Such care involves providing empathy and support, but it also requires advance preparation, discussions and participation in learning processes after an event, in addition to a conscious effort to restore trust and relationships. Many of the same elements are important for patients, users and relatives on the one hand, and employees on the other.
Compassionate leadership and culture are essential. Without this cornerstone, any measures will not have the intended effect. At the same time, good care will build a more open and learning culture. This will then help to reduce the number of patient injuries and other adverse events.
Structure of the guide
The guide comprises three main parts:
- caring for patients, users and relatives
- caring for health care professionals and other employees
- compassionate leadership and culture
The chapters in each part start with an explanation of why a particular topic is important, based on research and experience-based knowledge, and end with practical tools that show how it can be done. At the end of this summary is an overview of the practical tools and models in this guide.
The introductory chapter describes the background for the work on this topic. Excellent work is done by the health and care services; however, adverse events are unfortunately still too common, and not everyone who is affected finds themselves being properly cared for afterwards. In addition to such practical challenges and research-based justifications, new directive plans have been issued both in Norway and by the World Health Organization (WHO). These plans emphasize an open, learning and safe culture, which encompasses psychological safety, in the efforts to ensure patient safety, and the participation by those involved in adverse events.
A description of method and process is found in the final chapter. This guide is the result of a preliminary project and a main project with broad participation carried out by the Norwegian Directorate of Health. The knowledge model that underpins the guide includes research knowledge, experience-based knowledge, and user participation. It encompasses systematic review studies and literature searches, and participation in both working and reference groups by a large number of representatives from the health and care services, professions, user organizations, academia and other bodies.
Part 1 – Caring for patients, users and relatives
Care starts before an adverse event has even occurred, with good dialogue and the clarification of expectations when meeting with patients, users and relatives. This is necessary for ensuring user participation, and it can in addition ease dealing with handling an adverse event, should it occur. If an adverse event does happen, open acknowledgement and an expression of regret are vital. Adverse events can affect those involved for a long time afterwards – physically, mentally, socially and financially. Without acknowledgement, expression of regret and confirmation that those in charge are taking responsibility, patients, users and relatives may experience a double breach of trust.
This guide distinguishes between an expression of regret and an apology. Until the circumstances have been clarified, an apology should not be made. If a flaw is confirmed, it is very important that those affected receive a sincere apology. Chapter 3 specifies the elements of a sincere apology, and what characterizes poor or pseudo-apologies. This chapter also discusses the perspective known as the restorative approach. It emphasizes the rebuilding of relationships and trust between the service provider and those affected, which in turn contributes to the restitution of mental health.
The people affected want to help ensure that what they have been through does not happen again. This is an important reason for involving patients, users and relatives in the review of the event, learning and improvement work. It is also necessary to get their perspectives to obtain a complete picture of what happened, as noted by the WHO and the Norwegian Board of Health Supervision, in order to prevent recurrences of adverse events. The persons affected should be given alternative forms of participation and safe conditions in which to take part.
It is normal to react to unexpected and adverse events, and most reactions will pass without intervention. For patients, users, relatives and employees alike, the principle of "watchful waiting" gives important guidance. This entails monitoring how people are doing and taking action if needed. This approach and the roles involved in follow-up are explained in more detail in Chapter 5.
Part 2 – Caring for employees
Good care starts with preparing employees for the eventuality that adverse events may happen, and how they can handle them, support their colleagues, and talk to patients, users and relatives. Existing meeting arenas and specific educational initiatives can be used to raise the level of competence, while at the same time avoiding stigmatization, which often ensues from involvement in an adverse event.
Follow-up after an adverse event should be done systematically, with clear roles and responsibilities. Caring for employees is based on five basic principles for responding to people in crisis, and is summarized in Chapter 2 in a ten-point list, divided into an acute phase and a follow-up phase. Instead of psychological debriefing, psychological first aid and learning debriefs are recommended.
Support from colleagues is what is most important for employees following an adverse event. The benefits of formalizing peer support include that it helps ensure everyone has a colleague whom they can talk to, that it demonstrates the organisation’s support, and that it can promote culture change. This does not mean that the peer support programs need to be complicated. Chapter 3 on peer support discusses several possible options, as well as professional sparring and ethical reflection, and presents experiences with and efficacy studies of peer support.
Involving employees in reviews of adverse events is important in order to obtain their perspective and elucidate the incident. The chance to contribute to improving services and preventing that similar incidents are not repeated also promotes the employees’ processing of the event and restoration of a sense of mastery. Reviews of events should start as part of the everyday work, with reviews of minor incidents – and ideally also good experiences – and include a repertoire of methods. Chapter 4 presents a number of relevant methods.
Part 3 – Leadership and culture
The chapter entitled “Culture of psychological safety, openness and learning” expands on important qualities of a culture that safeguard both employees and patient safety. It describes the grounding in both policy and the literature, and how a positive culture can be developed in practice.
Psychological safety is a key factor. There are many conditions that can inhibit psychological safety: expectations of infallibility, hierarchy, focus on the individual rather than the system, and incivility. To overcome these obstacles, it is necessary to adopt a learning and system perspective on adverse events, and to strive for equitable, respectful and inclusive environments.
Leadership as a topic is discussed in light of both cultural leadership and caring leadership. Caring leadership is based on Michael West’s principles of compassionate leadership, and on a framework for promoting psychological safety for leaders developed by Amy Edmondson. Both formal and informal leaders, such as those with considerable experience in the discipline, play pivotal roles in developing culture and demonstrating compassion in the health and care services.
Overview of practical tools and figures
| Chapter | Practical methods, concretizations and tools | Figures, flowcharts, models, and tables |
|---|---|---|---|
Background |
|
| Flowchart with holistic perspective on care relating to adverse events |
Part 1 | 1 | Information – Dialogue – Four good habits – What’s important to you? – Teach-back – Shared decision-making |
|
| 2 | Determining who should hold conversations – Checklist for conversations– Contact person, with example form | Four-field table for who should hold converations
Escalation model for reporting adverse events |
| 3 | The elements of a sincere apology – | Flowchart for follow-up of patients, users, and relatives |
| 4 | Alternative forms of participation – Psychologically safe conditions |
|
| 5 | Roles in the follow-up – Possible delayed reactions |
|
Part 2 | 1 | Use of existing arenas – Example of seminar content – Local specification of incidents that should be reported |
|
| 2 | Roles and responsibilities - Five fundamental principles - A ten-point list for follow-up | Table showing the difference between psychological first aid, psychological debrief and learning debrief
Flowchart for follow-up of employees |
| 3 | Buddy system – Peer support role – Peer support team – Expert resources – Peer support in professional associations – Professional sparring – Ethical reflection |
|
| 4 Involvement in learning and improvement | Plus-minus – The green cross – TALK – After Action Review – Morbidity and mortality meetings – Incidents worth learning from – Simplified incident analysis – Incident analysis – Examples of organisational learning and changes/improvements following learning reviews | Figure with repertoire of methods for reviewing events |
Part 3 | 1 | Cultural leadership bullet list – Cultural development measures – Simulations – Assessments | Model for the link between culture with psychological safety and employee well-being and engagement, and patient safety and quality
Table showing cultural dimensions that inhibit or promote psychological safety, openness and learning |
| 2 | Compassionate leadership operationalized | Table showing the leader’s toolbox for psychological safety |