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The guide also provides helpful links and contact information for readers interested in learning more about the highlighted resources. The majority of DoD PSP tools and resources are available to anyone providing care in the Military Health Service. These evidence-based resources offer opportunities to make any heath care facility safer and more open to discussions to build a culture of safety.

Key messages: Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations. Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives. A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics. Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity.

The results found there were 129 unique mentions of barriers to patient safety; these barriers were categorised into five major themes. ‘Limited resources’ was the most prominent theme, followed by barriers related to health systems issues, the medical culture, provider training and patient education/awareness. Although inadequate resources are likely a substantial challenge to the improvement of patient safety in India, other patient safety barriers such as health systems changes, training, and education, could be addressed with fewer resources. While initial approaches to improving patient safety in India and other low- and middle-income countries have focused on implementing processes that represent best practices, this study suggests that multifaceted interventions to also address more structural problems (such as resource constraints, systems issues, and medical culture) may be important.

Practical guidance on the application of human factors in the investigation process is presented. Nine principles for incorporating human factors into learning investigations are identified: 1. Be prepared to accept a broad range of types and standards of evidence. 2. Seek opportunities for learning beyond actual loss events. 3. Avoid searching for blame. 4. Adopt a systems approach. 5. Identify and understand both the situational and contextual factors associated with the event. 6. Recognise the potential for difference between the way work is imagined and the way work is actually done. 7. Accept that learning means changing. 8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement. 9. Do not confuse recommendations with solutions.

Principle 1 – Culture of safety Every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning in which all staff feel safe to raise concerns. How can you describe a culture? What does it look like? I am sure that there has been many an hour at board meetings discussing this very subject. Describing the ideal safety culture is easy, we are told to adopt a ‘just culture’, however fostering a culture of safety is not that simple, following a guide doesn’t work. ‘Fostering a culture’ means to nurture and support a way of working. This principle also asks for Trusts to ‘actively foster’, to me this means that it is a dynamic action. It is not just a ‘thing’ that is said, but a ‘thing’ that you do. Working in the NHS for years, I feel I have become institutionalised, along with middle management. Bad habits are hard to break, we may start out trying to change our behaviours, but the old-world bites back. Its easy to fit in. It feels safer for us to fit in. There are multiple layers of management. Each layer has its own processes and brings with it its own culture. Hierarchy is steep in the NHS, if you do not go through the correct chain of command, you may be labelled as a troublemaker or whistleblower. This principle mentions that ALL staff should feel safe to raise concerns. As a clinician, I have the safety net of my professional body, they will support me. But what about porters, domestic and support staff or volunteers? Do they feel empowered to speak up? They may feel at the very bottom of this hierarchy. How are Trusts ensuring that they also have a voice? This principle excludes the most important group. Patients. Why are Trusts not empowering patients to speak up? Why are there no robust mechanisms for them to speak up? It is not just staff that need to feel safe in speaking up, it's patients and their families. Principle 2 – Culture of raising concerns Raising concerns should be part of the normal routine business of any well-led NHS organisation. I have raised concerns where I work, as I am sure we all have. We do it via Datix. There is a usual process. We spot the harm/concern and we log it on the computer. It gets graded by the safety team and we hear nothing back. It then happens again and the cycle repeats. This within normal behaviour. This is normal routine. Many staff are not happy with this routine of raising concerns. They have taken the effort to take the time to log the concern but feel disengaged when they hear nothing back. So why bother? They bother because it is to cover themselves and they also bother in the hope that improvements will be made. However, what if these concerns are larger. What if these concerns you have are a system wide problem? Datix is not always the correct route, it doesn’t fit. You can alert your manager, who then will alert their manager and so it goes up the chain. If at any point you feel you are not being listened to you can then go and see your Freedom to Speak Up Guardian (FTSUG). Sounds ideal. Some FTSUG work part time, some work clinically on top of this role. They are not always easily accessible. I am unclear on what value they bring to an organisation. What changes can they make? Are they listened to? Have they been put there to ‘tick the box’? Principle 3 – Culture free from bullying Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. I have raised concerns where I work. If I follow the usual routine of raising concerns, all is good. Nothing happens. If I raise a concern outside of the normal routine, this is where the problems start. Reflecting back on a time when I raised a concern about three wards and their lack of equipment, I raised the concern with the Matron and the Patient Safety lead. More equipment needed to be purchased to prevent harm from happening to patients. This equipment was needed urgently, and I felt that the Datix system would take too long and harm would have happened before the problem was addressed. I received an email from the Head of Nursing for that area, defending why there was a lack of equipment and that I was wrong for emailing the Matron and the safety lead, that I went through the wrong channels and that she would like to see me to discuss the matter. Of course, I accepted the offer of meeting up. After all, what had I done wrong? Emailed the wrong person? Raised a concern? Had I spoken out of turn? When I received this email I felt upset and scared, then angry. This was bullying behaviour from a senior member of the Trust. I then thought, why? The Head of Nursing was known to me. She has been a real inspiration to me, so what has happened? This must be a cultural way of coping with concerns that are directly involved in the way she had managed this area. Now she was being faced with a concern raised by someone low down in the ranks, which could possibly look like an attack on the way she manages this area. Was she annoyed that she wasn’t involved in the email trail? Whatever it was, the way that the concern was raised was out of the usual. It upset the way we do things round here. I don’t want to be labelled as a whistleblower. I am doing my job and doing what the board have asked. I am raising concerns. As you see this blog is anonymous. The fear of vilification is strong and is very real. And all this with an issue where my intervention prevented a never event and for which I was thanked. With this experience, will I raise concerns again in real time to prevent harm? Or will I choose to go through the official route, wait and see if anything happens and be ready to explain (if asked) when the Trust undertakes a serious incident investigation or defends a clinical negligence claim? Principle 4 – Culture of visible leadership All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. Initiating the FTSUG in every NHS Trust was a great idea, however, if we had visible leadership that welcomed and encouraged raising of concerns, we would not need this service. The FTSUP is a sticking plaster for a deeper routed problem. The Head of Nursing had a very human response to my concerns. She was defending actions that others had taken and defending why the problem happened. This is a natural reaction to feeling threatened, so perhaps I was in the wrong in the tone in which I raised the concern? This led me to question what training middle managers have on dealing with staff or patient concerns. When confronted with a concern do they know what to do? What do they do with this knowledge, how do they communicate with the staff or patient raising the concern? How do they raise up the line with their directors and the Board? Will they be thanked for highlighting opportunities to improve or will they be met with defensiveness and hostility? And what about ‘raising concerns’ training for staff and patients? We also need to know what is expected of us and what we can expect back, that someone has our back when we raise concerns. Principle 5 – Culture of valuing staff Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. If adequate training in this area existed perhaps more staff and patients would speak up as they feel that they were being heard, being cared for and feel safe. In turn, middle management would feel more equipped to handle concerns with a more inquisitive approach rather than one of defence. Being involved in improvements in care is a wonderful experience. Seeing that you have made a difference to patients is a privilege. We need to react to people raising concerns in a different way, using a different lens and we all need the training and support to do so. What are Trusts doing to show that raising concerns is welcomed, makes a difference and helps us improve safety? Shouldn’t this be publicly reported to staff, to commissioners and the general public? Principle 6 – Culture of reflective practice There should be opportunities for all staff to engage in regular reflection of concerns in their work. Reflections of our concerns for work could be taken as evidence, this has been seen in the Dr Garber incident. This has made us fearful of writing our reflections down. Shwartz rounds are great but take a lot of organising and are only for the few staff. Time will always be an issue, so quick-fire reflections about what has gone wrong, and even better what has gone right, with your immediate team are a fantastic opportunity. We try and have after action reviews, however the harsh reality of clinical practice does not lend itself to a half a dozen staff downing tools to talk about just what happened. The capacity to do this is just not there. I am reflecting now on concerns that I have raised. It’s a shame I don’t feel confident in putting my name to this blog for fear of what my Trust will say. As I said, I do not want to be a whistleblower, none of us do. We want to raise concerns, have them acted on and keep our patients safe. Call for action At present the conditions are not right for us to speak up safely for these reasons: Our current reporting process doesn’t fit large system wide concerns, this is set up for incidents that have already harmed patients or staff. A Just Culture approach is spoken about but is not demonstrated or welcomed when concerns are raised. Staff are not equipped to handle concerns once they are raised to them. Patients or staff are not encouraged to speak up or have the mechanism to do so. Taking time out to reflect on our concerns and our practice is not valued. There are some great initiatives out there, but unless the fundamentals are in place to allow safe speaking up repeated harm will continue to happen.

It has now been over 70 days since lockdown. Yes, the restrictions are easing – and this is great news for people who have been isolated for so long, it is great for the economy – but we are waiting for the second wave. My last blog spoke about how we are going to get back to ‘normal work’ and my anxieties about how we were going to do this. Slowly, we have been trying to get back to some kind of normal, but it feels confusing, slow and uncertain. None of us can see the ‘end’. None of us knows what the ‘end’ will look like, when it will happen or will even know when it happens. Remembering the early days of lockdown, the streets were empty, the roads were quiet, there were huge queues for food, and everyone seemed scared. It was a little like the post-apocalyptic film '28 Days Later'. We have all had our highs and lows: the NHS clap every Thursday, rainbows in windows, connecting with family, being furloughed, has meant some people have enjoyed lockdown. The flip side is that for some it has been a living nightmare: money worries, domestic violence, child abuse, operations cancelled and bereavements. Unlike the film that lasts 113 minutes, has a set plot that it follows and ends up with them being rescued, we are still stuck 70 days plus in and there seems no hope of a rescue. Real life does not offer us closure, does not always have a happy ending and, unlike dramas on the BBC, life is not always fair. I’m not even sure we are in the middle, which makes me feel even more helpless. I have been nursing for over 20 years. I have loved working with patients; I have even loved working in the institution that is the NHS. The politics, the hierarchy, the culture, yes, it's difficult work trying to negotiate around obstacles and blockers, but we do it and, weirdly enough, enjoy it. But this pandemic is different. In all honesty, I can’t do this anymore. Work was hard enough, but now it’s even harder. Knowing how to care for patients safely in the right area, wearing PPE all day, not being able to communicate properly through the masks, and having procedure and policy changing weekly, sometimes daily, is wearing. I feel like a new starter every day, especially after days off. I’m tired of it and can’t see an end. Due to this lack of enthusiasm, I feel I am failing at giving the care I want to, failing to give patients the care they deserve. This feeling is horrible. What kind of a nurse are you if you have ‘run out of care’? I know this is burnout. I didn’t want it to be. But it is. In January, I didn’t feel like this. This burnout has been because of the pandemic. I am interested to find out why now? I can’t be burnt out from a few months of difficult working conditions, can I? While looking into this and trying to make sense of my feeling, I came across Kanter’s Law. Rosabeth Kanter is a Harvard Business School Professor and according to her “in the middle, everything looks like a failure". Everyone feels motivated by the beginnings and obviously we love happy endings, but it is in the middle where the hard work happens. She states that in the middle, we all have doubts. This feeling is principally produced because important changes are not developed the way we would like it to, lineal and smooth. The changes that remain usually involve two steps forward and one step back. This is evident when we are trying to get back to ‘business as usual’ but new cases of the virus are detected and we can’t proceed as we thought. In addition, it’s easy to feel that when we are in the middle we are very far away from the expectations we had made. Unexpected events take place as well as deviations. What it had been estimated in regard to the need of resources appear to not be enough. It is then when despondency appears. We can’t plan, we can’t mitigate risks effectively, which often leads us into failure. This is why it’s important to fully understand that failure is a necessary part of change, because there will be periods of confusion in which the temptation to abandon will be great. I’m at the abandon bit! This work is difficult. I am not in the position where I can make big changes in my Trust. I must trust that others are making good decisions and they will support us if things don’t go as expected. Call to action I can’t be the only person feeling this now. What are Trusts doing to guide staff through uncertainty, prevent burnout and inform staff of plans for the future?

Currently, as I work from home developing materials for our new PgCert and MSc ‘Human Factors for Patient Safety’ course, I am also, as are many others, watching our current pandemic unfold and reflecting on how this emphasises the importance of such a course for those working within the health and social care sectors. We are living in uncertain times, which for most people is stressful and worrying for many different underlying reasons: loss of income, loss of a job, fear of contracting the illness and the lottery of outcomes, living in isolation or living in crowded homes 24/7, reduced opportunity to exercise, concern for children and other family members and friends, fear of what comes next… to name just a few. As a human factors professional, this comes as no surprise since our job is always to consider the range of human responses and human characteristics in order to identify to what extent it is possible to support this range; and this is indeed happening. For those with mobile phones and internet access, the virtual world is rapidly expanding with new and newly found apps to connect extended families and friends, to undertake virtual meetings, online lessons and assessments, access to art and museums, research opportunities, theatre performances, online exercise classes and increased opportunities to shop. For those without this access the difference is stark. Let’s turn our attention to these apps; someone first has to have the idea and check that there are people out there who would be interested, then there is the need to design the app, and in such a way that we want to use them and can use them. To do this is dependent upon considering the user, i.e. us humans – this is achieved by integrating user-centred design (UX design) and human factors (ergonomics). Turning our attention back to the health and social care sector, we need to consider human factors when assessing the myriad of health apps out there and the increasing use of apps to support our health and social care – from prompting individuals to take their medication to monitoring our health or providing health advice. So what else are we seeing as this pandemic embraces us all? Information is constant, we are truly a connected global society, from daily ministerial briefings to news reports and social media. This provides very public and graphical representations of our human responses – intellectual, emotional, behavioural and physical. For example, we see numbers of confirmed COVID-19 cases and deaths, graphs and charts showing where these are occurring, the age and gender, we see percentages of the population affected BUT to do something about this requires us again to dig deeper. We need to find out the underlying reasons. In the same way, when we respond to patient safety incidents we need to dig deeper and identify the underlying and root causes so that we can truly do something about it. I'd like to provide some examples of how my work in human factors is influencing COVID-19 research and resources. In response to the UK Government asking for businesses to provide thousands of ventilators to help tackle the COVID-19 pandemic, myself and other human factors professionals collaborated with Patient Safety Learning to provide human factors/ergonomics input to support the design effort for these new ventilators. This resulted in a ventilator safety in use driver diagram developed by Patient Safety Learning and a human factors guide from the Chartered Institute of Ergonomics and Human Factors. In addition, in an example of cross-industry collaboration, Yorkshire Water gave me permission to share their human factors engineering specification with designers of ventilators and other critical medical device designers, which quickly took place. Following this, my attention was turned towards sharing advice on working in high heat and heat stress. Based on the Health & Safety Executive Guidance (HSE (2013) INDG451 ‘Heat Stress in the workplace’), I produced a document and flowchart addressing what happens to us when we experience extreme heat, this has been welcomed and shared by the London midwife managers. Next, came questions relating to shift work and fatigue, which led to me creating a summary document based again on a Health Safety Executive website and an ORR document (Office of Rail Regulation [Jan 2012] Managing Rail Staff Fatigue) that emphasises the need for a fatigue management system plus tips for helping ourselves and each other to sleep better when shift working and to recognise and respond to the symptoms of fatigue (www.staffs.ac.uk/clinical-skills). It has also been interesting to note the range of public and enforcement behaviours shown in the media that relate to our response to the ‘lockdown’ in this and other countries. Human responses often link to aspects of culture and sub-cultures, power and influence, personal responsibility and risk perception. All of which are highlighted during our Human Factors for Patient Safety course. Looking ahead, I can see many learning and research opportunities evolving from this pandemic and the opportunity to add to our human factors knowledge base for the good of society. Within the Staffordshire School of Health and Social Care our mix of staff provides us with a unique opportunity to achieve new research in human factors and patient safety and we look forward to embracing the opportunity to learn together.

Key benefits of tool Raises the profile of Health & Safety – engages the workforce to talk about health and safety issues. Captures sensitive information – participants respond anonymously. Enables active management of health and safety - allows companies to highlight both areas of concern and good practice. Provides a baseline measure - can help you evaluate whether health and safety initiatives have had the desired effects on performance. Key features Generates paper and HTML versions of the questionnaire. Quick wizard guides the user through easy set up to produce the survey. The survey can be tailored towards the organisation, for example by incorporating the company logo and supporting Management statement and by tailoring terminology within the SCT statements. Allows for up to 9 demographic questions and an additional 6 open questions. The software automatically analyses the data to produce a series of charts and also allows detailed filtering to further interrogate your findings