Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Communication and Perspective

I always try to build in one to one time at the end of our training courses, knowing that this may well fit certain people's preference type better.

Recently one of the theatre staff took me up on this offer. I wasn't sure quite what was coming next; they had appeared quite harassed at the start of the course, looking tired and stressed, not that this is unusual in the NHS.

They stated that they had enjoyed the course but wasn't so sure at the outset when I had introduced myself as being ex-Ambulance Service. They proceeded to tell me a sad story of how they witnessed a close family member collapse and die in front of them.

They took all the correct initial chain of survival steps until the ambulance crew arrived (quickly thankfully!). However, two things stuck in their mind and have caused a great deal of angst.

Firstly, before emergency help arriving, our client delivered CPR at a ratio of 15:2, not the currently recommended 30:2 ratio.

They stated that they ought to have known better!

I gave reassurance about this, we both agreed it is compression rates over a minute etc. that matters, plus this is not a work context, you are dealing with a loved one unexpectedly collapsing.

We do need to give ourselves a break at times, but we are the 100 percenters' that exist throughout our NHS. In retrospect, investigations showed sadly that the outcome was never going to be a positive one in this case.

The other more interesting fact is how much anger they felt towards the ambulance crew.

The male crew member appeared very efficient, but our client had a real issue with the female crew member as she had asked if the patient had "taken anything?" prior to collapse. The answer was "No".

However, the female crew member asked the same question twice more during the resuscitation attempt.

From our client's view, there was an insinuation that perhaps medication/drugs misuse could be a factor.

They have been unable to stop thinking about the offence the crew caused, to the point that they have been looking out for the crew, the female one particularly. They felt the need to put her straight about what a good, decent person their relative was.

I chatted generally about emergencies in a pre-hospital setting, also about competence and confidence levels amongst ambulance crews. I asked if they had considered the situation from the crew's perspective?

Often there is one experienced crew member and one less so (or even under training), this is quite normal in most Trusts.

I explained that we are all desperate to add to the effort of resuscitation and are continually running protocols/possibilities (CABCDE's, 4H's & 4T's BM's, SAT's, BP's, rhythms, ETC02….) through our minds, trying to rule out causes of collapse and unconsciousness.

Asking about drugs/meds is one of the correct enquiries.

I also explained that we often think out loud, and when we have run out of things to ask (usually due to stress), we sometimes end up repeating ourselves. This is especially true when we are inexperienced and have run out of options more quickly, despite our desperation to help.

This verbalised thinking is widespread; it can also be the crew communicating to one another about the point they are at in their thought process.

It may also be a way of asking for a colleague's prompt, rather than saying in front of the family "I don't know what to do next!"

It is also a method of maintaining the professional facade to preserve confidence with the patient's family.

Frustration quickly builds when there is no apparent cause, and therefore no clear treatment plan.

Our client was quite understandably upset and had been crying at points in our discussion. There was though a point of realisation when they acknowledged the crews' possible perspective. They agreed that this was something they had never considered.

There was a physiological change to their expression, akin to a weight being lifted. They had never considered anything other than the crew being judgemental about their loved one.

What a privilege to be able to help someone move forward with such an emotive issue. We also laughed that there was now no need to keep stalking the ambulance bays!

I concluded by giving the reassurance that they had done everything possible in terrible circumstances and to focus on that.

I believe my explanation is valid, I could be wrong, but I have been there on the ground, desperate to help and sometimes unable to.

Stress affects us all, and nobody has all the answers. Taking another's perspective, view or position can often be of great value in so many situations and relationships.
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What’s in a name?

In our everyday lives, people are typically polite to each other. At social events, we carry out personal introductions a matter of course.

So why is this behaviour not the norm in healthcare?

When working with healthcare teams that are sometimes experiencing challenges with safe team workings, we often observe a reluctance to introduce ourselves by name - especially our given first name.

When I joined my first airline employer in 1971 that was indeed the case.

The Captain was always addressed as Captain or Sir, on and off the aircraft.

I still vividly remember my first BOAC flight as a very lowly second officer under training. The Captain was a very senior manager and trainer, and he exacerbated the situation by referring to me to his chums in the bar in Manhattan as 'one of those bloody cadets still wet behind the ears'. What an excellent example to set.

It was an example I chose as a model of what not to do when I finally achieved Command 18 years later.

Furthermore, I made a point of never introducing colleagues as 'my First Officer' or 'My Cabin Crew'. These are professional people in their own right and deserve all the respect associated with it.

This is an important issue because failure to use given names in the workplace can create a significant barrier to people speaking up when they have doubts about safety.

Why would any professional want to place an additional block to open communication, especially if someone's' life could be at stake?

I met one senior clinician in the last few months who looked with abject horror when I suggested they make a point of introducing themselves by first name at a pre-surgery huddle! "I really don't think I could do that", she said! Why on earth not?!

The unit in question has an appalling staff attitude survey result, a string of 'Never-Events' and 'near-misses', a high sickness rate and high staff turnover. Go figure!

The excellent Rob Hackett in Australia had the astonishingly simple idea a while back of putting name and job title on his theatre hat. This has become known as 'the theatre cap challenge'. Odd isn't it that it should even be regarded as a 'challenge'!

It's quite amusing to hear all the excuses why people can't adopt this simple practice of the theatre cap challenge in their own unit.

Infection risk? Well, there is a chap out there making them integral in theatre caps. You could invest in a few to get you through the week if you like your own personalised hat.

Power is granted, respect is earned.

We must not forget either that using titles can help in difficult situations.

As an airline captain, there were many occasions where a colleague referring to me as Captain Dale was useful to re-establish appropriate hierarchy in front of passengers or an engineer.

The other week I was delivering a talk in Bath, to a room of around 100 healthcare professionals, ranging from medical students to retired senior consultants.

When I reached the end of my talk, I asked how people in the room felt about using first names? I explained that when you have to think about titles and ranks, you are creating an additional barrier to someone helping you out when you need them the most.

I don't mind if you introduce yourself as Professor John Smith, but I prefer if you call me Professor Smith. This might not be as beneficial as working on a first names basis, but it sure beats the all too common introduction, "We all know each other don't we?" which equates to "You all know me, don't you? .. and you don't matter".

Do get in touch to discuss how our human factors training for critical teams can help you maintain and enhance safety.

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