Patient safety: embedding a workplace culture of learning rather than blame

Making simple shifts in approach and language to patient safety investigations can be key to changing the culture of health and care organisations.

The golden thread of patient safety continues with NHS Resolution’s recently published new guidance on how leaders of all health and social care organisations can support staff when things don’t go as planned. The guidance provides the latest “thinking, ideas and prompts” which will help to drive a just and learning culture within health and social care.

The need for change is clear: NHS Resolution received 317 claims valued short of £27.5 million in the last four years relating to staff stress and bullying in NHS trusts. The 317 claims cover a range of staff from doctors, nurses/midwives to AHPs within an organisation, reflecting the extent of the issue and that it can affect staff at any level.

The numbers are “significant” and are driven by a range of “avoidable factors” in relation to how staff are supported says the guidance.

These include:

• Failures to follow policies effectively relating to investigations and workplace stress
• Failure to follow advice given by Occupational Health an conduct timely investigations, grievance or appeal
• Failure to provide a safe system of work and have regard for staff members’ mental health and personal safety
• Failure to follow recommendations set out in the investigation report which caused the staff members’ trust and confidence to be undermined
• Failure to carry out suitable or sufficient assessments of the risks to the staff members’ mental health
• Failure to implement any adequate preventative or protective measures for the safety of staff members

Being fair guidance

This sets out what it means to have a just and learning culture for staff and patients when things go wrong. It is described as “the balance of fairness, justice, learning – and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong.” But the guidance accepts that whatever the culture, dealing with concerns about professional practice can be challenging.  

It advocates organisations adopting a more reflective approach to learning from incidents and supporting staff which it says can be key to improving patient care as well as the wellbeing of staff.

The guidance has drawn on NHS Resolution’s data set to explore best practice across the health system. It provides examples of practices used across the NHS as means for others to see the different ways in which a just and learning culture could be built. The guidance accepts that there is a variety of approaches being taken, with no single approach recommended over another and acknowledges that organisations are at different stages, and still working out what is effective.

Nevertheless, the consensus is that the use of an agreed tool, charter or framework by organisations is helpful in supporting a more consistent approach towards all staff groups.

Examples include:

• Just and learning culture charter
• Restorative approach – adopted by Mersey Care NHS Trust
• Triage system– adopted by Barts Health NHS Trust and the use of a triage system (pre-disciplinary checklist) to determine whether disciplinary action is necessary or inappropriate
• A just culture guide - NHS Improvement’s 2018 guide acts as an aide memoire for people to assess the appropriate response when something goes wrong

By embedding a more open and just culture it is hoped that this will lead to an avoidance of inappropriate disciplinary action against staff, including those from BAME backgrounds who appear to be disproportionately subject to such action.

Concerns about equity and fairness were raised back in 2012 by the Court of Appeal in Crawford & Anor v Suffolk Mental Health Partnership NHS Trust in which the court remarked on the “….almost automatic response of many employers to allegations of this kind to suspend the employees concerned…irrespective of the likelihood of the complaint being established…”.

It is worth noting that NHS Improvement recently published guidance to help NHS trust boards deal with investigations and disciplinary procedures – implementing this guidance across the NHS will contribute to ensuring we treat people fairly and protect their wellbeing.

Other identified challenges to creating a just and learning culture include: bullying and harassment and fear of being inappropriately blamed following an incident, the effect on future employment and what peers will think. Those factors risk preventing NHS staff from sharing and learning. There is no doubt that there is more work to be done but the guidance, it is hoped, will start the conversation which might lead to a change in mindset and attitudes to current practices across the NHS.

Do get in touch if you would like support with any of the issues discussed – we have a friendly and expert team ready to help.