Sue leads the Zero Suicide Institute of Australasia.
What prompts a person who has spent years training as a health professional to want to pack up and leave — or even more concerning to be so distressed that they seek to take their own life?
Perhaps it is the threatening behaviour of a surgeon who held a clenched fist in the face of a theatre nurse. Or the community mental health nurse who returned to her desk, after witnessing the suicide of a person under her care, with never a word of support from her supervisor. Maybe it is the ever-present fear of presenting evidence to an inquest following the death of a person receiving care within a health care service…..
No matter the circumstance, losing highly skilled and experienced health professionals is a severe blow to our health systems. So, what are we doing to ensure that we retain our workforce and they feel safe to raise their concerns; to participate in review processes to understand and learn from what went wrong when an adverse event occurs?
Professor Sidney Dekker is a world-renowned expert on restorative just culture and building psychologically safe workplaces. He has recently shared his expertise with a number of health services implementing the Zero Suicide Healthcare framework in both the UK and Australia. He notes that “too often, the response to the death of a person while under care is a punitive one.” It is driven by an investigation involving other health care workers who were not involved in the incident — people who did not know what was happening at the time or already know the outcome so are most likely influenced by hindsight bias.
Health care professionals apply their knowledge daily and practise their skills within excessively complex situations. At times this results in unintended outcomes for the patient. The people impacted by these unintentional errors are the first and obvious victims of medical mistakes. However, those who care for them are also wounded by the errors and have needs that must be met.
In most organisations, including health care, how work is designed often differs from how work is done. Highly trained and competent professionals learn how to adapt to the constraints, complexities and contradictions of actual workplaces. However, the need to perform workarounds or adopt common sense practicalities signals that the work has not been planned with the legitimate interests and knowledge of the people who perform the work, does not recognise goal conflicts and is ignorant of the resource constraints that drive real work.
Professor Dekker points out that a restorative just culture is not a culture without rules. “It seeks to bring work as it is imagined closer to work as it is done,” he says. The involvement of those who do the work increases ownership by workers, strengthens confidence in rules that apply to people’s work and makes the rules more likely to connect with reality.
Recognising the loss of expertise and experience is very costly to health systems, Australia has made strengthening a restorative just and learning culture an essential foundation for implementing the Zero Suicide Healthcare framework.
Dr Kathryn Turner is at the forefront of Zero Suicide Healthcare leadership in Australia. She says that to ensure that staff are competent and confident to care for people presenting with suicidality, they need to know that the organisation has their back should an adverse event occur.
“Before embarking on the Zero Suicide Healthcare implementation at the Gold Coast Mental Health Specialist Service, we worked with the executive leadership and our teams to understand what was required to make staff feel safe to raise concerns about an issue,” she says, “or processes and practices that need to change or behaviours that contributed to safety.” “To feel that the workplace was, both physically and psychologically, a safe place to work.”
Health care is a challenging environment for the conduct of accident reviews. The setting is complex and many people are involved. There is the fear of humiliation, litigation, disciplinary action and blame. The fear of these repercussions can result in avoiding reporting medical errors. Implementing programs that increase transparency in reporting and support health care professionals will help organisations learn from things that went wrong and prevent them from happening again. Professor Dekker notes it is the organisation’s response that will enable those involved not only to survive but to thrive. “That response needs to be empathetic, confidential and nonjudgmental,” he says.
A restorative just culture identifies and sets out to repair the harms that have resulted from an event. It asks about impacts, needs and obligations. It holds people accountable in a forward-looking way: what do we do now to heal and improve? In short, leadership needs to take action:
Defuse: action should be taken immediately post-incident to offer psychological first aid and meet the needs of the practitioners involved.
Empower: debrief to understand and create a narrative of what happened. Consider if there is an opportunity to involve practitioners in the investigation.
Follow-up: consider anniversaries and other significant dates that may impact the practitioners. Be prepared to offer support.
In his book, “Just Culture: Restoring Trust and Accountability in Your Organization,” Professor Dekker writes that a just culture is a culture of trust and accountability. A just culture is particularly important when an incident has occurred. A just culture gives people the confidence to report safety issues because they are confident that the organisation will respond fairly. A just culture would enable your organisation to learn from an incident and yet it is also a deep accountability where all hold themselves accountable to be part of a healing, learning and improvement process.
A climate of psychological safety is critical for building a restorative just and learning culture. Teams often consist of members of varying seniority resulting in some voices being raised above others. Building trust and respect within the team is essential to overcome power influences. Organisational leaders set the tone for what is normal and expected and what is allowed or not. This involves explicitly empowering all members of the team, not just by asking them to speak up but also by acknowledging their inputs and taking their ideas seriously. Trust is easy to break and hard to fix.
In a recent publication, Dr Turner stated that “a restorative, just culture fosters a psychologically safe work environment. It has been demonstrated to counteract a blame culture & provide an ideal framework to build trust among staff by creating an environment in which all stakeholders involved in an incident can feel safe to be open to learning & improving care systems.”
Psychological safety blossoms in a climate where not everything goes. Psychological safety goes hand in hand with accountability. A team with high psychologically safety is a team with accountability. When both come together, you build effective, innovative teams ready to learn new things. Adopting a restorative just and learning culture as a foundation for Zero Suicide Healthcare implementation will build trust, encourage innovation and strengthen the capability of the health service to support all those who may be impacted by an adverse incident.
