Wednesday, 11 September 2019

Promoting a safe and just culture in nursing: Aligning Human Factors with the Courage to Speak Up

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the first of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

The theme "Patient Safety: a global health priority", with the rather apt slogan “Speak up for patient safety” is a call to action for all healthcare workers across the world to help reduce the 134 million adverse events, which results in 2.6 million deaths each year globally.
Ensuring patient safety is an essential role of all healthcare organisations and arguably all health care professionals; this role, being enshrined within both the UK Nursing and Midwifery Council and General Medical Council Codes.

Human Factors
Within healthcare in recent years, the term human factors has been synonymous with patient safety. In an attempt to make sense of the causes, the facts and the myths associated with near misses, healthcare failings and individual responsibilities, the study of human factors has sought to identify problems and generate effective solutions in order to reduce the risks associated with maintaining patient safety.

In accordance with the World Health Organisation, human factors examines the correlation between humans and the processes and systems with which they interrelate, the aim of which is to improve efficiency, creativity, productivity and job satisfaction, whilst seeking to reduce the risk of errors. Investigating adverse incidents within the healthcare setting, often identifies a failure to apply these basic principles.

Contemporary organisations, particularly the aviation industry has recognised human factors as being an important element of safety; this recognition now evident within the NHS. The Clinical Human Factors Group (CHFG) highlights the seriousness of the iatrogenic consequences of accidents and incidents borne out through error. Disturbingly statistical data highlighted by the CHFG makes for stark reading; most of all the cost to human life insurmountable. But it doesn’t have to be this way? Improving safety through speaking up is both an ethical and financial imperative, and organisations should be responsible for encouraging employees to speak up and share their concerns.

For many healthcare professionals their first introduction to human factors may be as a result of an incident in which a patient was harmed, as a result of potential failings. It should not be this way. By gaining an insight into the complexity associated with human factors through educational tools including the well-publicised videos ‘Just a routine operation’ and ‘Gina’s Story’, many healthcare workers can learn about the devastating effect experienced by many. Many more stories, such as these no doubt exist.

These real-life events have in some way occurred as a result of clinical error and a lack of professional judgement, perhaps something that any one of us could be subject to, if exposed to the right situation. We just need to be in the wrong place at the wrong time, for catastrophe to happen.

The Swiss Cheese Model
One theory, of how such incidents occur was proposed by James reason in 1978; known as the Swiss Cheese Model. This model can help to identify potential hazards, demonstrate how incidents occur and help to illuminate or clarify potential causes in accident investigation. When all the holes line up, anything is possible. Inadequate staffing levels for example, could be a contributory factor in helping to align those holes, another perhaps inadequate skill mix. Agency staff can be a buffer to reducing the risk, or can be a mitigating factor, but buffers should no longer be acceptable. Other factors such as skill set and skill mix, attitude, beliefs and values, all play their part, the willingness to challenge senior staff and as nurses make your voice heard could be argued is a significant factor, and is particularly evident in the Elaine Bromiley tragedy as shared in the video ‘Just a routine operation’. Promoting a positive safety culture in which all staff feel able to speak up may also be a positive step in reducing risk.

Developing a safety culture
Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns is an essential element of any healthcare organisation seeking to reduce patient harm, and not simply the NHS. From domestic staff to consultant and all roles in-between, staff must be aware of the importance of raising the alarm, when they think something may be wrong or when it has gone wrong. Disappointingly staff working within healthcare settings continue to be overwhelmed by the challenge of speaking up, so eloquently discussed by Professor Mannion in his article ‘Speaking Up in Health Care: The Canary in the Mine?’ that they fail to do it. So, despite the introduction of Freedom to Speak up Guardians created as a response to the Francis report; a lack of confidence in speaking up remains evident.

The World Health Organisation has produced a multitude of technical reports, a link which can be found here. These reports describe the nature and impact of harm, and provide some potential solutions and rational steps to take in order to help improve patient safety.

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