Promoting health and safety in health care: a bottom-up tool development

Abstract: The objective of this project was to develop a tool for safety and health monitoring in operating theatres that tried to overcome the limitations of existing methods. Sixty health care operators (nurses and physicians) of six ligurian hospitals joined the project in 2010-11. Following the action-research methodology, we facilitated them in developing a tool – tailored on their cultural and operational environments – for the detection and solution of issues related to health and safety at their early stage. The tool is composed of three parts: (1) anomaly detection (problem description, potential consequences and proposal solutions); (2) problem setting and problem solving (definition of timeline and roles for problem management); (3) solution process monitoring (effectiveness assessment and new actions to do). The tool has several strengths both at the organizational and individual level: it enhances interaction and information sharing, improving organizational health, it empowers operators self efficacy and locus of control in influencing organizational processes, it can become a database of already solved issues concerning safety and well-being, allowing operators to learn from these experiences, it can also afford a clear monitoring of processes that are generally long and tortuous due to the organizational complexity of health care units.

Keywords: organizational health; action research; operating theatres

Bruno, A., Bracco, F., & Sossai, D. (2012). Promoting health and safety in health care: a bottom-up tool development. Global Congress for Qualitative Health Research,  Università Cattolica, Milano, 28 – 30 June. PDF of the proceedings

Risk management from incident reporting to criticalities detection: a methodological proposal. A case study.

Incident reporting in the Health Care could be underused or misused because of a cultural and organizational context characterised by the so called blame culture, whose effects are that workers perceive it as a control tool used by the management to find guilty operators. We believe that incident reporting is not effective for safety if it is not supported in advance by other tools that focus on weak signals and treat anomalies and human error as a resource for organizational learning and not something to hide and blame (Weick and Sutcliffe, 2007). This frame was the ground for a project realised in the Italian health care domain, whose aim was to increase the commitment of operators and managers towards an organisational culture oriented to safety and well-being, of both the operators and the patients. The project involved 60 operators (nurses and physicians) from six hospitals, during 2010 and 2011. Using the action research methodology, the participants analysed their own activities and developed a tool for the detection of organisational criticalities within the SHELL model frame (Hawkins, 1975). Each participant has been supported in order to involve the hospital workers in the implementation of the tool. The tool has been developed starting from activities, and it is aimed at providing outcomes at the operational level. It is composed by three steps that allow: 1) to detect and monitor problems concerning well-being and safety. It allows operators to signal problems, their frequency, and take into account the factors that produce them and the potential consequences; 2) to propose a solution for those problems in order to give a personal contribution to the increase of the general safety and well-being. This enhances an internal locus of control and assumption of responsibility in process management; 3) to involve operators in process monitoring and tracking the steps towards a solution, assessing also the adequacy of intermediate outcomes and the possibility of further actions. This methodology had as positive outcomes: the reduction of the learned helplessness and resignation, the enhancement of an internal locus of control, the development of a traceable process monitoring that unifies the problem diagnosis phase and the solution implementation assessment, and the possibility to be used for evaluating work related stress.

Bruno, A., Bracco, F., & Sossai, D. (2012). Risk management from incident reporting to criticalities detection: a methodological proposal. A case study. 10th EAOHP Conference, Zurich 11th-13th April. PDF

Chi ha cura di chi cura? Un progetto sistemico di formazione e intervento in sanità secondo l’Approccio rogersiano

Gli operatori sanitari sono stati formati per raggiungere elevati livelli nelle prestazioni tecniche, nelle competenze specifiche della loro disciplina. Purtroppo questa eccellenza non è stata accompagnata da altrettanta formazione sul piano della relazione con l’utenza e, soprattutto, con le proprie emozioni. Le conseguenze più evidenti di tali lacune sono state riscontrate sul piano della cura del malato e della relazione con i familiari. Tuttavia è nostra opinione che ogni attività di cura debba essere preceduta da una cura dell’operatore stesso. Se sul piano clinico è obbligatorio che l’operatore sia addestrato (con la formazione) e protetto (con vaccini e dispositivi di protezione individuale), sul piano emotivo non si riscontra la medesima attenzione. Eppure i casi di operatori “feriti”, affaticati, difesi, svuotati, soli, arrabbiati, cinici o distaccati sono numerosi e purtroppo trascurati. Non si può stabilire una relazione di cura efficace se prima non si è avuta cura dell’operatore, non gli si sono dati gli strumenti emotivi, motivazionali e relazionali per costruire quella resilienza indispensabile nella professione sanitaria. Il progetto che presentiamo in questa sede è tuttora in corso e intende muoversi in tale direzione, ispirato dalle tre condizioni dell’approccio rogersiano. Si tratta di una formazione di tipo teorico-esperienziale rivolta a 4 livelli della ASL 2 savonese. Il primo livello è quello dello staff di dirigenza, ai quali è stato erogato un corso sulle competenze comunicative per imparare a gestire le relazioni e la comunicazione in modo più costruttivo ed efficace. A questo livello l’obiettivo è di sensibilizzare i vertici della dirigenza rispetto ai bisogni dei loro interlocutori, ai diversi vissuti e all’efficacia di una leadership di tipo partecipativo. Il secondo livello di formazione ha interessato i direttori di strutture complesse e i primari, per trasferire i fondamenti della comunicazione medico-paziente e della comunicazione interna all’équipe. A questo livello l’obiettivo fondamentale è stato quello di costruire un linguaggio comune e un terreno su cui progettare una disseminazione dei principi ai livelli più operativi. Infatti al termine di tale modulo formativo i direttori hanno convenuto sulla necessità di formazione dei facilitatori, ossia personale interno alla struttura che possa catalizzare quei processi comunicativi e relazionali funzionali al benessere, alla sicurezza di operatori e pazienti e all’efficacia del rapporto di cura. Il terzo livello ha quindi interessato i facilitatori, che hanno ricevuto una formazione approfondita sulle tre condizioni e sulle modalità più efficaci per gestire la relazione con i colleghi, i pazienti e i loro familiari. Un ulteriore aspetto, approfondito a questo livello, è quello della resilienza personale, ossia la capacità di gestire nel tempo un carico emotivo dato dalla specificità del lavoro sanitario e dalle condizioni fisiche, sociali e organizzative in cui si trovano ad agire gli operatori. Infine, il quarto livello sarà mirato agli operatori che forniscono assistenza domiciliare a malati cronici coni quali si instaura una relazione che talvolta fatica ad essere empatica e oscilla tra il distacco emotivo per autoprotezione, e il legame affettivo dato dalla lunga frequentazione, che sfocia però in dolore e lutto vista la natura degenerativa delle patologie trattate. Questo modulo si articola quindi a due livelli: dare agli operatori competenze di ascolto e di sostegno al paziente alla sua famiglia e dare anche strumenti per il monitoraggio delle proprie emozioni, dei vissuti, paure, fragilità, resistenze, al fine di arricchire la relazione senza caricare l’operatore di carichi emotivi che nessuno poi solleverà. L’intero progetto è impostato secondo i principi rogersiani delle tre condizioni e ha natura sistemica, ossia interessa tutti i principali livelli dell’organizzazione, dal direttore sino agli operatori sul territorio. L’obiettivo è la facilitazione, ossia il fornire agli operatori e ai lori dirigenti un linguaggio comune per trovare risorse e strategie interne verso l’obiettivo del benessere e della promozione della salute.

Bracco, F., Ferrara, P. (2012). Chi ha cura di chi cura? Un progetto sistemico di formazione e intervento in sanità secondo l’Approccio rogersiano. Presentazione al Congresso Nazionale dell’Istituto dell’Approccio Centrato sulla Persona – Messina, 15-17 giugno 2012. PDF

Improving resilience through practitioners’ well-being: an experience in Italian health-care

Abstract: Building and maintaining resilience in health care requires psychological and organizational attitudes that could be affected by the lack of worker well-being. Resilience requires the ability to give strong responses to weak signals, but, if well-being is threatened, workers are more committed to defend it, than detecting and monitoring weak signals in foresight. Malaise is a weak signal itself that, as well as leading to accidents due to fatigue, miscommunication, distraction, etc., blocks operators at a resource-saving cognitive level that prevents noticing and reporting further weak signals. We adopted the Skill-Rule-Knowledge model by Rasmussen as a framework to conceive resilience as continuous movement of workers along the three steps of the ladder. According to this model, we describe a research-intervention project carried out in a few Italian hospitals where trainees were enabled to develop a tool for detecting and monitoring malaise and threats to safety. Its potentials for reducing effects like distrust, resignation, cynicism, helplessness are discussed in light of a well-being-based resilience engineering.

Bracco, F., Bruno, A., & Sossai, D. (2011). Improving resilience through practitioners’ well-being: an experience in Italian health-care. In E., Hollnagel, E., Rigaud, & D., Besnard (eds.). Proceedings of the Fourth Symposium on Resilience Engineering, (pp. 43-49). Paris: Presses des Mines. PDF

Risk perception in the health care domain, between clinical risk and practitioners safety: a study among operating theatres practitioners

Objectives: Risk perception among operating theatres’ practitioners is investigated concerning both the relationship between personal safety and patients’ safety and the perception of causes of accidents.
Methods: A quantitative checklist of Incident Reporting has been used. It consisted in 13 items about clinical risks and 8 items about practitioners’ risks, considering injury frequency and seriousness, its causes and near misses. Participants were 139 and were recruited among physicians, surgeons, anesthetists, nurses of 14 operating theaters of a north Italian wide hospital.
Results: Spearman’s Rho index reveals mild positive correlations between injuries to operators and injures to patients concerning frequency (means = 0,10) and gravity (means = 0,22). The same trend is found for near misses involving operators and patients (r = 0,26); the perception of the frequency and severity of injuries (means = 0,54), and the frequency of accidents and near misses (means = 0,66). We notice also that injuries are positively associated with communication problems and the lack of personal protection devices. The personal and professional characteristics have a positive correlation with accident frequency in case of missed control of devices (correlation with age: r = 0,29; with job experience: r = 0,24). Age and expertise negatively correlate with the frequency of accidents in case of patient injury due to devices failures (r = 0,30 and 0,27 respectively).
Implications: Frequency and seriousness of the practitioners’ and the patients’ risks are positively correlated, and this relationship strengthens when also considering near misses. Communication problems and the absence of devices for personal protection seem to be the most probable causes of accidents, the first if injuries are very frequent, the second if injuries are serious. Professional experience seems to be linked with perceptions of accidents due to behavioural routines, while low surgical skills are correlated with perceptions of accidents due to lack of technical expertise or a scarce sensitivity to dangerous conditions.
Conclusions: These results suggest that the promotion of safety in operating theatres could concern both operators and patients, thanks to an organisational commitment investing in technical matters like personal protection devices to reduce the most frequent accidents (technical approach to safety), but to reducing severe accidents needs making actions at the level of staff management (social approach to safety), also considering age and expertise differences. This tool could be used as a link between organisational practices and the health and safety promotion culture.

Bruno, A., Bracco, F., Chiorri, C., Pugliese, F., Sossai, D., & Palombo, P. (2010). Risk perception in the health care domain, between  clinical risk and practitioners safety: a study among operating theatres practitioners. Talk given at the 9th Conference of the  European Academy of Occupational Health Psychology, Rome, 29-31 March.  PDF

Resilience engineering in Emergency Room operations: A theoretical framework

System resilience implies practitioners’ capacity to cope with unexpected events, i.e. cognitive resilience. To address it, we outline a framework based on the Skill-Rule-Knowledge model grounding it in the operators’ sensitivity to the variety that normally occurs in complex systems activities. This variety can contain hidden information enabling the organization to be proactive and to manage unexpected events. Each situation can be described with a SRK profile, according to the kind of cognitive processes necessary to control it. Operators’ reliability can therefore be analyzed by evaluating the match between their cognitive SRK profile and that demanded by the current situation. System resilience is ensured by the capacity of operators to: (i) choose the most suitable cognitive level; (ii) freely move along these levels according to the situation; (iii) be mindful towards variety; (iv) transfer their personal mindfulness into group dynamic adaptation. The outcome of these behaviors is a balance of mindfulness (constant attention to anomalous signals) and dynamic adaptation (organizational adjustment of existing rules according to the new information). This continuous equilibrium between chaos and order is the strategy followed by adaptive complex systems in order to evolve and can be successfully applied to high risk organizations to enhance the emergence of resilient behaviors.

Bracco, F., Gianatti, R., & Pisano, L. (2008). Resilience engineering in Emergency Room operations: A theoretical framework. Third Symposium in Resilience Engineering, Antibes, October 2008. Link