime body clock had an error rate of 5.4 errors/sector. It is well-understood that performance is degraded during the 'window of circadian low' – that phase of the circadian cycle when humans are supposed to be sleeping – but in my previous blog, I made the point that raw error rates are not necessarily the issue, rather it was how errors shape the operation. Fatigue and decision-making The table below shows error outcomes across consecutive flights. An ‘additional risk’ is where, in dealing with the initial error, the crew either committed a subsequent error or the consequence was a ‘Undesired Aircraft State’ (UAS). It is common to see improved performance on the second sector as crew build familiarity but there is a sharp fall-off in performance on the third sector, including a significant increase in the number of mistakes made by crew. Mistakes in this context are errors of decision-making. In short, fatigue affects judgement. We see the same in other domains: in finance, traders make riskier trades when fatigued.[7] This data on fatigue and error points to job design and staff deployment as risk factors. Organisational responses to self-management of fatigue Workers absent themselves from the workplace for a variety of reasons. It could be for genuine ill-health, no-notice personal needs and disaffection (morale). Or it could be personal fatigue management. Again, the control of unplanned absence is a legitimate management activity. Workforce absenteeism places an increased burden on the attending workforce and adds to fatigue. The graph below shows the absence rate for a group of pilots and the percentage of pilots who did not take a single day of unplanned absence in a year. The absence management rules were changed to address the problem. The next graph shows how the duration of absences changed in response to the new policy: Pilot absence episode duration (days) The data suggests that management and workforce exist in a dynamic relationship and management’s attempt to exert control results in a corresponding response. The deployment of the workforce is a legitimate management function, but the way contracted effort is utilised shapes safety. Shift duration and timing induce fatigue and, importantly, fatigue can result in riskier decisions. In the previous blog, decision-making in normal operations was also seen to affect risk. Conclusion In this series of blogs, I have suggested that to understand safety we need to look at the factors that increase risk. Risk is a function of the tension between organisational controls and the need for flexibility that flows from variability in the workplace. Three areas of interest have been suggested: the preparation of staff for work, their control and, finally, their deployment. To understand ‘what goes on here’ we need to better understand the dynamics of these three domains. References Samn SW, Perelli LP. Estimating aircrew fatigue: A technique with application to airlift operations. Brooks Air Force Base. San Antonio, TX. Report No: SAM-TR-82-221, 1982. Petrut B, et al. Mental fatigue evaluation of surgical teams during a regular workday in a high-volume tertiary healthcare center. Urol Int 2020; 104(3-4): 301–308. Bihari S, et al. ICU shift related effects on sleep, fatigue and alertness levels. Occup Med (Lond) 2020; 70(2):107-112. Navigatus Consulting (2017). Queenstown Airport Night Operations Foundation Safety Case. Klinect JR. Line Operations Safety Audit: A Cockpit Observation Methodology for Monitoring Commercial Airline Safety Performance. Unpublished PhD thesis, 2005. University of Texas. Unpublished PhD thesis. University of Texas. MacLeod N. Crew Resource Management Training: A Competence-based Approach for Airline Pilots. CRC Press, 2021. Dickinson DL, Chaudhuri A, Greenaway-McGrevy R. Trading while sleepy? Circadian mismatch and mispricing in a global experimental asset market. Exp Econ 2019; 23:526–553. Further reading from Norman Can you measure safety? Part 1 Errors as clues in the search for safety measures: Measuring safety part 2