From triple helix - Spring 2019 - You are not your mistake: Compassionate responses to clinical errors
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Steve Fouch looks at an individual story of how a clinical error was dealt with, and at the lessons learnt
We all face them. Situations when fatigue, overload or simply a momentary lapse of concentration or judgment lead us to do or say the wrong thing in a clinical situation. Most of the time these are minor mistakes that have no serious consequences, but we often live in fear of the clinical error that may harm or even kill a patient or end a career.
Much more difficult though can be the way our colleagues and those in authority treat us when we are dealing with the consequences of such errors.
Jemima has experienced this reality twice. A paediatric staff nurse with many years' experience, she made a drug error on a paediatric ward and was initially taken through a capability procedure, being supervised on all drug administrations by a senior member of staff. However, the Trust then decided to take her to a disciplinary hearing.
Though she was eventually reinstated, her colleagues ostracised her and she no longer felt like an accepted and valued member of her previously close-knit team. She decided to leave her job.
Five years later, in a new post at another Trust, she had established herself as a competent nurse with her colleagues but was still suffering stress, anxiety and self-doubt as a result of her error. On one shift she found herself having to undertake a procedure that no one on her unit had taught her how to do and with no supervision immediately available. Again, she was suspended and taken to a disciplinary.
This time she lost her job. In the lead up to this, and during the subsequent tribunal, it became apparent that she had been bullied and intimidated by senior members of the team and had been under considerable emotional stress as a result. Regardless, and despite further evidence from members of the medical team about the quality of her nursing care, she lost her job.
While she accepts her errors were her fault, the bullying and lack of support and training from her seniors were significant contributing factors. But worse than this was that her colleagues, including some other Christian nurses on her unit, totally cut her off. The junior doctors in the unit were highly supportive, but as soon as she was suspended facing disciplinary action, no one would return her calls or even acknowledge her presence.
Shocked by this, she began to talk to others who had also been through a disciplinary procedure, both nurses and doctors. What became apparent was that her experiences, both of bullying and shunning by colleagues, were not unique. She has subsequently set up a support group for people who have been through this process. The group exists as an online forum called 'You Are Not Your Mistake'.
She has consistently found that doctors support one another much more and much better than nurses.
Why is this the case? In Jemima's experience, nurses tend to be more passive and tend not take a leadership role unless specifically given it, while doctors tend to assume leadership roles more readily. This inclines nurses towards passivity and outwardly accepting the status quo, while moaning behind the scenes and behind each other's backs.
Fear is also a factor. Being seen to be associated with someone who is facing professional disciplinary action risks guilt by association. Everyone is busy watching their own back and ensuring that their own status is secure rather than supporting their colleagues, for fear it will harm them.
Moreover, the NMC is much more likely to bring nurses to competency hearings than the GMC is to bring doctors, so the fear factor can be a lot stronger for nurses.
'I tell you, use worldly wealth to gain friends for yourselves, so that when it is gone, you will be welcomed into eternal dwellings' (Luke 16:9).
From this verse Jemima felt that God was telling her she would lose her job, but that this was the best course. It encouraged her to set things right with her colleagues before she left. She subsequently spoke to both her managers and colleagues, including her Christian friends. One of the issues they raised was that they felt she had become very negative and not like her old self. She realised that the process had changed her - making a positive, confident and capable person into someone negative and lacking in self-confidence. She felt that the culture of the ward as well as the disciplinary process had contributed to this.
A good leader recognises the skills and the weaknesses in their colleagues and seeks to encourage people's strengths and the sharing of skills between team members. They support and supervise in areas of weakness, getting those stronger in that area of practice to teach those who are weaker. This is not just good management; it also requires a degree of pastoral care. It is about concern for team members as people, not just as co-workers or subordinates. It means being willing to gently but firmly confront errors and problems, but in a constructive manner with the aim to build up and develop, rather than criticise and tear down.
This made Jemima realise that workplace culture shapes us as professionals and that again requires good leadership. But that leadership is not just for the senior staff member, it is taken on by all staff who assume appropriate responsibility for their team and themselves, regardless of who is in charge.
It is about being proactive in building a team rather than waiting on someone else to lead. And the core quality needed by such leaders is compassion - not just for patients, but for colleagues. It is this that shapes culture, which shapes the team that gives care. It is about catching people on a negative pathway before they tip over the edge into a more serious level of incapability. Burnout happens when staff not only stop caring but are no longer bothered by the fact that they do not care. An uncaring leadership team accelerates this process; a compassionate leader will anticipate and help prevent such a downward spiral.
Jemima learnt through this process that her identity and security cannot rest in her work or her professional status - it has to rest on Christ. We are not our profession, we are not our mistakes - if we let these define us, we are missing out on who we really are as followers of Jesus.
She also realised that forgiveness was key. Owning up to her own errors and accepting responsibility was the first step. But she also had to forgive those who let her down or ostracised her. In doing this, hard and painful though it was, she was able to let herself and her former colleagues move on.
More widely than our personal spiritual responses, we need to recognise that our professions and the NHS as a whole need some fundamental, cultural changes.
First, as professionals we need to focus on and make space for self-care; rest, spiritual refreshment, and being willing to seek help. A real weakness faced by doctors and nurses alike is that we find this really hard to do. We need to care for ourselves before we can really care for our patients and our colleagues, but so often we put ourselves last - to the detriment of all.
Second, there needs to be an emphasis on developing real leaders. Not managers, but nurses and doctors who lead out of a biblical sense of serving their colleagues and patients, bringing the best out in every team member. Compassion and vision are key qualities.
Finally, we need to be building community - teams that look after one another and know what they are there to do. Fear, self-interest and self-preservation are not good motivators. As Christians, we also need to be building a spiritual community in our workplaces - praying together as well as working together. Workplace fellowships are a vital part of building a good workplace culture.
As Christians we should be at the forefront of changing NHS culture from the inside. We need to grasp a biblical model of Christian leadership for our workplaces, leading by example. We also need to care for ourselves by nurturing our spiritual lives with our church families.
Jemima has moved on to a new role now, but her passion is to see more support and care for one another among the health professions, and in particular to see Christians leading and encouraging others by example.
Steve Fouch is CMF Head of Communications
This article originally appeared in Spotlight, Spring 2017