Seizing seismic change

Talk Tuesday - May 5, 2020

In this fast-paced time of system change, nurses have had to adapt their practice on a minute to minute basis - new PPE practices, testing guidelines, and clinical care plans. Information often comes from the top down, but what about understanding system change from the bottom up? Sarah shares her story about frontline providers transitioning to a new critical care helicopter environment and how those lessons relate in the context of nurses’ practice in a global pandemic.

Featured presenter 

Sarah Painter RN

Sarah Painter is a flight nurse for STARS Air Ambulance providing critical care helicopter transport in Manitoba. She has been a direct care provider for ten years, a career which began in the emergency room at St. Boniface Hospital. Sarah graduated with a Bachelor of Nursing from the University of Manitoba in 2009. During her undergraduate studies, she served two terms as president of the Canadian Nursing Students Association. She is a founding member and past board director of the Association of Registered Nurses of Manitoba. Sarah is currently pursuing a Master of Science in Human Factors and System Safety at Lund University in Sweden. 



Sarah Painter spoke with us this week and shared some of the learnings from the Systems Change and Systems Safety world. She has used the opportunity of STARS preparing to switch to new helicopters to observe how people react to and learn within significant systems change. and speaks She spoke about how that can help nurses and teams work through the changes that come with COVID-19. The findings presented here are part of her thesis and we're the first to hear about them.! Sarah describes how "hidden work" develops, it's benefits and risks, some risks and benefits that come with systems change, how individuals and teams react to systems change and how the flow of information in a time of change impacts the work done.

Her initial questioning about safety and performance came from her work in the emergency department where she noticed the hidden ways people get their jobs done when dealing with enormous complexity in an under resourced environment.

Complex systems are made up of interacting components whose behaviour is difficult to model due to inter dependencies or hidden relationships between parts and their interaction with the environment.

Health systems always include resource constraints, competing priorities, policy inefficiencies, overwhelming demands and changes to normal work. It's expected and typical for the healthcare system to function at above 100% capacity. Policies / flowsheets / practice changes don't always reflect the reality of the work done in an area especially if it was developed or validated in another area. In the world of patient safety, we try to mandate it by creating elaborate rules and processes and forms, but these restrictions take away the clinicians ability to pivot and address the context they're working within.

In complex systems like healthcare, it is the people who come to work who care for the patients and who make the systems work in spite of really daunting odds. These are the people who understand the complexity of the problems - Sarah described the psychologist's fallacy which occurs when an observer assumes that their subjective experience reflects the true nature of an event. It's also important to realize that some of the adjusted work people do is maladaptive - they devise ways to get the job done that may be unsafe. This is one of the reasons it's important to decrease the gap between the imagined and the practical worlds.

Any disruption to practice can have a negative impact on performance and in healthcare inevitably makes its way to the patient. No environment is neutral, and every environment is imperfect but the benefit of the familiar is that people have learned to work with it. When the practice environment changes we have to learn to navigate it all over again with new forms of risk. This shifts some cognitive bandwidth from caring for patients to managing complexity. But systems change opens a window into the actual practice world and that can be helpful.

There is a big difference in how people feel about a change they choose compared to one that is mandated. Safety scholars say that ambivalence toward change is a good thing for safety and performance because when people feel unsettled or uncomfortable they're more sensitive to finding interactivity that was unexpected and they ask really good questions.

The very best learnings from system change come from groups making sense of the change, figuring out how it impacts their practice and problem-solving systems that didn't work the way they were supposed to. This is an expected outcome in safety theory - prosocial motivation explains that people come to work because they care about the work they do and they care about their colleagues - they show up to help them (and in healthcare, their patients), not necessarily for the facility or their administration. Team environments tend to invest heavily in sharing learning through stories.

Systems Learning acknowledges information travelling from the top of an organization down and sometimes from the bottom up but what happens when that information hits the frontline can be hard to predict. There are often mechanisms for frontline staff to use a reporting system or email their manager about the changes but what Sarah observed as she followed STARS staff was the whole team identifying problems and potential solutions together and then bringing them forward as a group. 80-90% of the safety critical learnings were found in their group chat.

Question and answer

What are your three favourite readings on systems change, complex systems & safety?

  • Behind Human Error
  • Field Guide to Understanding Human Error
  • Resilient Healthcare

Do you have any tips for frontline nurses to share input when their leadership doesn't invite or appreciate feedback?

Try to create your own space to collaborate as a team productively, some teams use chat apps and as always be mindful of personal health information. It is often easier to bring forward an issue and suggestions as a group rather than as an individual.

Could you address the inter professional work from STARS perspective?

The teams are made up of nurses, paramedics, physicians (usually by phone) and pilots. The nurses & paramedics are crosstrained which helps them understand each others priorities and the team values input from all members.

Are there national & international best practice guidelines for air ambulance?

Yes, there are international guidelines and a north american accreditation body as well as professional associations.