‘Balancing risk, that is my life’: The politics of risk in a hospital operating theatre department

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

Managing ongoing swallow safety through information-sharing: An ethnography of speech and language therapists and nurses at work on stroke units

BACKGROUND

Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made.

AIMS

To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units.

METHODS & PROCEDURES

An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation.

OUTCOMES & RESULTS

An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information-sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed.

CONCLUSIONS & IMPLICATIONS

This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7-day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it.

WHAT THIS PAPER ADDS

What is already known on the subject It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work? Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.

Patient safety and professional discourses: implications for interprofessionalism

Patient safety has been presented as a unifying concern across the health professions. This conceptual connection has been accompanied with efforts towards standardized, interprofessional safety competencies, as well as increased attention towards interprofessional education for systems improvement. Despite numerous program initiatives and research endeavors, progress towards improving patient safety in hospitals is viewed as disappointingly slow. This paper adds to a body of literature that suggests patient safety remains a difficult problem to solve because safety is not simply a technical issue, but is a practice embedded in organizational and professional contexts. In this paper, we explore the differences between the professions, as different professional groups intersect with the ways patient safety is thought about, talked about, and known about in an acute care hospital in Canada. We draw on findings from a critical discourse analysis of documents related to patient safety, as well as transcripts from interviews from (a) formal health care leaders and (b) practicing clinicians from medicine, nursing, occupational therapy, physiotherapy, and social work. This analysis suggests implications for the way different professions may or may not work with one another in the service of patient safety.

Variations in risk perceptions: a qualitative study of why unnecessary urinary catheter use continues to be problematic

BACKGROUND

Catheter associated urinary tract infection (CAUTI) is one of the most commonly acquired health care associated infections within the United States. We examined the implementation of an initiative to prevent CAUTI, to better understand how health care providers' perceptions of risk influenced their use of prevention practices and the potential impact these risk perceptions have on patient care decisions. Understanding such perceptions are critical for developing more effective approaches to ensure the successful uptake of key patient safety practices and thus safer care for hospitalized patients.

METHODS

We conducted semi-structured phone and in-person interviews with staff from 12 hospitals. A total of 42 interviews were analyzed using open coding and a constant comparative approach. This analysis identified "risk" as a central theme and a "risk explanatory framework" was identified for its sensitizing constructs to organize and explain our findings.

RESULTS

We found that multiple perceptions of risk, some non-evidence based, were used by healthcare providers to determine if use of the indwelling urethral catheter was necessary. These risks included normative work where staff deal with competing priorities and must decide which ones to attend too; loosely coupled errors where negative outcomes and the use of urinary catheters were not clearly linked; process weaknesses where risk seemed to be related to both the existing organizational processes and the new initiative being implemented and; workarounds that consisted of health care workers developing workarounds in order to bypass some of the organizational processes created to dissuade catheter use.

CONCLUSIONS

Hospitals that are implementing patient safety initiatives aimed at reducing indwelling urethral catheters should be aware that the risk to the patient is not the only risk of perceived importance; implementation plans should be formulated accordingly.

Informal risk assessment strategies in health care staff: an unrecognized source of resilience?

RATIONALE

Recent reports indicate that approximately 10% of in-patients in UK hospitals are involved in an adverse event (these reports also state that 50% of these events are preventable). This is indeed a worrying finding, and indicates the need to look at how these incidents are handled or indeed, what is done to minimize their occurrence. The Department of Health, via the National Patient Safety Agency (NPSA) published a guide which is aimed at encouraging accurate reporting, learning from past events and changing the attitudes of key stakeholders (healthcare managers, frontline staf etc) towards risk taking and risk management.

AIMS AND OBJECTIVES

Our aim was to compare informally-learned and used risk assessment strategies volunteered by staff with the 'how to do it' guide published by the NPSA. We have compared each step of the NPSA guide with our empirical data relating to that activity.

METHODS

We interviewed forty-eight healthcare professionals (doctors from several specialties; nurses from a variety of settings; and an array of allied healthcare professionals). We used semi-structured interviews in order to discuss participants' views on their everyday working life, working relationships and patient safety.

RESULTS

Our results indicate that healthcare professionals develop their own unique way to approach the issue of patient safety and risk, based on their professional raining, seniority and role within the hospital. They did share the conviction that frontline and support staff need to have immediate and easy access to information about past adverse events. They see this as a powerful tool in minimizing the reoccurrence of the same errors/problems, as well as a vehicle to improve staff morale by feeling valued and having their opinion heard.

CONCLUSIONS

We believe that patient safety and welfare can benefit from the adoption of a more flexible and person-centred approach to how risk assessments are carried out. Enriching formal guidelines such as the 'Risk Assessment made easy' document with successful techniques and strategies which healthcare staff have informally developed has the potential to not only improve patient safety (since it will be based on the accumulated experience and knowledge of such staff) but also foster higher levels of self esteem amongst healthcare professionals.

Understanding culture and culture management in the English NHS: a comparison of professional and patient perspectives

RATIONALE AND OBJECTIVES

The growing interest in patient-focused health care in the National Health System (NHS), especially in the wake of high-profile failures in clinical practice, has underlined the need to involve patients in the design and evaluation of organizational change management programmes at the local level. This includes an evaluation of the relevance of culture and how culture might be assessed and managed in the delivery of high-quality and safe care. The purpose of this study is to compare and contrast the perspectives of health care professionals and patient representatives on purposeful attempts to manage culture change in the English NHS.

METHODS

We used the mixed approach, but with more quantitative than qualitative data. A postal questionnaire survey of clinical governance leads and patient representatives from 276 NHS trusts was followed up with a focus group discussion of eight of the survey participants and semi-structured interviews with 18, including health care professionals and patient representatives from various organizations. We used spss to analyse the survey data and Atlas.ti to analyse the qualitative data.

RESULTS AND CONCLUSIONS

Both clinical governance leads and patient representatives considered culture management and change to be integral to quality and safety improvement efforts. However, clinical governance leads were more positive than patient representatives about anticipated results from ongoing efforts to manage culture change at the local level. Further, in spite of general agreement on various attributes for culture assessment efforts, there was a striking difference in the level of importance respondents attached to blame free (more important to clinical governance managers) and customization (more important to patient representatives).

Shifting the sterile processing department paradigm: a mandate for change

Sterile processing department (SPD) staff members have the difficult task of processing complicated instrumentation, containing costs, and managing limited resources; and how they face these challenges has a direct effect on patient care. Recent technological advances require SPD staff members to be more knowledgeable about what instrument trays are used together and the conditions in which they are used to help prevent costly delays in processing. This article explores how one health care system was successful in facing these challenges by implementing a solid orientation and education program.

A culture of safety or coping? Ritualistic behaviours in the operating theatre

OBJECTIVES

The creation of a 'safety culture' is a health services priority, yet there is little contemporary research examining the tacit, customary practices that relate to clinical risk. This paper investigates how the ritualistic behaviours of surgeons and anaesthetists serve to normalize risks within the operating theatre, thereby inhibiting organizational learning and enabling such risks to recur.

METHODS

A two-year ethnographic study in the operating department of a large teaching hospital in the north of England, including observations of the organizational and clinical setting and interviews with 80 members of staff.

RESULTS

Three ritualistic types of behaviour are identified and described. Each illustrates the taken-for-granted assumptions associated with clinical risk in the operating theatre and is characterized by a patterned response to risk, the first being to tolerate and endure risk, the second being to accommodate risk through slight modifications to clinical practice and the third being to innovate or implement unorthodox practices to control for risk.

CONCLUSION

These ritualistic behaviours normalize risk within the operating theatre leading to the possibility that some threats will escape appropriate attention and may lead to patient harm. These culturally scripted behaviours also encourage a short-term reactive response to risk that emphasizes the importance of individual coping rather than the more systemic forms of learning associated with participation in incident reporting. This research extends and elaborates upon the current policy orthodoxy to better understand the cultural context of patient safety.