1. Medical Professionalism: Developing a serious game ‘PlayDecide’ to encourage junior hospital doctors to speak about and report safety concerns DR. MARIE WARD & PROF. EILISH McAULIFFE, Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin KAREN EGAN, Patient Representative, Patient and Public Involvement in Healthcare at HSE

2. Imbuing Medical Professionalism in relation to Safety (IMP-S) Funded under MERG by: Project Partners include:

4. Culture Change Improvements in aviation safety have come partly from a change in culture: – Blame No blameJust culture What is needed in healthcare is an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information i.e. a just culture (Reason, 1997). Break ‘culture of silence’ (Francis Report, 2015).

5. Requires a different view of human role…

6. To improve safety Staff must be supported in sharing information about near misses, incidents and serious incidents. Healthcare organisations must learn from past incidents and errors. Systems that support staff to analyse what went wrong and plan improvements based on knowledge and evidence are essential to becoming learning organisations. We must build trust in the system. Sharing information with others, and patients in particular, is core element of Professionalism and essential for Doctor – Patient Trust and trust in healthcare system.

7. Freedom to Speak up “Staff want to do the best for their patients. They want to be able to raise their concerns about things they are worried may be going wrong, free of fear that they may be badly treated when they do so, and confident that effective action will be taken. This can be a difficult and a brave thing to do, even in a well run organisation or department, but will be extremely challenging when raising concerns is not welcomed.” “A listening system is a safer system. Organisations which ignore staff concerns, or worse, victimise those who express them are likely to be dangerous places for their patients”. Francis Report, 2015

8. UK & Irish Research In UK NHS survey over 30% of those who raised a concern felt unsafe afterwards. Of those who had not raised a concern, – 18% expressed a lack of trust in the system as a reason, – 15% blamed fear of victimisation. (NHS survey, carried out as part of Francis Report 2015) In Irish study 88% of nurses observed an incident of poor care but only 70% of nurses reported it. – Only 25% of nurses who reported poor care were satisfied with the response of the hospital. (Moore & McAuliffe, 2012)

9. The primary reasons given by Irish doctors for decisions not to report concerns about a colleague were "nothing would happen as a result" (44%); "fear of retribution" (25%); and "thought someone else was dealing with the problem" (19%) (Medical Council, 2014:34). Each time someone is deterred from speaking up, an opportunity to improve patient safety is missed.

10. Conclusion from Francis Report 2015 There is a need for a culture in which concerns raised by staff are taken seriously, investigated and addressed by appropriate corrective measures. Above all, behaviour by anyone which is designed to bully staff into silence, or to subject them to retribution for speaking up must not be tolerated.

11. Imbuing Medical Professionalism in relation to Safety (IMP-S) Project Aim: To imbue a culture of medical professionalism in hospital culture and support junior doctors to raise issues of concern, whilst shaping a culture of trust, transparency, responsiveness and learning.

12. Culture change Very difficult to change culture. Recent systematic review on the effectiveness of strategies to change organisational culture to improve healthcare performance found only 2 studies to have shown improvement (Parmelli et al., 2011). Need for more rigorous research on changing culture in healthcare.

13. IMP-S and Culture Change Aim is to trial an embedded learning approach that centres on the use of a custom designed game to encourage speaking up, as well as inclusive leadership (words and deeds by leaders that invite and appreciate others’ contributions) and organisational responsiveness in the hospital system.

14. Embedded Learning through use of Serious Game ‘Serious game is a game in which education (in its various forms) is the primary goal, rather than entertainment’ (Michael and Chen 2006, p. 17). ‘PlayDecide is a discussion game to talk in a simple and effective way about controversial issues’ (PlayDecide.eu). Played with 4-6 players. Purpose here: To share knowledge and understanding among interns and junior doctors about safety and the importance of discussing and reporting safety concerns.

15. Development of PlayDecide Game Key Stakeholders Involved – Intern tutor, NCHD lead, HSE Patient rep, Hospital patient liaison officer, Risk managers from both hospitals, Q&S manager, Nurse rep, SCA, UCD researchers – Discussion with Intern group re identifying and reporting safety concerns Workshops with key stakeholders – 5 two hour sessions to develop game – 1 two hour session playing and piloting the game External validation – Game materials were sent to 2 people external to the process; an experienced incident investigator and a Human Factors in healthcare lecturer

16. PlayDecide Game Components Story Cards Bruner (1996) argues that “when human action finally achieves its representation in words, it is not in a universal and timeless formula that it is expressed but in a story – a story about actions taken, procedures followed and the rest”. Stories were developed using workshop participants personal & professional experience of patient safety as well as actual reports of incidents or complaints. Importance of story from different perspectives – doctor, nurse, patient, family member, risk manager.

17. PlayDecide Game Components Information & Issue Cards Information Cards – researchers worked through academic literature on patient safety, HSE & NHS documents and policies on incident investigation & patient safety, SCA annual reports on incidents and accidents, Medical Council work on Professionalism – to pick out salient information on patient safety.

18. PlayDecide Game Components Issue Cards & Position Statements Issue Cards – research team & workshop participants explored key challenges and dilemmas in reporting safety concerns – e.g. who is responsible for reporting, how to foster a Just Culture, how to learn from incidents, Open Disclosure, fear of litigation. Working group developed set of 4 position statements. The group try and reach consensus on a position that represents their shared views. If they cannot then they have the option of writing their own position statement.

19. Implementation to Date 4 weeks of gathering baseline pre- implementation data in one hospital with Interns on reporting behaviour Played game with 36 Interns on 3 rd November Collecting post- implementation data at the moment Began cycle with SHOs this week Will move to second hospital in New Year

20. References Bruner, J. (1996) The Culture of Education. London; Harvard University Press. Francis Report (2015) An independent review into creating an open and honest reporting culture within the NHS. Medical Council (2014) Talking about Good Professional Practice, views on what it means to be a good doctor. Medical Council, Dublin. Michael, D., & Chen, S. (2006) Serious games: games that educate, train and inform. Thomson, Boston. Moore, L., & McAuliffe, E. (2012),"To report or not to report? Why some nurses are reluctant to whistleblow", Clinical Governance: An International Journal, Vol. 17 Iss: 4 pp. 332 – 342 Parmelli et al. (2011) The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review. Implementation Science. 6:33. Reason, J. (1997) Managing the Risk of Organisational Accidents. Ashgate, London.