Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care

Effects of the Interaction Between Time-on-Task and Task Load on Response Lapses

To investigate the interaction effects of prolonged working periods and different task loads on response lapses, focusing on the mechanisms of delayed responses and error lapses. Professionals such as pilots, truck drivers, and nurses often face extended work hours and fluctuating task loads. While these factors individually affect performance, their interaction and its impact on response lapses remain unclear. Twenty participants completed the Uchida-Kraepelin (U-K) Psychological Test and a dual-task version with functional near-infrared spectroscopy. Independent variables were time-on-task and task load. Dependent variables included measures of fatigue, arousal, workload, task performance (delayed and error rates), and brain functional connectivity. Both time-on-task and task load significantly affected cerebral connectivity, response lapses, workload (frustration level), fatigue, and arousal. Arousal levels significantly decreased and reaction times increased after 60 min of work. Cognitive resource regulation became challenging after 90 min under high task load levels. A decline in the connection between the prefrontal and occipital cortex during high-load tasks was observed. The findings provide insight into the mechanisms of response lapses under different task load levels and can inform strategies to mitigate these lapses during extended work periods. This study's findings can be applied to improve work schedules and fatigue management in industries like aviation, transportation, and healthcare, helping reduce response lapses and errors during extended work periods under high task load conditions.

Restorative Just Culture: An Exploration of the Enabling Conditions for Successful Implementation

BACKGROUND/OBJECTIVES

Restorative responses to staff involved in incidents are becoming recognized as a rigorous and constructive alternative to retributive forms of 'just culture'. However, actually achieving restoration in mostly retributive working environments can be quite difficult. The conditions for the fair and successful application of restorative practices have not yet been established. In this article, we explore possible commonalities in the conditions for success across multiple cases and industries.

METHODS

In an exploratory review we analysed published and unpublished cases to discover enabling conditions.

RESULTS

We found eight enabling conditions-leadership response, leadership expectations, perspective of leadership, 'tough on content, soft on relationships', public and media attention, regulatory or judicial attention to the incident, second victim acknowledgement, and possible full-disclosure setting-whose absence or presence either hampered or fostered a restorative response.

CONCLUSIONS

The enabling conditions seemed to coagulate around leadership qualities, media and judicial attention resulting in leadership apprehension or unease linked to their political room for maneuver in the wake of an incident, and the engagement of the 'second victim'. These three categories can possibly form a frame within which the application of restorative justice can have a sustainable effect. Follow-up research is needed to test this hypothesis.

Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives

INTRODUCTION

Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media.

METHODS

Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis.

RESULTS

Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills.

CONCLUSIONS AND IMPLICATIONS

This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

External inspection approaches and involvement of stakeholders' views in inspection following serious incidents - a qualitative mixed methods study from the perspectives of regulatory inspectors

OBJECTIVE

The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection.

METHODS

Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data.

RESULTS

Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes.

CONCLUSIONS AND IMPLICATIONS

Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals

BACKGROUND

Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability.

METHODS

A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work.

CONCLUSIONS

The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.