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As occupational therapists our aim is to maximise independence and support people to carry out daily life activities - their ‘occupations’. These activities include self-care, leisure and productivity - ranging from brushing your teeth to going to the supermarket. Our role requires a deep understanding of the significant impact that these seemingly ordinary routines have on peoples’ health and wellbeing. Occupational therapists are found in a variety of services across both physical and mental health. The role of an OT in any setting involves striking a balance between optimising patient safety, and positive-risk taking. Both of us are currently hospital-based and our primary role is to assess how each patient will manage at home. Our goals are to ensure patients are discharged safely and effectively and to prevent readmission. When working with a patient to increase their independence, we look at three areas: the person, the environment and the activity. We might make adjustments in any or all of these areas. The person For every patient, we consider the physical, cognitive, spiritual and psychological aspects that might affect their recovery and independence. By establishing what restricts, motivates and matters to a patient, we can tailor our support to best support them. Fear of falling is a major barrier to independence for many patients we see in hospital, and helping them overcome the associated anxiety and lack of confidence can make a huge difference to their quality of life and ability to function. Fear of falling can result in patients displaying physical symptoms such as shaking or stiffness and avoidance behaviour. Patients can enter a deconditioning spiral of loss of confidence and anxiety, causing a reduction in activity which leads to decreased muscle strength and mobility. This in turn further decreases independence and increases the patient’s falls risk. As occupational therapists, we can make patients safer by helping them overcome this fear and regain mobility. There is evidence that encouraging someone to keep active through positive risk taking can increase confidence and help them form a realistic view of their falls risk. We educate patients on the actual risks and provide opportunities to learn-through-doing, helping them translate this knowledge into experience and change their behaviours. This might be as simple as suggesting a patient gets up at each advert break when watching TV, walks five steps then sits back down. The environment Occupational therapists consider all aspects of a patient’s environment and use clinical reasoning to decide on interventions to promote their safety and independence. When a patient has fear of falling, we can put in place changes to the environment to help mitigate that fear as well as the actual risk of falling. When we look at a patient’s environment, it’s important we have a clear picture of the setting a patient will be living in. I (Susanna) hate only having a downstairs toilet because it is so far away during the night! If one of our patients was in this situation and needed easy access to a toilet, we would consider all aspects of their living space before deciding on interventions, for example: Do they have a partner living with them who could help if needed? Do they have blood pressure issues and associated risks? Do they have urinary urgency? Are they at risk of falls? In this case, a simple urinal bottle or commode placed next to the bed can save a patient from having to travel large distances to access a toilet during the night. We could also introduce adaptations such as grab rails to assist independent toilet transfers (sitting down and standing up). As a last option at home, carers could be provided to assist with personal care in the morning. The activity (occupation) There is huge pressure on bed-capacity in the NHS, and occupational therapists can play a key role in patient safety in this area. We help free up beds for other patients that need them and make sure our patients are safe to be discharged. An inpatient who is medically fit for discharge is also at risk of picking up hospital-acquired infections, so we need to reduce this risk with prompt discharge. We carry out functional assessments of a patient’s ability to fulfil the basic activities required for independence at home: mobility, transfers from bed/chair/toilet, washing and dressing, and meal preparations. If we can find out the dimensions of a patient’s home furniture, we can sometimes replicate this on the ward to help us assess them more accurately. Working closely with physiotherapists, we provide walking aids and assistive equipment that will make patients safer at home. We also liaise with social workers to put packages of care in place to support independence once a patient has left hospital. Under a new ‘discharge to assess’ government policy, this assessment process is changing to become more community-based and occupational therapists will be carrying out more of these assessments in patients’ homes. Although this is hard to picture now, it means we will get a much more accurate understanding of a patient’s occupations within their own home, where they know where things are and ‘have a knack’ of doing things their own way. Are you an occupational therapist with an interest in patient safety, or a patient who has benefitted from working with an occupational therapist? Tell us about your interests and experiences in the comments. Further reading Roots of recovery: Occupational therapy at the heart of health equity (1 November 2021)

The 4th #EndPJparalysis Global Summit will bring people from health and social care around the world together to share best practice, to explore the research, case studies and lived experience around the impact of deconditioning. The Summit will include a wide range of clinical presentations as well as leadership discussions and perspectives on looking after those in the caring professions. Like previous years, there will be an eclectic mix of speakers, panel discussions and the opportunity to ask questions and build up your peer network. The Summit will run online for 36hrs. Sessions will be recorded and available to those registered after the event. The Summit is free to all people in health and social care. Register

In March 2017 in Nigeria, we had two very shocking incidents which left everyone saddened and disturbed. The first case was Emmanuel Ogah, a medical doctor, who stabbed his 62-year-old mother to death in Lagos. Then, whilst we were all trying to come to terms with that incident, on the 19 March 2017 Allwell Orji, another medical doctor, asked his driver to stop in the middle of the popular ‘The Third Mainland Bridge’, got out of his car and jumped into the lagoon where he drowned before help could come. The loss of these two medical professionals happened within a space of one week. As an occupational health consultant and a patient safety advocate, this got me thinking about how it further increases the risk exposure to the patients. These were both doctors who were trained to care for patients. Could they have been overworked? Were there issues surrounding their personal lives, their family lives and other very personal issues that were responsible for these acts? Nigerians were not known to commit suicide, but we cannot boast that any more, we are fast losing our resilience and coping capabilities. The World Health Organization (WHO) 2016 report revealed that Nigeria had the highest suicide rate among African countries, ranking sixth globally. This is concerning and needs urgent actions to stem the tide. Let’s look at healthcare professionals being overworked as a key example. According to the Premium Times Report published in November 2015, the population of Nigeria was 173 million people in 2013. Going by that report, Nigeria needed a minimum of 237,000 medical doctors to care for the Nigerian population, in line with the WHO ratio of 1 doctor to 600 people within a population group. But from all reports available at that time, there was only 35,000 doctors actively working as medical doctors in Nigeria. According to this ratio there is no way that doctors will not be overworked. Using these figure, this meant 1 doctor to 4,960 people. Although, the Nigeria Medical College train more than this number of doctors, many move into other professions. Using these figures, we might conclude that workload could be a strong contributing factor to suicide or death amongst doctors and other healthcare workers in Nigeria. So the question is, how does this impact on patient safety? It is sad that mental health was not included amongst the list of occupational health diseases or illness in the International Labour Organisation list of occupational diseases until much later when the toll of mental health issues became so obvious. Psychosocial hazard has become a huge issue within the healthcare work environment leading to burnout, fatigue, exhaustion, stress, tiredness and sleep deprivation amongst healthcare workers, and these outcomes impact negatively on the safety and quality of care when treating patients. The need to keep healthcare workers safe and look after their mental health is something that needs our collective actions and commitment. It takes a safe healthcare worker to deliver safe healthcare to patients. We should be looking at the workload – the duration and frequency of duty shifts within the healthcare sector – which has long changed over the years, making healthcare professionals work longer hours per shift, dealing with a workload that is beyond their coping capacity. We all agree that in healthcare we deal with lives and any mistake within healthcare delivery is always a costly one which innocent people pay for with their precious lives. Work overload is a critical issue surrounding daily patient harm in the hospital. It hurts the patient as much as it hurts the healthcare workers. This workload, if allowed to persist for too long, alters the mental wellbeing of the healthcare worker leading to avoidable mistakes, irrational behaviour, lack of co-ordination and a disrespect to the right and dignity of patients. This is never in anyone’s best interest. There are many doctors, nurses and other healthcare staff who love their jobs and keep giving all they have, giving mutual support to colleagues when they perceive them to be overwhelmed with work, which sometimes leads to collective burnout within a team. which leads to patient harm. Such healthcare staff are seen as trusted by everyone and tagged 'MR FIX IT' because of their willingness and availability to always show up to help or assist. They become a victim of patients' and colleagues' continuous demands; they never say NO but instead are always there to help, but over time they become emotionally overdrawn and this can lead to patient harm. The mental health of doctors and other healthcare professionals should be taken seriously owing to new and emerging conditions and disruptive behaviour noticeable amongst healthcare workers. The two doctors cited at the beginning of this write-up were managing patients entrusted to their care. Any doctor that has suicidal thoughts is a risk within the healthcare environment, no matter the department or unit he or she works in. I really think this is where we must look more closely at human resources, management and leadership in the healthcare environment. These are not roles that should be assigned to a newcomer, but a role carried out by very experienced professionals with a strong analytical background in human psychology and a big heart for employees’ wellbeing. We cannot rule out the fact that the two doctors cited earlier never displayed violent or suicidal behaviours that would have attracted the attention of co-workers, or even the human resources managers who would have been expected to have a meeting with such an employee with obvious suggestive indicators. We need to start engaging our colleagues, we need to start setting up Employees Assistance Programs (EAP) and we need to start looking beyond work – taking an interest and asking what happens in the home of our employees and colleagues. Are there issues? Are there smart ways we can help out? This should be our thinking. It will save both the patient entrusted into the care of the healthcare workers and the healthcare workers themselves and maintain a good reputation for the healthcare facilities. We must understand that healthcare workers are human beings just like us all; they are not super men and women, and they are fallible like every one of us. We need to start re-humanising our workplaces. Let’s start reviewing the workloads, timelines and deadlines, let’s once again treat healthcare professionals the way we would want them to treat our patients. Let’s bring dignity of labour back to healthcare, let’s again work like one big family where we all continuously watch each other’s backs, let’s rebuild the lost confidence while having the patient at the centre of these thoughts. Losing more doctors from healthcare, seeing others behind bars due to homicide, and seeing others incapacitated and feeling invalid when we know the work pressure and work environment contributed to these conditions and states is no good to any of us. We can change it. It takes a HEALTHY doctor to offer a SAFE healthcare.