When I started nursing thirty-six years ago, it was our custom on occasions to wander down to the pub and chat about the shift or week just gone by over a few beverages. It was an informal (and sometimes slightly messy) way to debrief. The pub was a great place to gather, get to know each other better, chat about colleagues, patients, processes and solve the problems of the world and whatever ward or unit we were working on at the time. We came up with some great ideas (admittedly, some were not so great) about how we would run a ward, handle a wayward Charge Nurse (now called a Nurse Unit Manager) and manage a tricky patient. These experiences helped to strengthen my faith and trust in my frontline colleagues and along the way, helped to form some lifelong friendships.
Of course, what we were doing was an informal type of collective reflection on our practice. Reflection is an approach that taps into experiential knowledge “to enable professional and personal development while reinforcing continuous learning”. Being informal, the pub discussions were never noted or shared with our non-pub frequenting colleagues. More importantly, our reflections were never shared with hospital management, so the good ideas for improvement were never implemented.
So, it was a process of reflection that allowed us to let off some steam. But, since it was done without focus or structure, it was of limited benefit to us as individuals, in terms of our professional development, or to the hospital we worked at, in terms of continuous quality improvement.
Not much has changed as far as frontline staff having informal debriefs with colleagues (although not at the pub during the COVID-19 pandemic!). However, reflective practice is now recognised as an important component of clinical practice. Indeed, Australian professional bodies now include reflective practice as part of their standards of practice. Some agencies have webpages dedicated to why and how to implement reflective practice.
What can farming teach us about reflective practice in healthcare?
Reflective practice has a place in all industries, but I admit to being really surprised to learn of its importance in the agricultural sector. For many decades, farming has used a reductionist approach to guide the behaviours of farmers. This approach reduces complex farming systems to individual components and treats each component separately, all in the interests of increasing yields – and therefore profits – for large agribusinesses. The result has been degradation of farming lands and, ironically, reduced yields.
Enter agroecology, which applies systems thinking to farming practices.
Agroecology draws on scientific research grounded in the natural sciences, but marries this with farmer-generated knowledge and grassroots participation. This underpins the new regenerative approaches to farming, which tap into the reflections of farmers – positive and negative – on their practices and outcomes, to work out what works, what doesn’t and why. The results have been amazing, with regenerative farmers able to rehabilitate unproductive farming lands and better manage ever-worsening droughts and other impacts of the changing climate.
These new approaches in farming provide some important lessons for the healthcare sector. By and large, the approach adopted by healthcare organisations to delivering high-quality healthcare is a reductionist one. Rather than look at the system as a whole and acknowledge the web of interconnections they contain, healthcare organisations tend to consider their systems as collections of individual processes or inputs. This reductionist approach is attractive because it simplifies the collection of indicator data and therefore offers the (often overstated) promise of rapidly determining the root cause when a problem occurs.
Reductionism makes us view problems the wrong way
This can best be illustrated by a real-life example that a colleague shared with me.
The Director of the Emergency Department (ED) received an email from the hospital’s Quality Manager who, after reviewing ED incident reports, found that some patients were receiving repeat investigations because of incomplete handovers between clinical staff at shift changeovers.
The ED Director was asked to implement some quality improvement activities around clinical handover. She responded by mandating that all her staff undertake re-education about handover. The medical staff, who were fully aware of how to conduct good clinical handover, found the mandatory re-education slightly patronising and a waste of time. The result was little impact upon the quality of clinical handovers being conducted in the ED.
The ED Director then undertook some further investigation. She found the problematic handovers were mostly occurring when the night duty staff commenced at 10PM. Discussions with night staff revealed they were not fully aware of what had occurred with their patients during the day, as they received a rushed handover from the day shift staff as they were departing at 10PM. The rushed handovers were the result of there being no formal time allocation for a detailed handover between staff in the two shifts.
The discussions with staff also revealed – unsurprisingly – that staff finishing at 10PM were tired after a 12-hour shift and were keen to get home. With no quarantined time for handover, vital documents were often not completed and computer-based rather than face-to-face handovers were the norm. The result was that some critical steps in the handover protocols were not being practiced correctly or at all.
This example demonstrates that what might appear to be human error can often be traced back to the system. It was not the lack of skill of staff in conducting handover, but rather the lack of time allocated for high quality handovers, that was the source of the incidents. Re-educating staff about clinical handover processes was never going to be the solution, but reductionist thinking meant that the process of clinical handover was looked at in isolation.
Had the ED Director and Quality Manager immediately asked the frontline staff to reflect on their routine practices, they could have explored a range of other processes and inputs related to clinical handover. This would have resulted in the underlying cause for the poor handovers being identified without staff undergoing unnecessary training that did not address the problem. Indeed, the solution to the problem was to institute a 30-minute crossover time between shifts for key staff. This was something the clinicians had been requesting for some time and had been complaining to each other about at their weekly catch-up at the pub.
Reductionism and reactivity go hand-in-hand
The ED example reflects a broader reactive approach to quality improvement within healthcare organisations. Adverse incidents and events occur, which are then reported to management and in extreme cases (called “sentinel events”) to external governing authorities. The response is, by definition, a reactive one, because it’s a response to something that has already gone wrong.
More importantly, the response is usually underpinned by reductionist thinking, that is, finding out what specifically went wrong to cause the observed problem. Armed with that information, we then set out to fix that specific thing.
In the ED example, clinical handovers were incomplete, so the reductionist-perspective solution was to re-educate staff on how to properly complete handovers. It wasn’t a “bad” solution, it was just the wrong solution for the actual problem.
If instead, collective reflection had been part of a regular proactive approach to safety and quality, the issues with having no designated handover time between shifts could have been identified before a problem actually occurred for any patients. Regular collective reflection will necessarily involve reflecting upon the things that go well with routine practice, as well as things that are “accidents waiting to happen”, enabling a more preventative approach to problems and challenges in healthcare.
From individual insights to collective reflection
Knowing that group reflection results in many positive outcomes including improved quality of care, then a shift in the mindset within healthcare organisations is required to enable these reflections to be captured and utilised. Hoping staff will reflect individually about their work and have “lightbulb moments” about quality improvement projects is neither structured nor sustainable.
Frontline healthcare workers are continually reflecting on their practice and their views usually cut to the core of issues. “I could have told you that for free”, “if only they asked”, “clearly this ward design was not done by a nurse”, “it is very obvious that if you put the medication room where it is, you will have a load of problems” are all comments I have heard from my colleagues. They have great individual insights into how “the system” is functioning in relation to their local unit, their practice and how it impacts on their quality of care. It’s when we bring these individual insights together that we build a more three-dimensional understanding of how the system is really working.
The problem has been that no systematic effort has been made to bring these reflections and insights together in a regular, structured and consistent manner.
Instead, feedback from staff is sought through annual staff engagement surveys and various ad hoc exercises. Management will also conduct regular audits of practice, but this a compliance-focussed tool known to be somewhat inaccurate because of the Hawthorne effect (where individuals modify their behaviour when they know they are being observed). Both the surveys and the audits are reductionist data collection exercises that deliver hard data, but lack the context that comes from collective reflection. More often than not, the quality improvement ideas derived from review of these data are one-dimensional solutions to a three-dimensional problem.
Why do healthcare organisations persist with a reductionist approach to quality improvement? I believe it’s because collecting this kind of data is straightforward and tidy and delivers quantitative results that give us a (false) sense of being “in control” of the system. Achieving a three-dimensional view of the system and showing complex interconnected activity streams with clarity is more challenging.
However, if healthcare organisations are serious about reducing the rate of patient harm, which has barely changed in 20 years, then the first step is recognising that reductionist approaches have worked no better in healthcare than they worked in agriculture. If, like regenerative farmers, we want to leave our industry in better shape than we found it, we need to start using techniques that will enable a more systems-based approach to improvement.
Through my own research with frontline staff, I have found a collective reflection technique that can assist with what I see as a regenerative approach to quality improvement within healthcare organisations. The technique uses diagrams that reflect the complexity of the system, but in terms that make sense to people that work at the frontline. It provides a structured mechanism to capture the wisdom generated through collective reflection, helping management develop a more holistic and three-dimensional understanding of the systems all staff contribute to. The effort that went into those collective reflections was amply rewarded with genuine improvement in indicators of patient harm, as well as sustained engagement of frontline staff.
One thing I’ve definitely learned after nearly four decades of nursing, we’ll know we’re in a better place when we no longer need to go to the pub to reflect with our colleagues about what’s going on at work.