The view from the corridor

Standard

The following blog is from LfE fellow, Alison Jones.  Alison’s professional role has changed significantly during the pandemic, and here are her reflections on her recent experiences:

 

One of the central tenets of Appreciative Inquiry is the importance of storytelling or the power of narrative. MariaSirois said in her DLCCenterforAI webinar that if we talk authentically about how we have lived events, our story will resonate with someone, somewhere and as a consequence meaning will be added to both experiences. This story was part of my #COVID19 experience:

I have a background in adult ICU nursing but haven’t been registered with the NMC for many years. With the onset of the pandemic my greatest wish was to regain registration and join my colleagues on the ‘front line’ to help ‘fight’ this dreadful virus (the language of war we so easily adopt in these scenarios). It soon became clear that I had been away from the bedside too long to qualify for expedited re-registration; I was deeply disappointed and also experienced a strong sense of guilt at not contributing in the way I felt I should.

And so my role during COVID19 became that of ‘clean runner’ outside the intensive care unit at the children’s hospital where a new zone was created: an area made necessary by COVID19 isolation procedures. In this space, along with numerous hand sanitizers and the sequential PPE donning stations (first a gown, next a mask, then goggles, visor and finally gloves) a new team convened whom I shall call the Corridor Crew!

Once a nurse is in PPE and through the unit doors, s/he cannot come and go from the patient’s bedside out to store rooms and facilities beyond the isolation area. So they need ‘runners’. Runners for supplies – linen and IV fluids, blood products and medicines, ventilators and feed pumps; send swabs and specimens, bring tubes and wires.

In my role as a clean corridor runner I have been struck by the variety of people and emotions and responses passing through and gained a new perspective on this COVID experience: the view from the corridor:

Mums

Some in wheelchairs hours after an emergency C-section, some beginning to establish a routine – new normal. Post-partum people trying to heal and bear milk (often difficult enough at home with a healthy baby) now having to navigate the land of critical care, separation from baby, family, other children maybe … and carers in full PPE another type of separateness. I see in them dependency, vulnerability, shock and disbelief – how on earth did I get here? 3 weeks ago I was a chief exec/happy-go-lucky 17 year old/ran my own business/had all my ducks in a row.

But the thing I remember most is what they said to me in that corridor: ‘I have never met so many lovely people in one place’ and, tearfully, ‘you are all so kind, I can’t thank you enough’

Dads

Red-eyed dads displaying anguish, fear and frustration. Not in an aggressive way, although I know that happens too, but in a keyed-up, dumbed down sort of desperation. Through no fault of their own they are facing their greatest challenge; not only does their child require intensive care, but the world is in lockdown, global pandemic. Visiting is restricted, medical teams are cloaked in PPE and of all things, touch is prohibited. We witnessed brave but ever so slightly broken young dads walk past whilst we simultaneously adhered to social distancing and resisted the most natural instinct to give physical reassurance. Caring at arms length takes its toll on all of us.

Seeing, thinking, feeling these things emboldened me to enquire – how are things today? (eye contact, be brave, the answer might be tough to hear but it’s his answer and this is how we must express our love in the time of COVID).

The Day Shift

Mindful, rehearsed, #weareinthistogether. As they calmly progress through the donning stations I hear breathing exercises, the odd mantra and, whenever I ask ‘Are you hydrated? Feeling OK? Ready?’, ‘As I’ll ever be! Oh yes! Absolutely!’ come the replies. Thanks to stellar leadership from the ICUnurse management team we are as prepared as we can be for the daily evolution of the COVID19 response.

Throughout the shift they appear at the unit entrance often with gloved hands folded, steady eye contact and clear articulation through the mask: ‘Could I please have the special feed for Sally Morris, the blue thingy that adds a neb to the vent, some Micropore and a small sharps bin. The nurse next to me needs a temp module for the Philips monitor and 2 Weetabix cos her patient has kept free fluids down for 4 hours. I’ll come back for them, thank you so much’. They turn on their heels, speed walking back to their patient so they don’t waste a minute of care-giving time.

Short, frequently interrupted conversations punctuate the clean corridor day. Full of intimate details shared now like they never would be on a normal office day. Brief exchanges spanning the whole of our current existence: the grey roots showing in our hair (reframe: appreciation of hairdressing as a craft), supermarket queues (reframe: how lucky are we to live in a land of plenty), Generation C19 – adolescents with no exams and no motivation, the death of a neighbour (oh god, I’m so sorry) and dad’s had surgery so urgent not even COVID19 could stop it …nurses have lives too.

To The Corridor Crew:

27,000 steps today. We bring our whole selves to the job at hand – manning the corridor can be a fetch and carry task or an observing, serving, providing, learning experience

I know more about you now than I did before [Simon/Esther/John/Jen]

More unites us than divides us [tech/stores/pharmacy/labs/housekeepers/admin]

(Corridor) Music soothes, lightens, connects and heals

Thanks for the opportunity

So often we dismiss the value of our own stories and dwell on what we are not.We must cultivate an appreciation of who we are and the stories we have lived; show up to the situation as we can and bring our whole selves to the task. And the best stories end with an invitation into the next chapter so, when you tell your stories of what happened during COVID19, enrich them with how it made you feel, who or what inspired you and what good has or could come of the experience.

Alison Jones

On exnovation

Standard

I attended an excellent meeting in OLVG Hospital, Amsterdam recently. It was a convention of healthcare practitioners with an interest in LfE and safety-II. Delegates shared some presentations on LfE implementation and some related topics, including Appreciative Inquiry and joy in work. It was a stimulating and inspiring day, and as I reflected on what I had learnt, I became aware of a stream of thought about LfE and related endeavours: there is no single way to “do” LfE, Safety-II, appreciative inquiry or “joy”.  None of them is a panacea, and none should be ‘done’ in isolation. But they share a common thread of positivity: a kind of positivity that naturally emerges in a deficit-based culture. This type of positivity is not a highly energetic, celebratory force (although, I’m sure that sort of positivity has its place); it is a calming, warming, appreciative, nurturing sort of “everyday” positivity.

This thought has been with me for a while, just out of reach. But it started to take shape during the seminar while I listened to a lecture on exnovation, by Professor Mesman.

I first came across the term exnovation when I read Hollnagel’s “Safety-I to Safety-II”. It was listed, along with Appreciative Inquiry, as a methodology which may be used to facilitate safety-II. I confess that I never found the time to investigate further, and so I was pleased to find myself listening to a lecture on the subject.

I learned that exnovation is, in some respects, opposite to innovation. Where innovation may be considered to be the creation of novel improvements; exnovation is the process of improvements based on understanding current solutions within a system; many of which we don’t see because we take then for granted. Exnovation is a process to help us see what is right in front of us.

Exposing (or unmasking) these solutions, for the purpose of improvement, is the business of exnovation. Prof Mesman demonstrated how this can be done with in situ video ethnography. In other words – filming daily activities and then reviewing and analysing these videos in order to understand what is working.  The beauty of this approach is that the “solutions” or “recommendations” already exist and can be shared more widely.

Reports from the LfE initiative often focus on “everyday” excellence, and therefore, the potential to collaborate with the process of exnovation is worth further exploration. A vital part of exnovation is the recognition of something which works, and this is also the business of LfE. In both LfE and exnovation, the recognition of something good comes from the staff who are actually doing the work. This makes the process highly valid and relevant.

I returned to work inspired to see if I could turn my appreciative eye to some everyday excellence: something apparently mundane which I could learn from, or could share with colleagues. Whilst I was bemoaning the length of our ICU ward rounds, I noticed that a colleague routinely delegates certain tasks to team members during a ward round. This simple act saves vital time, minimises stress and inspires team members to engage with the round. Such a simple act is typical “everyday excellence” and I immediately adopted into it my practice.

Have you seen everyday excellence recently? Try actively looking for it, by watching your colleagues go about their work; and you might be pleasantly surprised about how much you learn.  Feel free to share examples (or other comments) below.

Adrian

Choice architecture

Standard

It’s very easy to focus on the negative aspects of one’s experiences. It’s the path of least resistance – it actually takes more effort to refocus one’s attention onto the vast amount of excellence which occurs everyday. Much has been written on the reasons for this negativity bias, and I won’t explain it here. And I do concede, very willingly, that much of our progress in healthcare (and in society in general) has resulted from our ability to notice the negatives; so I would never say that we should stop doing it.

But there are also many benefits from noticing the good. When you notice what is working, you learn something new. When you show appreciation or gratitude for the good, you improve your mood and that of those around you. Unfortunately, it takes effort to use the lens of positivity. Can we make it easier to access our positive worldview?

I contend that we can use choice architecture to make it easier for us and our colleagues to CHOOSE to see the positive aspects of their work. Providing easy access to an excellence reporting system, and making sure that the system works (i.e. positive feedback is forwarded in a timely manner) are key steps to making it easier to recognise excellence and to show appreciation. Linking the excellence reporting system with the adverse incident reporting system also provides an easy opportunity for staff to balance their observations of their workplace.

We know from 4 years of experience (and thousands of excellence reports) that this does not reduce the amount of adverse incident reports- it simply adds more intelligence to the reported data.  It also  makes it easier for staff to chose to notice what is working, and to show appreciation to colleagues.

 

Adrian

Hawks and Doves

Standard

I just spoke about LfE to some laboratory staff. There was an excellent question from the audience (paraphrased):

“I perceive excellence as rare and exceptional. As a ‘hawk’ this makes sense to me. Is LfE about capturing this stuff, or more about the everyday ‘good’ activities?”

In my answer I tried to articulate that excellence is subjective. It doesn’t come with a priori definitions. It also doesn’t have to be intimidating. We have thousands of LfE reports from our institution and the vast majority describe a simple episode of non-technical activity involving one or more colleagues. On the face of it these reports often seem to be descriptions of ‘people just doing their jobs. But in every case, there was something excellent about the episode, in the eyes of the reporter.

That is all that is required to trigger an excellence report. The positive feedback is powerful and informs the recipient about the impact of their actions, the extent of which is often not known by the recipient until the report arrives.

Hawk or dove, you can use LfE to show appreciation to colleagues, based on your own definition of excellence.

 

Adrian

Is Learning from Excellence “Safety-II”?

Standard

Learning from Excellence is often described as a “Safety-II” initiative.  I can see why this is the case, but the truth is that I implemented LfE before I had even heard of Safety-II.  That’s not to say the Safety-II was an underground movement; I was just a bit slow to find out about it.

The principle aims of LfE are to improve quality (through gaining insight by looking at hitherto under-studied parts of our system) and to improve morale (through formal positive feedback).  Safety-II is a concept based on the idea that safety can be considered a condition where as many things as possible go right; rather than the prevailing approach to safety – Safety-I – where we consider safety a condition where as few things as possible go wrong.  In the history of ideas, Safety-II is a very new one.  Whilst its theoretical principles are increasingly well defined, there is a distinct lack of practical application – particularly in healthcare.  How does one actually “do” Safety-II?  While we wait for the answer to this question, which may take years to come, we are tempted to “fit” initiatives, like LfE, into the Safety-II label.

Does LfE fit into Safety-II?  I think the answer is yes and no.  But a bit more yes than no.  LfE is about identifying success, and viewing it through a learning lens.  The name of the initiative suggests that it tends to identify extremely good (i.e. excellent) examples of work.  Indeed, this was the original idea of the initiative.  However, after looking at over 2000 reports, I have concluded that we are not capturing rare episodes of excellence – we are actually capturing “everyday excellence”.  The vast majority of the reports are a description (or short story) of a small work-around, improvisation, or a generous human touch which allowed success to occur in difficult circumstances.  It turns out that neither difficult circumstances, nor generous human touches are hard to find in healthcare. The success of the initiative is due to the fact that these have been happening since the start of organised healthcare, but have been unrecognised through formal reporting systems.

In the Safety-II construct, we could make our systems safer by understanding day to day work better.  Since success happens most of the time, we should be studying and understanding what happens most of the time, in order to recognise the work-arounds / adaptations / improvisations which create (and underpin) the conditions which allow success to happen.

If most of our LfE reports are about everyday work, I would argue that we have essentially created a system for “doing Safety-II”; at least in part.  What we haven’t created is a system which understands every element of everyday work.  This is someway off.

The fact that LfE is not a perfect practical solution for Safety-II is not a reason to change it. On the contrary, it continues to grow and spread positivity and positive change in healthcare (and beyond), so there is no need to make it fit into anything.

Show me the “learning”

Standard

Questions from the sceptics: 2. Show me the “learning”.  This is the second in a series of short blogs about common questions we receive about LfE.

I’m sometimes asked to demonstrate the “learning” from learning from excellence.  Often, LfE is regarded as a mere “pat on the back” for a job well done:  a harmless initiative, but not of any tangible utility.  What is the actionable intelligence?  Where is the “learning” which can be transferred from one situation to another?  This view of LfE is missing the effect of feedback on performance.

The core of LfE is a simple, formal positive feedback tool, which allows peers to show appreciation to each other.  Recipients of excellence reports are made aware of the positive effects of their actions.  This gives them the opportunity to reflect and think about why their actions were so well received.  This may prompt comments like “I was just doing my job”, yet staff members often go on to make changes in their future behaviours based on the new awareness they have of their positive actions.

So the principle type of “learning” in LfE is the same as the learning we experience from any type of feedback.  The main difference is that LfE is exclusively positive feedback – an extremely rare phenomenon in today’s NHS.

Adrian