To improve patient safety, lean in

Abstract

Early in the last decade, “lean in” became a rallying cry for women in business, taken from the title of the book by Sheryl Sandberg, then Chief Operating Officer of Facebook, and her collaborator Neil Scovell. The expression was orginally intended to encourage women to confront workplace discrimination and aim for leadership roles. Since then, it has taken on a broader meaning, i.e., to “take on or embrace something difficult or unpleasant, usually through determination or perseverance; to find a way to benefit from, or alleviate the harm of, risk, uncertainty and difficult situations.” The expression has practical and even literal meaning in our field of health care. Recently, one of us (MN) went to see a patient in a pediatric neuro-behavioural unit. It is a place with a high staff-to-patient ratio because these patients have an elevated likelihood of being dangerous to themselves and those around them. As he was being oriented to the unit he noticed all the staff members were wearing jackets with thick sleeves, arm protection, and sturdy face shields. He asked his nurse guide about this and she said, “You never know what will happen here. If a patient bites you, don’t follow your instinct and pull away—you will make it a worse injury. If you are bitten, lean into them. It will put them off balance and others will come to help.” When attacked, when cornered, when you don’t know your next move, rather than react and run, lean into the situation. Leaning in, and the mindset that goes along with it, can improve patient safety, and help to foster a culture of safety. Important examples include disclosing adverse events to patients and families, supporting distressed colleagues, and addressing workarounds and near misses. As humans, most of us have an aversion to confronting difficult conversations. Every clinician has certainly been there. We know there are times when we must talk to a patient about something awkward and potentially volatile. Even though we know that we should have that conversation, sometimes we avoid it. Disclosing adverse events is an important example. Harmful medical errors cause great distress for patients and their families. Physicians know that when they make a mistake, they should attempt to correct it, disclose it to the patient, and apologize. It is the patient’s right to know when they have been injured by an error, and disclosure is an important component of professionalism in medicine. However, physicians are afraid of the reactions these disclosures may elicit, and that they could harm their personal careers. In reality, there is considerable evidence that supports disclosure of adverse events to patients, including some suggesting that it is helpful in resolving the issue and does not increase the chances of legal action. And, although an apology does not erase the adverse event, it can have profound healing effects for both the patient and physician. The right strategy for organizations and individuals is to lean in to these situations. Organizations must publicize their disclosure policy, and provide training and support for the discussions. These should include in-person and online materials and readily available just-in-time support for having the actual discussions with patients and families. Organizations should also offer emotional support for involved clinicians who will inevitably be traumatized by the incidents. A related topic is the need to support health care workers who are traumatized by their work. It is most obvious that clinicians can be gravely injured when their error harms a patient.8–10 However, there are many more occasions for health workers to be traumatized by stressful patient related events. There are many disappointments in medicine, including patients who have bad outcomes despite excellent care, deaths of patients that providers found relatable, conflicts with patients or family members, and workplace violence. Clinicians are at risk for these events, but so are other workers who interact with patients and feel invested in their care, including workers in nutrition, environmental services, security, and patient transport. When these events happen, the affected health care workers react in a predictable way: they feel badly about themselves, lose confidence, and withdraw. Although one may feel it is best to leave the colleague alone, it is actually more helpful to lean in and provide emotional and informational support. One can ask them if they are okay, remind them that we all experience similar situations, and reassure them that they are still competent and valued members of the team. This can help them regain their equilibrium and allow their intrinsic coping mechanisms to kick in. Another area where leaning in is crucial is in dealing with workarounds. A workaround is a method for overcoming a problem in a workflow or system. In healthcare, this strategy circumvents a barrier to achieve a goal, or to Editorial