We all want to provide services and care that are safe and appropriate for the women and birthing people in our care. “Safety” has taken on a negative role in recent years. In this article Professional and Clinical Advisor in Patient Safety Suzette Woodward, explains the different approach “safety II” takes for maternity services.
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Patient Safety Now: safety II and maternity
There comes a point where we need to stop just pulling people out of the river. Some of us need to go upstream and find out why they are falling in.
Desmond Tutu
Anyone working in maternity services wants to ensure the safety of the women and birthing people in their care. However, healthcare is an uncertain world and the difference between safe care and unsafe care can be decided in minutes.
‘You have to know the past to understand the present’. A famous quote from Carl Sagan and the sentiment of which is vital for the science of safety. Predominantly the way we have done safety in healthcare, is to try to understand how safe we are through the lens of failure. This is a laudable but flawed approach. We have tried hard to prevent things from going wrong, to detect them quickly if they do, to limit the harm as much as possible and to learn for the future. Today though, we are asking two crucial questions:
- why are we not as safe as we should be, given the amount of effort we have put into the science of safety over the last two decades?
- why do we simply focus on the things that go wrong and not on the times when we get it right in order to understand how safe we are?
As Sidney Dekker and Todd Conklin said, “Change happens through learning and when people are exposed to a new way of thinking. The more individuals who are exposed to these new ideas the more there will be an increase in critical mass leading to impact”
The new approach to safety is coined as ‘safety-II’. This is where we move away from simply recording incidents and undertaking flawed investigations towards an approach that is about understanding the realities of everyday work in a constructive and positive way. It is about becoming more proactive and preventative, helping reduce the risks and minimise their effects. Statistically we know that we fail far less than we succeed. In many other areas of life, we study the good in order to improve. Should we not learn from the majority of times that things go ok in order to strengthen them and when they do fail, ask ‘why did it fail this time when it goes ok most of the time’?
Our traditional approach, safety-I, has largely limited itself to incidents at the tail end of the distribution – when things fail. Safety-II is about the whole distribution – all forms of work and all outcomes, routine work, incidents and accidents, and exceptional performance – how things go every day. Healthcare is a complex adaptive system; a dynamic network of interactions with people and processes acting in parallel, constantly reacting to other people and processes. The reality is that the world of healthcare is a world filled with uncertainty, variability, and constantly changing. In any normal day people:
- Adapt and adjust to actually demand and change their performance accordingly
- Deal with unintended consequences and unexpected situations
- Interpret policies and procedures and apply them to match the conditions and patients
- Detect and correct when something is about to go wrong and intervene to prevent it from happening
As healthcare becomes more complex, adjustments become increasingly important to maintain a functioning system. The challenge for those that work in safety is to understand these adjustments. In other words, to understand how performance usually goes right in spite of the uncertainties, ambiguities, and goal conflicts that pervade complex work situations.
The best way to finding out what people are doing is to observe and listen to the people doing the work. We cannot predict the next incident, but we can predict environments and circumstances where events and failures are more likely to happen. We can constantly strive to reduce complexity. Ask them what frustrates them, what would make work easier to do? Crucially don’t go out to fix the individual, don’t enact immediate policy and rule change. Slow down and learn.
Our response matters. Respect, be kind, enable people to feel safe to participate and speak up, build a psychologically safe environment where people can be themselves, feel they belong, can ask questions, can contribute and challenge. Add to this a restorative just culture for when things inevitably do go wrong means we are non-judgemental and seek to support and learn rather than blame and sanction.
We can all do this by asking the three questions (Dekker):
- Who was hurt?
- What do they need?
- Who is obligated to meet that need?
Three small questions with such a large and widespread impact, questions that have the power to help develop new levels of understanding. They seem simple; however, they are not. They determine the response and provide the best opportunity of moving from a retributive response to a restorative response. It provides an opportunity for those most affected by these events to talk about their experience in a process which is focused on rebuilding relationships, and trust rather than creating fear and blame.
‘What do they need’ helps us care for the people that care. Our workplace has been impacted significantly over the past two years, and we know that healthcare staff have felt this too. Even before the pandemic, for many frontline clinicians the working conditions were intolerable; few breaks, less time outside, fatigue, not enough staff, the list could go on and on. All of this has impacted on safety and in the way people behaviour towards each other. We know that studies have shown that burnout, depression and suicide are increasing amongst healthcare practitioners, and the pandemic has substantially increased all of these issues. Safer care is only possible if we care for those who care for patients. The proactive and positive approach to safety, safety-II, together with building compassionate cultures and treating each other with kindness and respect is a great way to start.
Prof Suzette Woodward DProf, DSc, MSc, DipMS
Professional and Clinical Advisor in Patient Safety, Visiting Professor of Patient Safety, Imperial College
Website: https://suzettewoodward.org/
Author: Woodward S (2017) Rethinking Patient Safety. 978-1-4987-7854-1. Boca Raton, FL: Productivity Press.
Woodward S (2019) Implementing Patient Safety. 978-0-8153-76859. Boca Raton, FL: Productivity Press.
Woodward S (2022) Patient Safety Now – Boca Raton, FL: Productivity Press.
– out October 2022