In our view, patient safety can only ‘happen’ when it exists in the minds of those at the point of delivering care: managers, clinicians, patients and carers. Thus part of our work is to explore how risk and safety are understood at this ‘low level’ organisational space and how to help those responsible for constructing safe care for patients do so effectively.

This study looked at how notions of risk and safety become learned as part of professional training, and how they are balanced in the day-to-day work of staff, managers and patients against such competing influences as quality of care, patient comfort and dignity, organisational efficiency, professional values etc. This is an interview-based investigation, conducted by Dr Konstantinos Arfanis and James Shillito. How notions of risk and identity shape safety behaviours such as checking, and the role of ‘non-clinical’ staff such as porters, ward clerks and records staff, in the maintenance of safe patient care, are also issues that we aimed to explore.

1 Risk,

Background

Industrial safety systems thinking has recently been promoted widely in healthcare as a means of improving the safety of care (Kohn et al. 1999). This reflects the increasing pressure from healthcare professionals and service users alike for higher quality care and the avoidance of unnecessary risk. However, there are important differences between the two settings. In particular, healthcare staff may be more likely to see themselves as belonging to a particular professional group than as ‘equivalent actors’ within a safety system (Amalberti 2005). Key to this is the notion of personal identity. The formation, understanding and expression of identity (Brown, 1986).and the part played in this by our relations to others (Markus & Kitayama, 1991,Hatch & Schultz, 2004) are central themes in social psychology. There is, however, very little work on professional identity in healthcare workers either in general or specifically on the relationship between identity and notions of risk and safety. Identity influences an individual’s understanding of his/her (professional) environment, including the notions of risk and safety (Lupton, 1999). As McDonald et al (2005) argue

‘individuals perceive and interpret risk in the context of their place in a society whose particular social forms influence what they come to perceive as risks. The implication of this approach is that challenges to risk perception represent not an appeal to individuals to adopt an alternative cognitive perspective, but a threat to existing forms of social order and, by implication, the shared values and beliefs which underpin those.’ (pp 399-400)

Personality, culture and professional identity, and how they relate to risk and safety is at the centre of our scrutiny. Most work has been in the operating theatre setting, (McDonald et all 2005). In handover communication between anaesthetists and nurses in the postoperative recovery room (Smith et al 2007) there were informally-negotiated practices which demonstrated different and sometimes conflicting conceptions of what each professional groups considered as within the boundaries of safe practice. In MacDonald’s work, standardisation and the use of protocols in the name of promoting safety appeared to bolster managerial identities and seemed to be a key component of professional identity in nursing. In contrast, such developments appeared to threaten the medical identity. However, how these attitudes come about, how they are conceptualised within individual professional identities and what consequences they might have, have not been explored.

Aims and objectives

This project focused on the relationship between identity and risk in more detail in a number of contrasting groups of staff in acute care settings. Our specific research questions were:

1 To what extent are notions of risk and safety part of the way healthcare practitioners are thinking in order to guide their day-to-day work? How are these ways of thinking learned and/or adopted?

2 If patient safety is not included in these ways of thinking mentioned above, what is their relation to potentially conflicting aims of one’s daily routine – for instance, how do they relate to patient comfort, quality of care, efficiency, patient autonomy etc?

3 If we assume that some practitioners are more tuned to safety problems within their work routines than others, could professional status and/or training account for such a phenomenon?

4 Are there benefits and rewards to having a higher sensitivity to risk and safety in the workplace, and if so what are they?

Brief summary of findings:

Professional Identity:

Our data reveals that professional identity can constitute a major influence in a healthcare professional’s understanding of and behaviour towards patient care and safety. We found that many participants expressed a strong tendency to identify with several groups within their workplace. These multiple identifications took place at several levels of abstraction, each of them relevant to a specific context or situation. Participants’ accounts indicated their awareness of the existence of people’s identification with these groups and the potential implications to issues affecting the welfare and safety of patients. Communication has been identified as the single most important element in a patient’s care that could potentially be influenced by healthcare professionals’ group membership.

We believe that membership to a professional group entails from and elicits to its members behaviour, similar to that stemming from membership to any other type of group. Behaviour that typically favours the in-group and prejudices the out-group. While within a healthcare environment there might not be direct and open competition between groups since (as this paper demonstrates) healthcare professionals generally see everyone working with or near them as having the same goal (the patient’s welfare and safety), there still is privileged information reserved for members of the same group and suspicion for members of out-groups. This has the potential to indirectly harm the patient, either because vital information is not passed on to members of other teams/departments/professions, or due to lack of trust in the abilities of members of the aforementioned groups. We believe that there is an exciting prospect for future work addressing the need for closer scrutiny on group membership and its dynamics within such a sensitive and complex environment as a healthcare establishment. In doing so, ways of improving current discrepancies involving the flow of information between different professional groups may be identified.

Risk:

Our data reveals that the vast majority of healthcare professionals we interviewed understand risk as something intrinsic to healthcare; another variable one needs to prepare for.  In terms of identifying and dealing with risk, we found indications that the decision-making processes healthcare professionals use vary according to their training and experience. In a healthcare environment, risk is something that is incorporated into the ‘‘lived experiences’’ of healthcare professionals. Healthcare professionals are generally united in their opinion of risk. The vast majority of them bring to our attention the reality of risk in their everyday working life. Most see and understand risk, not as a formidable obstacle they feel unable to react to, but as something intrinsic to healthcare; as just another variable they need to account and prepare for. In terms of the nature of risk, a clear separation of risk types into professional and situational is made, with the further sub-division between risks that are avoidable and risks that are unavoidable. Participants are clear on their views regarding how they feel risk can be better managed. According to them, people who have better training and longer experience manage risk better. In regards to the perceptual awareness of risk, however, this appears to be widely varied. This current work provides a strong early indication that risky situations are defined, understood and reacted to differently by healthcare professionals depending on their training and experience. It is this training and experience that underlies an important decisional making process that requires healthcare professionals to accurately calculate the benefits of taking particular risks.

Dissemination

Data from this study was published in peer review journals and presented in national and international conferences:

Arfanis , K “Walk a mile in my shoes”: How inter-professional understanding could help improve patient safety. Making health care safer: learning from social and organisational research. St Andrews, 27-28 June 2011

Arfanis, K;  Shillito, J; Smith, A.(2011) Informal risk assessment strategies in health care staff an unrecognised source of resilience. J Eval Clin Pract.2011 Sep 13. doi: 10.1111/j.1365-2753.2011.01759.x. [Epub ahead of print]

Arfanis, K;  Shillito, J; Smith, A.(2011) Healthcare professionals' understanding of patient safety: relevance to the development of person-centered medicine. International Journal of Person Centered Medicine. Vol1, No3. 475-481

Arfanis, K;  Shillito, J; Smith, A.(2011) 'Risking safety or safely risking? Healthcare professionals' understanding of risk-taking in everyday work', Psychology, Health & Medicine, 16: 1, 66 — 73

Relevant literature

Amalberti R, Auroy Y, Barach P, Berwick DM. Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 2005; 142: 756-64.

Brown, R. (c1986) Social psychology, second edition, New York: Free Press; London:Collier Macmillan

Glaser, B. G. & Strauss, A. (1967) The Discovery of Grounded Theory: Strategies forQualitative Research. Chicago, IL: Aldine Publishing Co.

Hatch, M. J. and Schultz, M. (2003) Bringing the corporation into corporatebranding, European Journal of Marketing, 37 (7/8), p. 1041-1064

Kohn L, Corrigan J, Donaldson ME (1999) ‘To er is human’ National Academy Press, Washington, DC

Leape LL (1994) Error in Medicine. Journal of the American Medical Association 272: 1851-1857

Lupton, D. (1999) Risk New York: Routledge

Markus, H. and Kitayama, S. (1991) Culture and the self: implications for cognition, emotion and motivation, Psychological review, 98, p. 224-253

McDonald R, Waring J, Harrison S. (2005) ‘Balancing risk, that is my life’: The politics of risk in a hospital operating theatre department. Health Risk & Society 7:4, 397

McDonald R, Waring J, Harrison S, Boaden R, Walshe K, Parker D. (2005) An Ethnographic Study of Threats to Patient Safety in the Operating Theatre. Available at: http://www.pcpoh.bham.ac.uk/publichealth/psrp/Pdf/Harrison_Final_Final_Report_Dec_2005.pdf

Smith AF, Pope C, Goodwin D, Mort M.’ Contested conversations’: an observational study of patient handovers in the recovery room. Acta Anaesthesiologica Scandinavica 2007; 51(Suppl 118): 18-19

Triandis, H.C., Bontempo, R., Villareal, M., Asai, M. and Lucca, N. (1988) Individualism and collectivism: cross cultural perspectives on self-in-grouprelationships, Journal of personality and Social Psychology, 54 (2), p. 323-338

Wilson J, Woods I, Fawcett J et al (1999) Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. British Med J 318: 1099–103