In this blog piece I think about what we mean when we refer to the culture of the NHS and how psychologists have already had a significant impact in shaping the patient safety world, and what a next step might be as I see it.
The Frances Report (2013) highlighted the need to address issues of NHS culture in the wake of unacceptable standards of care at Mid Staffordshire NHS Foundation Trust. At a similar time, a large scale research programme examining culture and behaviour with the NHS, synthesised by Dixon-Woods and colleagues (2013) highlighted a mix of high quality and poor practice in relation to patient care, but stressed a universal desire on the part of stakeholders to achieve the best standards possible. So in essence, the individuals involved wanted something better than collectively was being delivered. Much like the Francis Report this research programme highlighted the need for an organisational culture which is patient centred to deliver excellent care, which was believed to be lacking in some cases.
Whenever think of NHS culture I am minded of the Menzies Lyth (1959) paper we cover as in the second year at Leicester. Personally I would say it has been one of the most influential papers I have read during training (the reference is at the bottom of this blog for those of you that haven’t read it!), and the crux of it as I understand it revolves around social defences on the part of nurses to defend against the anxieties brought about by the challenging reality of the intimate physical and emotional care of patients. Defences include breaking down nursing into a series of routines and tasks to be repeated with many patients, rather than in depth care with one patient. Or discouraging the expressing of emotion or interest in the person that is the patient, instead referring to “the liver in bed 10”. All of these defences serve the function of avoiding psychological involvement with the patients, based on the premise that such involvement would naturally increase the emotion and psychological burden felt by the nurses in what is an extremely challenging and difficult role. Although written in the 1950s, this paper feels very relevant today.
What can psychology do?
Sometimes as clinical psychologists it can feel our role is on the sidelines in influencing NHS practice which seems so dominated by our medical colleagues, but as has been highlighted (Kapur, 2014),those with a psychology background have made significant contributions to our understanding of patient safety. Indeed, James Reason (e.g. 2008) has a longstanding contribution to the psychology human error that has been applied to patient safety, particularly at the organisational level. Charles Vincent, the Director of the Imperial College London Centre for Patient Safety and Service Quality (CPSSQ), trained and worked as an NHS clinical psychologist. And Pat Croskerry has contributed greatly to the role of cognitive bias medical errors (Croskerry et al, 2009). These high profile examples are examples give clear indication that psychology has something to offer to the debate around patient safety but more specifically can have something to contribute around the specific question of how culture within the NHS can be changed.
Can clinical psychology offer something palatable to those responsible for policy, resources and strategy, that is also empowering and useful to those NHS workers who are on the ‘frontline’ delivering care to patients? If real cultural change is to be made efforts must focus on both the sharp and blunt ends, to understand the system factors which prevent staff from functioning to their potential, but staff must also be given opportunity to be able to innovatively address and be accountable for, challenges they face. There is therefore a need for initiative which is palatable at all levels if we are to influence cultural change. If we are to consider culture as ‘the way things are done round here’, are clinical psychologists not well placed to be able to assess, formulate, intervene and evaluate how this system can be changed whilst operating at these different levels?
What could work as a campaign for clinical psychology?
For anyone who has been into an NHS building in recent years they are sure to be familiar with an emphasis being placed on hand washing, from seeing the posters and stickers, using the hand gel, being taught to wash them ‘properly’ on NHS induction, and occasionally being asked to anonymously report if the clinician we saw washed their hands as a patient, this is a very real part of daily life. This high profile example of a campaign which had notable influence on culture change within the NHS was the ‘cleanyourhands’ campaign facilitated by the now defunct National Patient Safety Agency (2004). This campaign was successful in reducing cases of MRSA and C Difficile infection (Stone, et al 2012). This campaign was centrally funded by the Department of Health and focused on the public health need to reduce hospital infection rates, yet also worked at a local level to empower frontline workers to be able to reduce the risks.
The campaign was simple in its aim, but crucially it helped to verbalise and bring into discussion and consciousness an issue that few would disagree with, but had perhaps been relegated in terms of priority. Could compassionate care not also fit this description? Based on this premise, is there not a possibility for a similar campaign or initiative, which can simply but effectively identify a component of culture change that is both amenable to frontline staff and policy makers?
These are just my own personal musings of thoughts I’ve had as a trainee, but I hope you’ve found them of some interest and I’d like to hear your thoughts. Do you agree or disagree? What theory or ideas could inform trying to bring more psychological mindedness to the NHS? Is the idea of an awareness style campaign too simple? Whatever your thoughts please feel free to share them and hopefully this space can be used for us to collectively think about and share our ideas.
– Tim Siggs, Clinical Psychology Trainee, 2012-2015 Cohort
Croskerry, P., Cosby, K., Schenkel, S. & Wears, R. (Eds.) (2009). Patient safety in emergency medicine. Philadelphia: Lippincott, Williams and Wilkins.
Dixon-Woods M, Baker R, Charles K, et al. (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety, 0, 1-10
Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: Stationery Office, 2013. http://cdn.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf.
Kapur, N. Mid Staffordshire Hospital Report. The Psychologist, 27(1), 16-20
Menzies Lyth, Isabel (1959) ‘The Functions of Social Systems as a Defence Against Anxiety: A Report on a Study of the Nursing Service of a General Hospital’, Human Relations13: 95-121; reprinted in Containing Anxiety in Institutions: Selected Essays, vol. 1. Free Association Books, 1988, pp. 43-88
National Patient Safety Agency. (2004) Ready, steady, go. The full guide to implementing the cleanyourhands campaign in your trust. www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=5923.
Reason, J. (2008). The human contribution. Farnham: Ashgate Press.
Stone, P., Fuller, C., Savage, J., et al (2012). Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study. BMJ Quality and Safety, 344
Vincent, C. (2010). Patient safety (2nd edn). Chichester: Wiley-Blackwell.