Individual and team wellness as a precondition for safe and quality patient care
In a previous blog, I sought to rationalise the basis for staff safety and wellness as a precondition for safe and quality patient care delivery. In this blog, I will outline five ideas on how we might approach the translation of staff wellness into healthcare outcomes.
1. We need to work to normalise the conversation around wellness within our ED workplaces.
This is far easier said than done, but what I’ve learned from working to institute a local program is that you just have to grit your teeth and get started.
Our local program is called ‘oneED’ [5] and it has some structured and non-structured components. One of our structured activities is a 4-min pause on a Thursday morning at handover, which consists of a variety of activities eg a wellness-related commentary, a short video or a brief guided meditation.
We also promote embedded activities such as square breathing before arrival of a resus patient, or even taking two deep breaths as your blood gas processes or while you await your computer to boot up.
We have now gained momentum with our program, but its ambition remains simple – that the activities do little more than start the conversation and give permission to staff members to experience struggle of any sort, and to hopefully feel comfortable to talk to someone about it.
2. We need to enhance the sense of psychological safety within our workplaces.
The importance of the psychological safety of the workforce has not been met with the same attention and focus as has physical safety (hoists, hand hygiene, needle-stick injury prevention and management).
We can consider psychological safety in several contexts, and several programs exist already.“Speaking Up for Safety” is a movement that promotes the training of staff so that they are equipped to vocalise and escalate their concerns if it appears that patient care may be at risk as a result of a decision or action (or inaction) by a colleague of any level. This campaign has great merit, but it is equally imperative to encourage a culture whereby staff, especially seniors, Listen Down for Safety. This concept was beautifully articulated in a blog piece by Ben Symon. It describes being overtly open to dialogue and collaboration, so that the burden of communication is not placed on a relatively junior staff member, who must muster up the courage and fortitude to speak up, but shared by senior staff members who invite this input from the outset.
Recently, I was team leader for a paediatric intubation in the ED. The Children’s Critical Care consultant kindly came downstairs to assist in decision-making and the procedure. When he asked what role I would like him to perform, I asked if he would mind sitting at the back of the Resus Room and simply provide a reassuring presence. However, I also expressed to him that I was impossible to offend, that I don’t conduct paediatric intubations very often, and that if he saw me or my team doing anything that he thought was unusual (or plain wrong), that I would sincerely appreciate if he told us. When he thanked me for articulating this, I realised that even as seniors, it is vital that we give each other permission to input into our care delivery.
Sidney Dekker has conducted a vast amount of important work on how we report and manage near-misses and error. He describes the concept of a Restorative Just Culture, whereby error analysis seeks not to find a single fault in an individual, and to apportion blame, but to detect individual and system errors, discern the multiple reasons why the error occurred, and then work to mitigate against this next time, while paying attention to the staff involved as second victims.
Psychological safety may also be enhanced by promoting an intolerance for disruptive behaviours that can compromise patient safety. Gold Coast Health has recently launched a Promoting Professional Accountability (PPA) program where staff can anonymously report behaviour that is unprofessional and potential unsafe, and this report is followed up informally and off-the-record by a carefully selected Peer Messenger to make the reported person aware of how they were perceived, and to invite reflection.
3. There is likely something to gain from changing our frame on performance and error. For example, a ‘near miss’ is actually ‘a good catch’.
Prof Victoria Brazil (@SocraticEM) runs our simulation program and one philosophy she employs is to “prepare and practise for failure”. An example of one such scenario is an Airway Management drill. The attitude taken is not “We will train until we will NEVER fail to intubate” but rather “We will train in a manner that anticipates a difficult airway, unable to be intubated on Plan A or Plan B, and we will test our systems for failure-mitigation approaches”.
Safety-II behoves us to consider more carefully why things go RIGHT as often as they do – and the interplay factors in these scenarios.[6] We can learn from excellence as much as we can learn from failure. We could consider incorporating into our M&M (morbidity and mortality) meetings a component on A&A (awesome and amazing) – to reflect upon why things go RIGHT as often as they do.[6]
4. A fourth idea on creating a safe environment is that of implicit coordination and shared mental models.
A number of characteristics of effective team performance in stressful events have been identified, such as the ability to adapt to changing situations, effective communication, and effective resource allocation, as well as the presence of situational awareness and clear leadership. To me, these concepts describe connectivity between team members, particularly in high-stakes scenarios.
These characteristics seem to depend on the presence of what’s called implicit coordination.[7]
Implicit coordination occurs when teams are able to recognise the task at hand, predict what needs to happen to conduct the task, anticipate the actions of other team members, and then adjust their behaviour accordingly.
This implicit coordination depends on a shared mental model, a common understanding of the situation, what needs to happen, and in what sequence.[4]
Again, from the genius of Prof Victoria Brazil at Gold Coast Health has come “oneTeam Practice”: a 5-minute Mental Rehearsal in the Resus Room at the start of each shift. We assemble the Resus team, read out from a card a scenario of an expected patient, and then the team leader talks about what she is expecting to find upon first assessment, how we manage these findings, what unexpected issues may arise, and how we will respond to these. The remainder of the team then introduce themselves and their roles, and how they will contribute to this plan. This is also the time when any issues (eg “I haven’t done B role before”) are raised and can be addressed, either in the rehearsal or afterwards.
The mental task rehearsal is important, but even more important is the connection and relationship that is created – one of trust, respect, communication – a sense that ideas will be shared and help will be sought and provided. Again, psychological safety is achieved simply by knowing who is on your team, and that everyone is committed to the same goal of excellent patient outcome.
5. Finally, we need to continue our efforts to promote the recognition of staff safety and wellness as an organisational priority.
We need to connect the boardroom to the resus room, so that work-as-imagined by our executive decision-makers is faithfully aligned with the work-as-done by our clinicians at the frontline.
We need to consistently promote the understanding that outcomes (whether good or bad) are not linearly related to single factors, individual or system, but that they are a product of complex, variable, logistical and social factors that are constantly changing and require iterative adaptation by frontline clinicians.
When it comes to patient safety (and error reduction), traditionally, the improvements were directed at refining systems and technologies while neglecting human/relational factors.[8] We are better recognising these factors, and raising these issues in fora like Patient Safety and Critical Incident committees.
There is also work to be done to define how organisations can support healthcare staff on an operational level. Shweta Gidwani (@global_EM) is an Emergency Physician in the NHS and is conducting a Churchill fellowship in this area. She is discovering that organisations enhance staff engagement, productivity and wellbeing when they address factors like autonomy, workload, teams, reward, fairness and morality.
Our EDs are learning environments – we are all teachers; we are all learners. We determine the spirit and culture of our workplace and we know that respect, humility and teamwork are key ingredients. We also know that these attributes are all grounded in individual and collective staff wellness.
Workplace preconditions of respect and safety, in which the well-being of every person is a priority, create the conditions for the workforce to habitually pursue excellence.
The psychological and physical safety (and wellbeing) of the workforce is integral to the provision of high quality and safe patient care. We will not advance the latter until we address and optimise the former.
1. Foundation, L.L.I.a.t.N.P.S., Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. 2013. Boston: National Patient Safety Foundation.
2. Reed, D.A., et al., Behaviors of highly professional resident physicians. JAMA, 2008. 300(11): p. 1326-1333.
3. Fahrenkopf, A.M., et al., Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ, 2008. 336(7642): p. 488-491.
4. LeBlanc, V.R., The effects of acute stress on performance: implications for health professions education. Academic Medicine, 2009. 84(10): p. S25-S33.
5. Braganza, S., et al., oneED: Embedding a mindfulness‐based wellness programme into an emergency department. Emergency Medicine Australasia, 2018. 30(5): p. 678-686.
6. Mannion, R. and J. Braithwaite, False dawns and new horizons in patient safety research and practice. International journal of health policy and management, 2017. 6(12): p. 685.
7. Weick, K.E. and K.M. Sutcliffe, Managing the unexpected: Resilient performance in an age of uncertainty. Vol. 8. 2011: John Wiley & Sons.
8. Riskin, A., et al., The impact of rudeness on medical team performance: A randomized trial. Pediatrics, 2015: p. peds. 2015-1385.
9. Kilner, E. and L.A. Sheppard, The role of teamwork and communication in the emergency department: a systematic review. International emergency nursing, 2010. 18(3): p. 127-137.
