This post is from The King's Fund Blog
Despite the availability of well-evidenced guidance and the best intentions of health and social care staff, there is still an ‘implementation gap’ between what we want to do to keep patients and service users safe and what actually happens in practice. We need to have a better understanding of what sustains this gap and what we can do to narrow it.
Recently, 90 people from across the health and care system came together for an event run by The King’s Fund, the Sign up to Safety campaign and NHS Improvement, to talk about keeping people safer.
When planning this event, we deliberately avoided expert presentations and lots of ‘talking from the front’ and instead adopted a more interactive format. The day started with four people sharing ‘catalytic’ stories around their experience of working to keep people safer. These were not stories of perfection, but gritty tales of work in the real world where resistance to change is to be expected and understood; where dilemmas need to be noticed and managed; where authority to act has to be negotiated; and where things go wrong or sometimes people get hurt.
We then organised people into groups – with the intention of creating a supportive environment for individuals – and asked people to think about questions they could ask the storytellers. The intention was to search out assumptions not expressed in the narrative and then to have a conversation about how these ingrained ways of thinking and behaving, which feel so personal, also reflect how the wider system is working. Critically, we encouraged people to consider how they would translate the insights generated by their conversation into practical action, to be tested and revised in the reality of their everyday work.
So, during the course of the day, what did we notice and what did we learn?
To state the obvious, keeping people safer is not simple or straightforward. ‘Safety’ is a combination of knowhow: resources, patient situations, and the regulatory environment. Keeping sight of how this complex chain of interactions and events works is part of how we keep people safe, but keeping this complexity in mind when trying to understand why we fall short is a challenge.
There was a strength expressed in the stories we heard on the day – people’s willingness to shoulder a significant level of personal responsibility for keeping people safer. This attitude will get things done, but the serious downside is an unreasonable level of personal scrutiny and accountability when things go wrong. People spoke of feeling embattled and isolated working ‘in the implementation gap’ – and of the personal sense of shame when things go wrong. This in turn leads to self-silencing and a consequent lack of open conversation that could help to identify and tackle problems in the wider system. If one assumes that most care is characterised by complexity, then just focusing on individual behaviour is simplistic, unethical and part of the reason why there is an implementation gap in the first place.
We now know that if you make time to talk in a way that shows interest in others (more simply known as being kind) then we can begin to understand the ‘why’ of others’ stories and how they relate to our own. This sort of talking is about exploration, it’s not driven by the need for agreement. We think this sort of conversation contributes to keeping people safer because more of what is really going on – unintentionally shaped by people’s assumptions and behaviours – can be surfaced and evaluated, alongside the question: how does this way of thinking, behaving and organising keep people safer?
So, at the end of a day organised around talking, we re-affirmed our commitment to conversation as the means to understand what really goes on in relation to keeping people safer, and as a way to be heard when there may be pressure to keep silent.
At The King’s Fund, we provide a platform to question how and why people who are close to patients are often silenced. We aim to develop opportunities that help people to re-acquire skills in thinking, talking and listening; in managing anxiety; and in intervening in those unpredictable, dynamic situations where you never quite have enough authority.
Conversation has been described by Theodore Zeldin (1998) as the ‘way of the weak’ and this seems apt in a system that can act to silence those with less power – more often than not those on the front line, delivering care to patients. But a well-led conversation can sometimes enable those with less power to move the powerful, by helping them to change the way they see the world.