Doing safety differently: creating fertile soil

IT never seems to stop – story after story of junior doctor distress, bullying and burnout, even suicide. How many of us sigh and wonder when things will ever change?

In recent months, we have heard of hospital teaching departments losing accreditation status, young doctors leaving training schemes, and tragic loss of life (here, here and here).

Over many years, the quest for a solution has particularly focused on working hours and competition for training positions. It is sometimes suggested that the pool of supervisors includes vindictive narcissists who think that today’s trainees should have to endure what they went through to somehow “toughen up”. Again and again there are calls to refine medical student selection processes – though it is 40 years since the University of Newcastle, for example, began selecting students through interviews and aptitude tests.

When we talk about “culture change” in hospital workplaces, though, what do we mean? Do we mean responding to the stress of toxic work environments by offering yoga lessons and sessions with the employee counsellor? Do we mean that we should all develop more resilience to survive a toxic workplace? Is resilience just “hardening up” by a new name? Is the incidence of bullying changing, or is reporting more prevalent?

Much has been written over the years, from various perspectives (here and here). We’ve had College reviews, a Senate inquiry, pages of press reports, interviews and panel discussions.

In an attempt to come to terms with this apparently intractable issue, many of us look back over our own careers. What has changed? Here is my take.

First, while there is no doubt that junior doctors still work long and sometimes unsustainable hours, objectively, working hours have improved over the decades. There are more women in senior positions than ever before. Medical schools take a mix of under- and post-graduates. Training involves more hands-on and problem solving than ever before. There are many senior role models with families, and part-time work is more available and accepted than ever before. And yet morale seems lower than ever. What’s different?

In my view, workplace dysfunction is characterised by not one but two F-words: fear and frustration.

In the mid-1990s, the Quality in Australian Health Care Study rocked the nation by publicising the harm from medical error. What followed was an enormous shift towards focusing on quality and safety by collecting data, analysing them and putting in place a huge body of guidelines, restraints and surveillance processes. We learned that standardisation improves outcomes, that working under surveillance improves compliance and that, if highly trained and skilled doctors would just swallow their arrogance and do as they were told, things would be better. But what did we think would get better? Patient care? Workplace safety? Teamwork?

Let’s look at where that got us. In reality, health care is much safer. At least, it is if you only count certain types of errors. We have reduced many errors that were avoidable by better process design – medication errors, wrong-site surgery. We have better processes for handover. We have a myriad of new processes for falls prevention, risk documentation, early identification of possible sepsis, procedural credentialling. We have a large number of policies and guidelines. But we have traded the risks of “missing something” with the risks of overtesting and overtreatment.

And, more than ever, we have disseminated the two Fs: fear and frustration. Fear of missing something, of being blamed, of being called out by peers as being below standard, of being considered responsible for patient harm. And frustration at seeing a quality management system that cannot keep up with the sophisticated, complex system it governs. A risk management system that focuses too much on error analysis and ways of restraining staff and nowhere near enough on trust and value of staff. A system that is more about fixing than fostering.

It’s possible that bad behaviour – including bullying, blaming and belittling others – is triggered by underlying fear and frustration. Though trained to rationally calculate and hold risk, we may be driven to push it between each other rather than hold and manage it between ourselves and our patients. We may be induced to act more out of fear of blame than fear for patient welfare. Ironically, the patient may be completely left out of this dialogue of blame-shifting. And when we feel ignored and powerless to do our best work – even sabotaged by the system – we might take our frustration out on others.

I want to call for a different F word: moving risk management forward.

Health care is a highly complex endeavour staffed with highly educated, skilled and motivated professionals. Risk management should be equally nuanced and skilled, aimed at maximising performance of staff, not just limiting error. The focus should be on building trust and motivation, encouraging clinicians to do their best possible job because they are motivated to work well, not just because they are afraid of blame. Institutions should employ managers who are at least as skilled in this area as the clinicians they advise, and who see clinical staff as an asset, not a liability.

A healthy workplace culture calls for doing safety differently. This approach sees safety as intrinsic to good work, not as a separate bureaucratic process. It sees staff as talent to be developed, not as sources of risk to be managed. Just like good clinical work, good management requires courage. The courage to trust clinical colleagues to want to do their best. The courage to call people out when their motivation is poor but also to recognise when it is good. And the courage to share risk explicitly with patients, knowing that error is inevitable, but that mutual acknowledgement is what most patients hope for.

Junior doctors are as well selected, smart, well trained and well motivated as ever. Let’s create a system that helps them flourish and doesn’t drive them to frustration and fear.

Dr Sue Ieraci is a specialist emergency physician. After 35 years in the public hospital system, she now works in telemedicine and health system consulting. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.