Royal Free Hampstead NHS Trust The Human Issues: -Why Exposures Happen -Responding to Reduce Distress Barbara Wren, C.Psychol. Occupational Health Psychologist Royal Free Hampstead NHS Trust

Why Do Exposures Happen? Individual Level Explanations: Knowledge Confidence Skill/Competence Stress/anxiety Internal factors- inattention, forgetfulness, carelessness Fatigue Solution=teach, train, motivate, (punish) Person – centred approach suits management agenda (isolate cause=no change)

Problems with Individual Level Explanations The best people can make the worst mistakes Errors are not random but fall into recurrent patterns Local human error = last, least easily managed part of casual sequence

Why Do Exposures Happen? (2) Team/group level explanation Communication Leadership Modelling safe practice Team-working Role clarity Learning Culture of team Solution= teach, train, motivate,( punish)

Why Do Exposures Happen?(3) System Level Explanations Errors = result of “upstream systemic factors” Organisational strategy, culture, management attitudes to risk and uncertainty Organisational Culture: safety vs. blame Information as a Learning Resource Integration of risk management into management structure

How Human Error Contributes to System Failure All organisations create barriers btwn source of hazard and potential victims/losses Human elements weaken or strengthen by  Active failures “unsafe acts”  Latent conditions arise from fallible decisions often taken by those not directly in the workplace, lie dormant, combine with trigger event = incident.

Latent Conditions High workload and fatigue Inadequate knowledge, ability,experience Poor equipment design Inadequate supervision & instruction Rapid change

Latent Conditions (ctd) Poor morale Macho culture Poorly expressed rules Lack of integrated safety culture

Active Failures and Latent Conditions Active failures hard to predict Latent conditions are always present, can be identified and removed BUT Call for change in culture or management attitudes and beliefs

Culture Change to Reduce Error Raise awareness of cost of risk Educate clinicians about their role in risk management Focus on near misses as well as actual incidents Ensure concerns can be reported without fear

Culture Change to Reduce Risk (ctd) Use external input to stimulate learning Effective communication & feedback to frontline staff High profile lead and personal commitment of senior clinicians A strong organisational culture for dealing with the findings of reviews of adverse events

The Way Forward Unified mechanisms for reporting and analysis of mistakes and near misses. A more open learning culture Mechanisms to translate learning into practice Wider appreciation of the value of the systems approach An Organisation With a Memory, DoH, 2000

Factors influencing Distress after Exposure Whose responsibility? (guilt, anger with self/others) Immediate/longer term consequences for self: –anxiety –uncertainty –health, –career, –relationships, –the “hoped for” future

Factors influencing Distress after Exposure (ctd) Immediate and longer term consequences for others: partner family Ability to manage anxiety & uncertainty Tolerance of side effects of prophylaxis

Providing Initial Psychological Support Listen to fears Communicate understanding Normalise reactions Check for information needs

Providing Initial Psychological Support Prepare for emotional impact, & for physical side effects of treatment Challenge thinking e.g, catastrophising Discuss stress/anxiety management

Possible Emotional Impact High emotion – eg tearfulness Hyperarousal Rumination Nightmares Shock and disbelief Irritability Emotional numbing Avoidance Guilt Anger

Issues to Consider in Planning Support Current life situation Previous coping style Social support Personal and social resources Psychological resources Current psychological state Impact on, and likely reaction of, partners, family etc.

Factors Influencing Coping Understanding and interpretation of the threat (appraisal, assumptions and beliefs) Ongoing stressors Coping strategies used Availability of social support Self-efficacy

What helps? Providing information sensitively Supporting problem solving, positive re- appraisal, & information-seeking coping Promoting self-efficacy Help to access opportunities to discuss fears and feelings Linking support provided to “the meaning of the exposure” for the individual