Why is staff safety a patient safety issue?

  • 3rd September 2020

Thursday 17 September 2020 marks the second annual World Patient Safety Day. The event was established at the 72nd World Health Assembly with overall objectives to “enhance global understanding of patient safety, increase public engagement in the safety of healthcare and promote global actions to enhance patient safety and reduce patient harm”.[1] The theme of this year’s event is ‘Health Worker Safety: A Priority for Patient Safety’.

It can be argued that staff safety has not been prioritised as it should have been in recent years. The Covid-19 pandemic has reinforced this. It has exposed risks to staff physical and mental wellbeing, with inadequate Personal Protective Equipment (PPE), intensely difficult physical and psychological working conditions, and, tragically, it has resulted in deaths from exposure to Covid-19 as a result of inadequate infection control.

At Patient Safety Learning, we believe that staff safety is intrinsically linked to patient safety.

Intrinsically linked: staff safety and patient safety

Patient safety focuses on avoiding preventable harm, making sure that all reasonable steps are taken to ensure safe care. It is very easy to see how staff safety leads to patient safety:

  • During the Covid-19 pandemic, staff, who had access to appropriate PPE helped prevent the risk of infection to both staff and patients.
  • Addressing the blame culture in health and social care benefits staff, enabling them to feel psychologically safe when speaking about incidents of unsafe care, near misses and sharing opportunities for improvement. This increases the likelihood that patient safety problems will be identified, reported and addressed.
  • Ensuring safe staffing levels helps avoid problems of burnout that directly impact on the wellbeing and health of staff. Over-stretched and exhausted staff leads not only to a decline in motivation but also to a decline in performance. This increases the risk to patient safety.

Six foundations of safer care

In our report, A Blueprint for Action, we set out what is needed to progress towards a patient-safe future.[2] Underpinned by systemic analysis and evidence, the report sets out six foundations for safer care and proposes practical actions to address them. When considering how we can improve staff safety in a way that complements patient safety, we can also look through the lens of these foundations:

  1. Shared Learning – as we aim to set and deliver goals for learning in patient safety, it would be complementary to share learning from unsafe patient and staff safety, as well as sharing good practice in both these areas.
  2. Leadership – the importance of overarching leadership for patient safety in health and social care is a key concept. Ensuring that leaders embed staff safety into safety programmes is essential.
  3. Professionalising patient safety – we argue that we need to develop organisational standards for patient safety performance, with all staff being suitably qualified and experienced to deliver safe care. We need to design health and social care systems for safety; patient and staff safety.
  4. Patient Engagement – encouraging and supporting the engagement of patients in patient safety is about co-producing safety improvements. We also need to engage staff more actively in safety improvements for the wellbeing of patients and their families.
  5. Data and Insight – we propose improvements to how we measure, report and assess patient safety performance. These improvements are equally necessary for staff safety.
  6. Just Culture – nurturing a culture in health and social care that eliminates blame and fear and encourages reporting of and addressing problems would serve to improve both staff and patient safety.

While it is not possible to cover the whole range of staff safety issues in one blog, over the next four sections we will look in more detail at some of the key aspects of this and outline how making progress in these areas is intertwined with improving patient safety.

Physical safety

The risk posed by Covid-19 in health and social care settings has emphasised the importance of the physical safety of staff in health and social care. This is important both in terms of its impact on patient safety, limiting the risk of passing on infection, and also the serious consequences for staff themselves. A recent report from Amnesty International highlighted the significant number of deaths of health and social care workers around the world resulting from the pandemic.[3]

One area of focus has been the availability of PPE. In the UK, staff working in certain settings, such as ambulances, found it more difficult to access appropriate PPE than colleagues in other settings, such as emergency departments.[4] Subsequently, differences between sectors have been highlighted, with staff in social care having had more difficulty accessing the correct PPE than staff working in healthcare.[5]

Not having the correct PPE during a pandemic obviously increases the risk both to the staff involved and the patients they treat. On our patient safety learning platform, the hub, we have highlighted staff experiences of this, such as a midwife speaking about her concerns about cross contamination and a Macmillan specialist nurse discussing the need for greater transparency around PPE requirements.[6]

We have also seen concerns, raised during the pandemic, about the potential for hospital acquired infections, with staff citing their fears about the impact this may have on them, their patients and their families.[7] Related to this have been issues around staff not having access to testing. This, again, threatens both staff safety and patient safety, where those involved could be put at increased risk, along with those they are caring for.

As we continue to live with Covid-19, ensuring we take action to protect the physical safety of health and social care staff will need to be a key priority to ensure patient and staff safety is not jeopardised.

Safe staffing levels

The NHS states that “ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm”.[8] It is about having the right numbers of staff, with the right skills, in the right place at the right time.[9]

For staff, ensuring safe staffing levels is intimately connected not just with being able to perform their job to the best of their ability, but also their own personal welfare. Insufficient staffing can result in them being unable to do basic things such as stay hydrated, eat and use the toilet, which takes both a physical and emotional toll over time.[10] On the hub, we have shared staff experiences about unsafe staffing.[11]

The current climate has the potential to exacerbate these issues, with concerns about staff being even more at risk of burnout, especially those who have been working through the Covid-19 pandemic.[12] In planning for the recovery of service post-covid, issues of staff wellbeing need to be built into workforce planning, rather than only being considered “if there was a staffing issue or high sickness, or even more cynically, a poor outcome in survey results”.[13]

A wide body of research highlights the negative impacts on patient outcomes as a result of insufficient staffing levels.[14] In addition, reports into major patient safety scandals, such as the Francis report on the Mid-Staffordshire NHS Foundation Trust, make clear links between patient safety incidents and safe staffing levels.[15] It is obvious that this is a key issue for improving both the safety of staff and patients.

Psychological safety

“a belief that the workplace is safe for speaking up, with ideas, questions, concerns and even mistakes, and it’s a sense of confidence that your voice is valued”[16]

Psychological safety is essential in providing the conditions required to effectively tackle incidents of unsafe care.[17] In the absence of this, organisational cultures that seek to assign blame when things go wrong make patient harm more likely to happen again.[18] This is because such cultures incentivise people to cover up mistakes, rather than reporting them, and often single out individuals for blame when incidents may have a systemic cause, thus failing to address the underlying problem.[19]

There has been much literature on the importance of psychological safety in the workplace and its role in contributing to improvements in patient safety. Despite this, embedding psychologically safe workplace cultures remains a major challenge.

On the hub we’ve shared the views of NHS staff who have expressed concerns that a "Just Culture approach is spoken about but is not demonstrated or welcomed when concerns are raised".[20] Connected with this are concerns about bullying, with instances of staff being reprimanded by senior colleagues when raising legitimate safety concerns.[21] [22] These concerns are evident when looking at the most recent NHS Staff Survey, where approximately 160,000 out of 569,400 respondents stated that they did not feel secure raising concerns about unsafe clinical practice.[23]

At Patient Safety Learning, we see these challenges in the way people interact with the hub. We regularly see a reluctance from staff in sharing examples of good practice, as well as concerns about unsafe care. Even when documents are anonymised to shield the identity of those involved, these concerns continue to weigh heavily. Staff express their fear that they will be ‘found out’ and do not have permission to share good practice. Staff not feeling safe to speak up and to share learning presents a serious barrier to improving patient safety.

We argue that, though the knowledge and stated commitment is available to create the conditions for psychological safety in health and social care, implementing it remains a huge challenge. Blame culture is deeply embedded in many organisations. Patient Safety Learning believes there needs to be concerted efforts by every health and social care organisation to develop and publish goals for culture change; that these are measured and monitored, and that best practice is shared widely. System and organisational leaders need to recognise the criticality of psychological safety as part of a Just Culture. And act accordingly.

Support to staff after patient safety incidents

Another aspect of staff safety which is closely intertwined with patient safety is the importance of providing emotional support to health and social care staff who are involved in patient safety incidents. Dr Albert Wu coined the term ‘second victim’ support to describe this, and while the appropriateness of this phrase is a point of debate, recognising the need for this support is important to patient safety.[24]

Such incidents can have a significant impact on the professional involved, many of whom may experience “intense feelings of incompetence, inadequacy or guilt after a medical error”.[25] Therefore, in the first instance, ensuring that this type of support is available would have an obviously beneficial impact on the health and wellbeing on the person involved.

Having access to such support is also closely interlinked with, as previously mentioned, creating the conditions for psychological safety in health and social care. Having support in place can help to foster an environment of openness; one of talking about patient safety and, consequently, supporting a culture of learning from patient safety incidents.[26]

Support systems for staff involved in incidents of unsafe care are not uniform across health and social care. At Patient Safety Learning, we believe that greater investment in such schemes would have a positive impact on encouraging reporting and learning from patient safety incidents. How many organisations adopt, as a matter of course, the NHS Improvement A just culture guide (previously published by the National Patient Safety Agency as the Incident Decision Tree)?[27]

We are sharing on the hub examples of good practice, such as the Safety Incident Support Our Staff (SISOS) scheme at Chase Farm Hospital.[28] We welcome more toolkits, resources and other examples of good practice to share on the hub.

Healthcare Worker Safety: A Priority for Patient Safety

The relationship between staff safety and patient safety is a symbiotic one, where improvements made in one area can benefit the other. As staff safety is the focus of this year’s World Patient Safety Day, over the course of the next few weeks Patient Safety Learning will be raising awareness of, and promoting action for, staff safety in the following ways:

  1. On the hub, we will publish interviews with staff from across the health and care system. By sharing the unique insights and experiences of the different experts we speak to, we will highlight the key issues in staff safety, draw common themes, share and promote good practice, and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe.
  2. We will hold an interactive workshop-style event for staff on 7 September. This innovative ’Whose Shoes’ model will allow participants to come together and explore scenarios related to staff safety and explore the impact these also have on patient safety. We will publish a video on 17 September, World Patient Safety Day, highlighting these discussions, what more we collectively need to do and how this will inform our work around staff safety and patient safety.

Do you have your own insights to share around staff safety? For example, do you see a lack of focus on staff safety in your own workplace? If so, how does this impact patient safety? Have you experienced or are you planning measures to help keep staff safe? Please share your thoughts with us on the hub or send us an email if you’d like to speak to us about sharing your story, which you can do so anonymously if you prefer.

[1] World Health Organization, World Patient Safety Day, Last Accessed 21 August 2020. https://www.who.int/patientsafety/world-patient-safety-day/en/

[2] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409

[3] The report states that in the UK there have been 540 deaths of health workers from COVID-19 (including 262 social care workers. Amnesty International, Exposed, Silence, Attacked: Failures to protect health and essential workers during the COVID-19 pandemic, 13 July 2020. https://www.amnesty.org/download/Documents/POL4025722020ENGLISH.PDF

[4] Patient Safety Learning, Coronavirus preparations – Questions for the Health and Social Care Select Committee, 25 March 2020. https://www.patientsafetylearning.org/blog/coronavirus-preparations-questions-for-the-health-and-social-care-select-committee

[5] Patient Safety Learning, Covid-19 and social care: we must act now to ensure patient safety, 14 April 2020. https://www.patientsafetylearning.org/blog/covid-19-and-social-care-we-must-act-now-to-ensure-patient-safety; The Guardian, Residential homes ‘desperate’ for PPE, as two care workers die, 6 April 2020. https://www.theguardian.com/society/2020/apr/06/residential-homes-desperate-for-ppe-as-two-care-workers-die

[6] Anonymous, Midwifery during COVID-19: A personal account, Patient Safety Learning’s the hub, 21 April 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/midwifery-during-covid-19-a-personal-account-r2095/; Martin Hogan, Safety culture during a pandemic: a nurse's perspective, Patient Safety Learning's the hub, 1 June 2020. https://www.pslhub.org/learn/improving-patient-safety/safety-stories/safety-culture-during-a-pandemic-a-nurse%E2%80%99s-perspective-r2311/

[7] Claire Cox, COVID-19: what are you wearing? Working in a soup of droplets, Patient Safety Learning’s the hub, 26 March 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/covid-19-what-are-you-wearing-working-in-a-soup-of-droplets-r1919/; Anonymous, Further serious patient safety incidents: why are staff still not being listened to when concerns are raised?, Patient Safety Learning’s the hub, 23 June 2020. https://www.pslhub.org/learn/culture/whistle-blowing/further-serious-patient-safety-incidents-why-are-staff-still-not-being-listened-to-when-concerns-are-raised-r2467/

[8] NHS England and NHS Improvement, Safe Staffing, Last Accessed 24 August 2020. https://www.england.nhs.uk/ourwork/safe-staffing/

[9] Royal College of Nursing, Safe and Effective Staffing: Nursing Against the Odds, 2017. https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2017/september/pdf-006415.pdf

[10] Ibid.

[11] Anonymous, What it feels like working with unsafe staffing, Patient Safety Learning’s the hub, 1 October 2019. https://www.pslhub.org/learn/improving-patient-safety/stories-from-the-front-line/florence-in-the-machine/what-it-feels-like-working-with-unsafe-staffing-r688/

[12] Pulse Today, Health committee launches inquiry into NHS staff burnout, 3 August 2020. http://www.pulsetoday.co.uk/news/health-committee-launches-inquiry-into-nhs-staff-burnout/20041269.article; Farzan Sasangohar et al, Provider Burnout and Fatigue During the COVID-19 Pandemic: Lessons Learning From a High Volume Intensive Care Unit, Anesthesia and analgesia Vol. 131. 1, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173087/

[13] In this blog Even Mitchell discusses what needs to be done as we plan for a recovery post-covid in terms of the healthcare workforce: Eve Mitchell, What’s the plan?, Patient Safety Learning’s the hub, 17 June 2020. https://www.pslhub.org/learn/coronavirus-covid19/lockdown-exit-strategies/what%E2%80%99s-the-plan-r2430/

[14] Anne Marie Rafferty, Research proves we need safe staffing, RCN Bulletin, 23 July 2019. https://www.rcn.org.uk/magazines/bulletin/2019/august/qa-research-behind-safe-staffing-aug-2019; National Quality Board, Safe, sustainable and productive staffing: An improvement resource for maternity services, January 2018. https://improvement.nhs.uk/documents/1353/Safe_Staffing_Maternity_final_2.pdf; National Institute for Health and Care Excellence, Safe staffing for nursing in inpatient mental health settings, Last Accessed 22 August 2020. https://www.nice.org.uk/guidance/gid-sgwave0701/documents/safe-staffing-for-nursing-in-inpatient-mental-health-settings-final-scope2

[15] Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf

[16] Amy Edmonson, The importance of psychological safety, The Kings Fund, 5 August 2020. https://www.kingsfund.org.uk/audio-video/importance-psychological-safety

[17] There is a significant body of research on the importance to patient safety of creating a Just Culture in healthcare, which considers systematic issues when things go wrong and staff feel able to speak up without fear of retribution. We have collated a number of resources on this respect on Patient Safety Learning’s the hub: https://www.pslhub.org/learn/culture/

[18] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409

[19] Ibid.

[20] Anonymous, We all want a culture of speaking up, don’t we? So, why isn’t it happening?, Patient Safety Learning’s the hub, 22 June 2020. https://www.pslhub.org/learn/culture/bullying-and-fear/we-all-want-a-culture-of-speaking-up-don%E2%80%99t-we-so-why-isn%E2%80%99t-it-happening-r2318/

[21] Ibid.

[22] You can find more articles on the impact of bullying on patient safety on Patient Safety Learning’s the hub: https://www.pslhub.org/learn/culture/bullying-and-fear/

[23] These estimates related to a question in the NHS Staff Survey, 28.3% of respondents answered that they would not feel secure raising concerns about unsafe clinical practice. In a separate question asking whether their organisation treats staff who are involved in an error, near miss or incident fairly, 40.3% answered negatively. NHS Staff Survey Results, Results Summary 2019, Last Accessed 18 February 2020. http://www.nhsstaffsurveyresults.com/homepage/results-2019/; Patient Safety Learning, Results of the NHS Staff Survey 2019, 18 February 2020. https://www.patientsafetylearning.org/blog/results-of-the-nhs-staff-survey-2019

[24] Albert Wu, Medical error: the second victim, BMJ 320:726, 2000. https://www.bmj.com/content/320/7237/726; Stephen Shorrick, The Real Second Victims, 4 December 2018. https://humanisticsystems.com/2018/12/04/the-real-second-victims/; Melissa Clarkson, Helen Haskell, Carole Hemmelgarn and Patty Skolnik, Abandon the term “second victim”, BMJ 364:I1233, 2019. https://www.bmj.com/content/364/bmj.l1233

[25] S D Scott et al, The natural history of recovery for the healthcare provider “second victim” after adverse patient events, BMJ Quality & Safety: Volume 18 Issue 5, 2009. https://qualitysafety.bmj.com/content/18/5/325

[26] Donna Willis, Joanne Yarker and Rachel Lewis, Lessons for leadership and culture when doctors become second victims: a systematic literature review, BMJ Leader: Volume 3 Issue 3, 2019. https://bmjleader.bmj.com/content/3/3/81

[27] NHS England and NHS Improvement, A just culture guide, Last updated 14 December 2018. https://improvement.nhs.uk/resources/just-culture-guide/

[28] Carol Menashy, Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital, Patient Safety Learning’s the hub, 27 November 2019. https://www.pslhub.org/learn/culture/second-victim/safety-incident-supporting-our-staff-sisos-a-second-victim-support-initiative-at-chase-farm-hospital-r997/

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