Creating a just and learning culture through staff support

The vast majority of veterinary nurses and surgeons work in veterinary practice because they wish to provide the very best level of care possible to their patients. There is rarely an intent by staff to provide care that is below expected standards. When things go wrong in terms of patient safety, these incidents are often treated as failures (NHS Resolution, 2019). Shorrock and Williams (2017) suggested that when things have not gone as expected within human healthcare, there is a fear of being blamed, of consequences regarding future employment and of what family, colleagues and friends will think.

A study undertaken by Hartnack et al (2013) confirmed a similar situation within veterinary practice, having reported universal acknowledgement among veterinary anaesthetists that when mistakes and near-misses occur, nobody speaks of errors and there is a fear of punishment in the aftermath.

Radhakrishna (2015) proposed that in complex systems, such as healthcare, it is impossible to create a completely error-free system as error will eventually manifest itself through a human act. The reality is that every single person who works in healthcare will make mistakes; it is inevitable, because they are human (Osborne, 2000; NHS Resolution, 2019). As a veterinary professional, you may understand what this truly feels like because you will likely have made a mistake at some point in your career. You will therefore understand the circumstances and situations that surround such mistakes as you know first-hand what it is like to look after patients with complex conditions under complex circumstances (NHS Resolution, 2019). Oxtoby et al (2015) suggested that the human medical typology cannot be solely applied to the veterinary context; there are some causes of mistakes that are unique to the veterinary context, including the ‘owner effect’ (i.e. that patients are ‘owned’), the nature of animal patients and pressures produced by the fact that clients pay directly for the service they receive in a competitive marketplace.

Unfortunately, within many organisations, the culture is to blame the individual for the error rather than to try and understand the various processes in the system that led to the fault (Radhakrishna, 2015).

Supporting staff to be open about mistakes enables valuable lessons to be learned in order to prevent the same errors from being repeated in the future (NHS Resolution, 2019). A recently published report from NHS Resolution, Being Fair, sets out a more reflective approach to learning from incidents, and supporting staff when things go wrong (NHS Resolution 2019). Within human healthcare, there is a growing body of evidence (Castel et al, 2015; Radhakrishna, 2015; Trueland, 2019) that demonstrates that a way forward is to embed a just and learning culture — but what exactly is this and how can it be achieved within a veterinary practice?

A just and learning culture

The medical paradigm demands that healthcare practitioners practise to perfection, and if a person falls short of this high standard, that person is to blame (Reason, 2000). Professional responsibilities of qualified veterinary personnel are explicit within their designated Code of Professional Conduct laid down by the Royal College of Veterinary Surgeons (RCVS) and, thus, the author believes that this statement can be extrapolated to veterinary professionals also.

Such a view, however, fails to appreciate that there are often two victims in a situation where a medical error takes place: the patient and the person who committed the error. Radhakrishna (2015) suggested that, naturally, the patient may suffer harm or distress as a consequence of error, but further suggested that the person who committed the error is often tortured by guilt and may suffer considerable mental anguish which may lead to devastating consequences. A high-profile example from human healthcare is that of Jacintha Saldanha, who in 2012 took upon herself the blame of leaking information regarding news of the royal baby after she was duped into putting through to Kate Middleton's nurse a hoax call by two prank callers; tragically, Saldhana took her own life as a result of the situation.

In 2014, the General Medical Council published a review of instances where doctors who were under fitness-to-practise investigations had committed suicide. During the period of 2005–2013, there were 28 reported cases of a doctor under investigation committing suicide, or suspected suicide (Horsfall, 2014). Radhakrishna (2015) suggested, however, that the 28 suicides reported may be merely the tip of the iceberg, as they do not reveal the full scale of the stress suffered by many others under similar investigation. Allister (2015) reported that a number of research studies conducted within the past 15 years had shown that the suicide rate among the UK's veterinary surgeons was three times that of the general population, and it was among the highest of all professional groups surveyed. Bartram (2009) suggested that people who went to veterinary school were generally from a particular sociodemographic background and were all high achievers. They further stated that among high achievers, there are higher levels of certain personality dimensions such as neuroticism and perfectionism, suggesting that these elements could be risk factors for suicide (Bartram, 2009).

Within human healthcare, Castel et al (2015) suggested that healthcare facilities must abandon their historical expectations of clinician perfection and take up tools beyond punishment to stem the human and financial costs of preventable medical errors. Within the NHS, much work has been undertaken examining lessons learned historically from other complex industries that also balance productivity and safety, such as aviation, air traffic control, and nuclear power.

In 1987, officials involved in the Chernobyl disaster were tried under the legal system; however, the reality of the system failure leading up to the nuclear catastrophe did not come to light until much later. Within aviation, incidents have been investigated which have pioneered and revolutionised the way in which failings are handled. The Aviation Safety Reporting System provides a platform for staff to self-report incidents, with immunity from prosecution (Castel et al, 2015; Oxtoby et al, 2015; Radhakrishna, 2015).

Such examination of other industries has led to the development of the just and learning culture initiative advocated by the NHS. Such a culture requires a balance of learning with accountability and assurance that staff and organisations take responsibility for making changes to help people work safely (NHS Resolution, 2019). When care does not go as planned, all actions should be understood before being judged, and staff should be supported to learn from their mistakes.

Maintaining accountability

NHS Resolution (2019) suggested that the blame needs to be removed from failure, further suggesting that this means altering the mindset and language associated with safety — from blame to learning. Where blame is the goal, any investigation tends to stop after the ‘culprit(s)’ have been identified and hence the opportunity for learning is lost (NHS Resolution, 2019).

Such an approach, however, does not mean an absence of accountability. Accountability is about sharing what happened, working out why it happened, and learning and being responsible for making changes for the future safety of patients and staff. It is important to ascertain whether the choices made by the individual involved in the incident were unintentional or intentional. As previously mentioned, the majority of healthcare personnel have no intent whatsoever to inflict harm on their patients. When a mistake occurs, therefore, the actions and choices made should be understood before passing judgement and deciding on action to be taken (NHS Resolution, 2019).

In the case of suspected intentional harm or a serious conduct issue — for example, the worker knowingly increasing risk by violating known safe operating procedures or arriving at work under the influence of alcohol or drugs — such matters must be dealt with responsibly and referred to the external bodies, including the relevant professional regulator, and even the police in some circumstances.

Example from the NHS

Mersey Care NHS Foundation Trust provides health services in North West England with clinical services provided across 80 sites around the region, with approximately 8000 staff serving a population of almost 11 million people (Mersey Care NHS Foundation Trust, 2019). At the onset of their work towards the project — based around moving to a just and learning culture — in 2016, Mersey Care had a significant number of disciplinary cases and associated suspensions. This was naturally problematic for safe service delivery and seriously affected the health and wellbeing of the Trust's employees. All staff agreed that a change was required and, in partnership, began to examine alternative solutions to when care does not go as expected. Management and human resources, alongside clinical staff jointly addressed the initial stages of their disciplinary process, introducing a template which encouraged the decision-makers to ensure all relevant information was gathered and examined prior to deciding to instigate formal proceedings (Mersey Care NHS Foundation Trust, 2019). The template was designed in order that the staff member, who may be the subject of the investigation, could contribute information about what had occurred or not gone to plan; deliberately avoiding terminology inferring something had gone wrong (Mersey Care NHS Trust Foundation, 2019). Just and learning ambassadors were also introduced by the Trust; these are self-nominated employees who work throughout the organisation to drive necessary cultural changes.

Since the introduction of the changes, Mersey Care has seen a reduction in disciplinaries, with one clinical division seeing a 64% reduction in disciplinary cases in 2016–2017. Addressing issues before they escalate has been key in improving staff morale, together with significant improvements to the Trust's 72-hour review process, with staff receiving feedback and learning being shared in a timely manner. Both staff side representatives and management advocate the positive impact of working in partnership to pave the way for a just and learning culture (Mersey Care NHS Foundation Trust, 2019). A shift in culture is not straightforward, however, and Mersey Care has acknowledged that some parts of the organisation had embraced their concept more than others, and hence the evolution of the project is ongoing.

Moving toward a just and learning culture within veterinary practice

As illustrated by the work of Mersey Care NHS Foundation Trust, implementing such a change of culture will not occur overnight. It is the author's opinion, however, that this should not deter veterinary staff from considering a different approach to mistakes as they may benefit from the implementation of a similar culture within veterinary practice.

Australian psychologist, Professor Sidney Dekker, is widely acknowledged for his work within this movement and he suggested that a restorative just culture is about repairing and building trust and relationships when things have not gone as planned (Dekker, 2018). This requires staff to develop working practices that move away from fear and blame and address the health and wellbeing needs of staff to help them work safely.

NHS Resolution (2019) proposed there was a need to build a culture where individuals feel able to speak up when they have made an error and to ensure that when they do speak up, they are fully supported by the organisation. Furthermore, staff must be encouraged to continually reflect on what factors can affect their behaviour and performance, such as system designs, protocols, equipment and environmental factors. Other factors including compassion fatigue and burnout, workload and team relationships must also be considered.

The detail contained in Table 1 contains some practical steps that may be used by veterinary personnel as a starting point towards a change in practice culture from one of blame to learning. However, it is beyond the scope of the present article to discuss the implementation of such a culture change within veterinary practice in depth, as it requires discussion with all team members and examination of organisational values. Interested parties therefore are directed to the work of Professor Dekker for further information (http://sidneydekker.com/just-culture/).

Conclusion

When the practice culture is one of blame and staff are afraid to report patient safety issues, a key pathway to reducing morbidity and mortality from medical error fails (Castel et al, 2015). Supporting staff to be open about mistakes allows valuable lessons to be learned in order that the errors can be prevented from being repeated. Supportive safety leadership appears to be central to reducing fear of reporting errors for healthcare staff; this will require all senior and supervisory leadership staff to receive training to help them move from bureaucratic to more participative leadership styles in order that they may hear about staff safety concerns first hand. Such an approach will enable leaders to help identify the chain of factors that lead up to medical errors in order that changes can be implemented that may help staff to work more safely. Finally, a just and learning culture is not only about promoting staff working safely; it is about how staff at all levels treat each other, every single day (Woodward, 2019).

KEY POINTS

• A just and learning culture is the balance of fairness, justice, learning and taking responsibility for actions.
• Every single person who works in healthcare will make mistakes; it is inevitable because they are human.
• Supporting staff to be open about mistakes enables valuable lessons to be learned.
• Organisations need to foster a culture where individuals feel able to speak up when they have made an error.
• There is a need to address the health and wellbeing needs of staff in order to help them work safely.