Oxford Open Grand Rounds

0:00 Olivia: Hello everyone just joining us. Good to see you all. We will take our typical two-minute start time and then we'll go ahead and dive into the content. Thank you for being here. I see some folks registered from all corners of the world. So hopefully this is an okay time for you all. It's good to see some familiar names and those who are new. If you're just joining, we'll get started in about one minute. Okay. Just want to make sure I can see. Welcome everyone. Thank you for joining. If you are just joining, we will get started in about one minute. Good to see you all here. Lovely. Okay. Well, the beginning is usually just a bit of housekeeping. So, as people are trickling in, we will make a start. Thank you all for joining us today again from all corners of the world. Hopefully this time zone is conducive to you. If not, thank you for being here. Anyway, we are talking about designing healthcare for clinician well-being and patient safety. And based on the number of registrations 

1:27 Olivia: and the questions that we got from your registrations, it seems as though this topic will be one of interest to the group. As we are going through the content, I just want to see say a big welcome to you all. My name is Olivia. I am the associate course director for the Master's in Surgical Science and Practice as well as the PGCert in Patient Safety and quality improvement at the University of Oxford. I work very closely with some of our panelists that you will meet today. And I'm very excited to welcome you here today. As I mentioned, this was a hot topic on registration. So, you will have an opportunity to ask questions in the Q&A feature. So, you can see Q&A in the toolbar at the top or bottom of your screen. And please do ask questions throughout. You may be aware that this Oxford Open Grand Rounds event is a little bit of a taster of some of the concepts in the Master's in Surgical Science and Practice and the PGCert in Patient Safety 

2:24 Olivia: and quality improvement. So, if you're interested in the concept today, I'll share some more information at the end about how you can learn more. I'm really excited to introduce our first speaker, Laura. 

2:35 Laura: Hi everyone. So, my name is Laura Vincent, and I am an ICU and anesthetic consultant in Oxford University Hospitals. I am the simulation and education lead in ICU, and I've worked very closely with Helen over the years teaching patient safety and human factors in OxSTaR. But actually, I came at my simulation interest through an awareness and interest of the impact that education and simulation has on staff well-being and I've ended up doing some research in burnout and well-being in ICU staff. So really interested to look at the scope of what we're going to discuss today and thanks all for joining. 

3:19 Olivia: Thank you Laura and I'll pass it over to Lily. Welcome. 

3:25 Lily: Hi. Thank you so much for having me here. I'm Lily. My background is plastics. So, I CCTED in plastics a couple of years ago. But I'm also a professional coach and I work with clinicians predominantly surgeons around aspects often of performance but also remaining well and as fulfilled and happy as possible in what is such an incredible career but can be such a demanding one. So, I'm really delighted to join the panel today. Thank you. 

3:50 Olivia: Thank you Lily. Great to have you. And last but not least, Helen, I will turn it over to you. 

3:55 Helen: Thanks, Olivia. And yeah, really great to be here speaking about honestly such an important subject and that became ever more apparent during the pandemic. So my background in is in anesthetics and I'm the director of the OxSTaR Centre here at the University of Oxford. And I run the HFTC module on the Surgical Science and Practice Master's and over the years I guess my interest in well-being as aside from being in the clinical workplace myself has arisen largely out of my experience in safety incident investigation it's become increasingly apparent to me the importance of workplace design and workplace culture and we're going to be touching on quite a lot of those issues in this session so I'm going to now share my screen. Olivia, I wonder if you could Thank you. Stop sharing yours and hopefully this is going to work beautifully. Can you all see that slide? 

4:52 Helen: Good. Good. Perfect. So, what we were thinking about for the flow of this session is that we'll start by thinking what resilience actually means in healthcare contexts. We'll discuss the impact of design on well-being and that's not just design of the physical workspace but also the way it feels the culture of the environments in which we work as healthcare professionals and then we'll think obviously about the sorts of things that could make a difference over the course of the next 45 minutes or so. And so, if I just pop this slide up to start with, I think it's important to define what we mean by resilience. It's a word that's bandied around quite a lot, and Lily and I were laughing about this on a recent podcast we did on the importance of education in surgery, and it means a lot of a lot of different things to different people. We've chosen to use this definition about that ability to adapt or respond when things get a bit sticky. And really the purpose of 

5:49 Helen: This session is to think about how we ensure that we all this is my gang in the orthopedic theater, right? How do we ensure that at the end of the day we're all still smiling, right? And how even during a pandemic are we there's Laura with the crazy backpack on running around the hospital intubating patients. That was a heck of a time. And you think about it, we still found time to think about the sorts of things that we were proud of. And we had orthopedic surgeons learning new skills helping us prone patients in intensive care and so on. How do we ensure that that resilience remains in the healthcare workplace in such hugely challenging environments that that we've already touched on and I think one of the one of the first questions that we thought we'd explore is what is it about the work environment whether it's equipment the physical space that you work in the outpatient clinic the operating theater whatever it is and the teams in which 

6:45 Helen: We work that makes a difference to our well-being and of course the important knock-on effect to patient care and safety. And I wonder Laura, I know you've done a lot in this regard and it's probably a little bit too obvious to say that in intensive care the amount of pressure that you're under on a daily basis to manage the workload and the complexities and the challenges of coping with family emotions and so forth. How do you support your teams in doing that without burning out? 

7:19 Laura: Yeah. I think obviously everyone comes to work to do a good job and to do the best they can. But I think that we have a role in trying to make sure that everyone comes to work and also has a good day. And there's quite a lot of evidence that patient experience is a direct result of staff experience. So, paying attention to the culture in the workplace that we're operating is going to be fundamental to staff having a good experience and having good well-being in their workplace. And that is going to have a direct impact on patient safety. It's going to impact outcomes, incident risks, and it's going to impact, the patient care as a whole. And it's it goes I think you've got a slide coming up that to include Maslow's hierarchy. And this can be applied in all organizations and in all walks of life. But paying attention to all areas of this pyramid right from the very basis of making sure everyone's fed and watered as has somewhere to rest is safe in their 

8:35 Laura: Workplace and is invested in I think is important to pay heed to at all times not just when you're having a teaching session or when you're having a debrief about something. 

8:46 Helen: Yeah, absolutely. And I'm going to bring Lily on in on that fairly extensively in a minute because I know she's got huge experience in certainly from her coaching practice in thinking about these key issues. But I just wanted to explain to the audience the pictures here. So, we wanted to convey the importance of the physical workspace in which we exist. And we don't just mean the what it feels like to be in in an operating theater. It's about the human device interfaces. All these different tools that we use, the electronic interfaces that we that we come across every day during the pandemic, these hideous mask dispensers that never work properly. Either pull out 15 or get one, and you rip it in half and so on and then no one's ever going to want to use these devices. But I think all of us can think of physical environmental issues that cause us grief. And when we think about the core tenets of human factors, which are when you're thinking about human-centered design, you should be thinking about what is it that's going to make 

9:42 Helen: Work easy to do. But the twin aim has to always be that that work must that the design of the space must feed into work well-being. It must make people feel good to be in that environment. And that's not always the case in healthcare. And Lily, if I could, I'm going to I'm going to bring you in now onto this issue of culture and support in the workplace for for the highly pressured jobs that surgeons do because I know you have very personal experience of that. 

10:09 Lily: Yeah, thank you. And I love that Maslow's hierarchy is up because I think we often forget that well-being is about a well human being and we're people, as my mom would say, warm warm-blooded mammals. She grew up on a farm and she always she's always amazed by how isolated we can feel as clinicians despite being surrounded by other people and I think when you look at this at Maslow's hierarchy he actually later in his career divided these into deficiency needs and growth needs and the deficiency needs are exactly as Laura said your food water warmth absence of disease physical safety psychological safety, belonging, esteem, and love. And those actually, when you think about it, in your average hospital job, aren't all met. And when you don't meet your deficiency needs, you're in a state of stress because you're trying to meet them. And only once you do and throw in a bit of esteem and status, can you start to grow and learn and ultimately self-actualize, 

11:14 Lily: become the best version of you that you can, and then self-transcend, start to do things in in honor of others. So, I think there's quite a lot of work for a lot of us to do in creating work environments where those human beings behind the clinician feel safe enough to grow and to really contribute in the way that they want to. And I'd like to share an anecdote which I think lots of you will probably relate to which was the reason I got into coaching was because I experienced performance anxiety as a second-year plastic surgery registrar. So, I'd been a doctor for about 5 years, and I vividly remember the day this started. I was doing micro just joining together two ends of an artery for breast reconstruction kind of two 3 mm vessels and a consultant that I really respected walked behind me, looked at the screen and said, "Beautiful stitching." and I just suddenly became really self-conscious and started shaking. And I sort of looked around. Everyone 

12:13 Lily: looked really embarrassed and kind of looked away. And I the more I tried the worse it got, and I got through the case, but I then became really worried that it would happen again. And of course it did in certain cases in front of certain people. And I asked some mentors of mine, some consultants I really respected what to do. And there was just no advice available apart from take beta blockers and get on with it because that's what everyone else does, which is fine and many people do, and I did for some time. But I couldn't believe that there wasn't more advice particularly when I started noticing it around. I often notice people with a tremor or with what looked like a cognitive manifestation of performance anxiety. Anyway, about a year later, I went to a conference and there was a doctor giving a talk and he supports athletes and runs a performance center for athletes with this multidisciplinary team and he was explaining all of the stuff they do, high-tech tracking and 

13:06 Lily: intervention, psychological support, physical support, nutritional, all of it, sleep therapy, everything. And I sort of girded my loins and I approached him in the questions and I shared this really shameful secret of mine that I just felt so mortified about that I had this tremor and could I book in to see his team and he just turned to me and really dismissively said, "Oh, you probably just need to do some mindfulness and just turned away and spoke to the next person." and I felt so angry because this was such a massive issue for me and I'd been hiding it and I felt so ashamed of it. I wondered if I was even cut from the right cloth to be a surgeon. And what was worse, it worked. And literally within two weeks, I was practicing mindfulness every day, and I was able to completely manage my performance anxiety. Occasionally I'd get a tremor. I knew what to do. Never took a beta blocker again. And it made me so mad that there is understanding around how to manage these things and the psychology behind it. This desperate 

14:04 Lily: need that we have to belong and to be good enough that's based on our evolutionary past and yet it wasn't being shared with me and with the 87% of surgeons that we now know experience performance anxiety that negatively impacts their surgical performance in two-thirds of cases and their well-being in 96%. So, I think it's really really important to consider the education in our workplace, but also the openness with which people share their totally normal reactions to really unusual situations and create a culture where we talk about it. Sorry. 

14:42 Helen: Yeah. No, Lily, that's great. It's such an important thing to get out there, isn't it? And I think the performance anxiety is different for us in anesthesia. I don't know about you, but I you go into an emergency situation and as an anesthetist, what tends to happen is you arrive and you say, "I'm the anesthetist." and there's this massive, "Oh, great." oh, massive relief. Someone's here that's going to just take over and sort it all out. And that can most definitely lead to performance anxiety in the way that that you're describing. And in fact, that's where the kind of training that Laura has been talking about, this experiential training that can be offered in simulation, but isn't done enough in in these high pressure specialties to help us cope with the management of acute stress in these situations is very obviously missing and it's missing at a very basic level. If I just point to the surgical curriculum and ask you where within that curriculum is any of this where is there clear guidance on how simulation can support 

15:42 Helen: not just technical skills development which of course we know is extremely important but arguably more importantly those sorts of skills that you're managing under pressure performing when everybody's watching you and I thought this over the years yeah when I've been in theater and I'm looking at surgeons and the number of distractions that that you guys get in the middle of a case for example I consultant coming in saying when are you going to finish when are you going to finish yeah then oh I'm on call as well as trying to suture this nerve and you're like are you crazy this this is unacceptable and these are the cultural issues that I think we're touching on here and that very nicely feed into what you've just described in Maslow's hierarchy of needs I'm going to say something quite lighthearted now and say that when you look arguably you look at the bottom there the need for air food water health that underpins everything Right. And I laugh about this a lot 

16:32 Helen: Because at the start of the pandemic, I honestly have to say that there was a massive sense of relief in our hospital because we got an M&S at one end suddenly and a Pret at the other just before it all booted off and you could suddenly get a decent cup of coffee in our hospital at pretty much any time of the day or night. And it's not trivial, is it? These sorts of things. There was a question that came in from the audience that said, what are the sorts of things the NHS could be doing that really aren't that difficult? And arguably that is one of them, right? [laughter] but I think that the other aspects of system design that that we don't think about enough and one of these issues came up in the question is what is the patient experience like? What does it feel like to come into an organization like ours and experience the physical environment, the technologies that they're exposed to, the team cultures and the way that healthcare professionals speak to patients, you 

17:28 Helen: know, how do we address those issues in the context of worker well-being and patient safety when everyone's under pressure, and we're all I've watched this on ward rounds recently. Everyone's on a computer writing on the computer, not looking at the patient. How do you, how do you fix that?   

17:47 Laura: that? What can we do about that? Well, I actually have a strategy on my ward for that. So, the with the number of people on the ward increasing, so does the number of computers. So, I try and limit it for two, but also, I have this thing that everyone laughs at me about with the ward feng shui. So, I don't allow them to place the computers in front of the patient, which is the natural thing to do at the end of an intensive care bed. And we sit and we stand at an angle so that you can see the patient, they can see you and you can see the rest of the team and it's just silly little things, but I think it makes a really big difference to a patient not seeing a wall of screens in front of them. I completely agree and I think that sometimes Lily, I don't know what your thoughts are on, 

18:27 Helen: particularly around how we achieve better support for staff in the workplace, but there are some relatively simple things that that we could be doing. And I know that coffee example was a fairly good one, but I do think it's important. But around training, the things that you and I spoke about on our podcast a little while ago, I don't know whether you wanted to highlight any of the things that you think we could be doing more effectively and relatively cost effectively around, worker well-being.  

19:00 Lily: Absolutely. So, in preparation for this call, I went back through my coaching clients with nearly 100 surgeons now and other clinicians too, and there are two really clear themes that obviously everyone's different but two really clear themes. One is the performance anxiety one technically also in relation to interviews and exams public speaking that sort of thing, but the other one is this real sense of overwhelm of demands outweighing resource and I think one of 

19:27 Lily: the things that's really simple and could be really effective speaks to exactly what you were just saying Helen about interruptions so interruptions are incredibly disruptive it takes on average well there's a lady called Gloria Marx who's done a lot of research about this She reckons it takes an average of 23.3 minutes to get back to anything you you've started after an interruption, for instance. But at the very least, whatever happens, you get drawn out of a potentially a flow state, a very effective state. You have to switch. Usually, you have to switch context and then you have to get back to reconnect with what you're doing. And there's an attention residue and it's meant to take at least 25% longer to complete any given task if you're task switching. Now there are obviously times where interruptions are welcome and important like the anesthetist arriving at a cardiac arrest. That's an interruption that everyone wants but most of the time it is taking people away from their work 

20:22 Lily: From what they're trying to do from their focus area. So I think small things in the workplace like creating permission around but also space for uninterrupted work that includes bleep free time and specialties differ but it's still the norm for the surgical registrar to have the bleep in theater as you were alluding to I think could massively reduce the concept of demand by reducing the length of time for each task but also it could massively increase our ability to perform what we're trying to do effectively. I dare to say that the majority of people on your ward Laura are unable to be effective because there are so many different interactions going on that the net sort of constructive output is very low. But I think the other time where it's really important for well-being to minimize interruption is when people aren't at work and again, I'm not sure about other specialties but it is normal in surgical teams to have WhatsApp groups for not necessarily patient details but even just clinical chats 

21:19 Lily: around staffing and thing stressful things that stressful messages people can read when they're in bed with their partner when they're trying to bathe their baby when they're just trying to have time out and the importance of strategic rest is really built in. It's interesting to look at other professional groups. If you look at athletes or aviation, rest is enforced not only between shifts but at weekends or booking leave and I think we're very guilty of not doing that and I noticed there was a question around the quality of sleep which has I was going to bring that in. Well, sleep is there is nothing we can do in 

22:03 Lily: Waking hours that's as important as the quality of our sleep for performance. It is critical not only in physical and mental repair but also encoding memories, in emotional regulation, which is a big issue when you're talking about well-being and burnout and so on. And there are understood parameters that are required to optimize sleep. You have to sleep deeply enough in the first half of the night to get enough deep sleep and you have to sleep for long enough to get enough REM sleep and have enough overall sleep opportunity. And in order to get that deep sleep at the beginning of the night, you need to be able to access a deeply parasympathetic state which means not engaging with stressful content which includes work messages amongst other things. Regularity of sleep is also really important and of course shift work is a big problem for that. And we aren't recording the [clears throat] levels of fatigue at the moment. I think that it's such an important point, isn't it? There was a there was a 

22:58 Helen: question, as you say, in a very specific one about how we're monitoring and managing fatigue, and the recent HSSIB report on fatigue is really insightful in this regard. The fact that we're just not doing it. We know it's a problem. And it's almost like that that NHS mantra of feel free to cope is still pervasive across our organizations. Wherever we work, whether it's in primary care, whether you're a nurse or a doctor or a physio or a pharmacist, it's the same thing. Feel free to manage in this awful system that is frankly sometimes setting you up to fail. 

23:38 Laura: And no one's going to reward you for staying up all night if you then, make an error. And it's this thing, this sort of still this kind of message that you shouldn't be sleeping when you're in a night shift. And it's like if someone's going to do an operation on me at 5:30 in the morning, I've had two hours sleep an opportunity earlier in the night and there is the opportunity to share that workload. Absolutely. But that comes down to environment and Maslow's hierarchy and what we're providing for staff as well because there is a complete a deficit of rest facilities within the hospital and that's another thing and it's always the bottom of the priority pile with new estates and in fact restrooms and I see have all been taken up by officers for staff and it's like this is not acceptable this is base level food water sleep isn't it. 

24:23 Helen: I want to bring it back a little bit if I may to the idea of how we support our people and mentorship and where that might sit because I had a I had a recent call I'm going make sure I anonymize this, but a call from a colleague who said that a new consultant colleague had arrived and was displaying all sorts of problems with behavior and this was calling it causing a great deal of stress to other members of the team in the in the workplace. And what did I think they could do about it? And I said, "Okay, well, let's just back off a little bit and think about this sounds to me like a person in distress. What is it that you've got in place as a 

24:58 Helen: new consultant to support that person in coping with a transition from a registrar to which we know is a huge step and arguably in in craft specialties like ours it's a hu it's even more stressful because suddenly it is you where the buck stops and you're the one that has to make all the decisions and I said what have you got in place in terms of mentorship oh we don't do that in in our group and I thought gosh That's I am going to confess that it was a surgical group. I'm not going to say where, but it was a surgical group, and it really interested me because it's absolutely routine in our team in anesthesia. A new consultant arrives; they are allocated a mentor, and that mentorship can go on as short as long a time as is functional for that person. And in fact, I'm still mentoring two colleagues that started a number of years ago. They still come to me when there's when there's issues. And to me, that should be an integral part of what 

25:54 Helen: It means to be a consultant in a team wherever you work. And I'd value both of your thoughts on how that works. Lily, do you want to go first? 

26:00 Lily: Yeah. I absolutely believe and it's interesting that we started with the definition of resilience. There's a psychologist consultant for psychologists in Bristol, Dr. Olivia Donnelly, who I've done some work with, and she's also part of the support initiative. And she often says, "Resilience is between us, not only within us." and I think this is a real example of that. That those relationships that feel safe to connect with other human beings when you're making these massive and really uprooting transitions. I did a qualitative piece of work a few years ago where I interviewed 10 plastic surgeons from kind of right the very in fact core trainee who wanted to be a plastic surgeon right up to very senior consultant and one of the consultants who was relatively newly appointed at that grade said once you become a consultant the expectation is that everything and I think 

27:01 Lily: There's a culture of that if we're talking about workplace culture and change switching from that sense of needing to be unassailable into one where there is always learning and always growth and mentorship can exist in any direction. As a junior, you can mentor a senior consultant. As someone just a step ahead, you can mentor someone just behind you and as a senior consultant, you can mentor someone who's just stepping up to the level that you're at. And it all has so much value for both parties.  

27:42 Helen: Really nice points. And arguably, Lily, I don't I don't know what how you feel about this because we've been doing some work with ICU nurses and nurses in our surgical emergency unit on stepping up to more senior roles and realizing that our colleagues in nursing don't do this terribly well either, and you make assumptions, don't you, about other professions that you're not embedded in yourself that, oh, nurses, they must get this, they must, do mentoring really well, but they don't have the bandwidth, frankly. They've got too many other jobs to be doing [clears throat] and there's no time. I think that's the constant refrain. So, this program of of being bringing these nurses in and exploring with them using very simple tabletop simulations about what you do to prioritize at night when you're the one that's got to make decisions about patient care, about staff allocation, what happens when someone's gone off sick, how do you reallocate? These sorts of important safety based decisions are not taught and there's not that kind of strength of mentorship automatically in 

28:37 Laura: place for nurses or doctors I don't think and in in ICU it's often down to you to find your mentor isn't it and if you're lucky to be in environment where there's a plethora of people that you would turn to then great but some people are as you say much more isolated which is why I think setting it up and that being you look at other huge successful organizations big businesses they'll often have a kind of formalized on boarding process where you kind of have a supervisor period you're supernumerary you've got people checking in on you kind of orientated etc. and there's just no time for that seemly in the NHS and you kind of often hit the ground running we've actually tried to introduce this a bit for our fellows starting an ICU from overseas because not only are they starting in a new department but they might be starting for the first time in this trust in the NHS and actually in this country and they could have come from a completely culturally different setup. So, the overwhelm that they're feeling is just so extreme compared to somebody who's kind of come through our system and we've tried to create an onboarding program a bit like that. 

30:00 Lily: I think that's brilliant and I and what I really love about that and about mentorship generally as well is particularly for those people who may feel even more anxious than everyone else but actually everyone as you said is likely to feel very anxious at these transition points through having a regular mentor appointment for example it's almost using that concept of worry windows which is used a lot in psychology when you and I spoke to a friend who's a professional rugby player he has the same he has a regular appointment with his coach and with his therapist in his team and he said for him it gives him so much relief because he knows he can park his worries somewhere. He doesn't have to constantly ruminate on them. He knows he has his Wednesday appointment with Helen to talk through those things. And he can put them in one place and know he's going to get through them and move on from them. And just having that structure in place, I think, can be really helpful in and of itself. Plus, of course, the benefits of saying it out loud, still belonging, and receiving advice back. Yeah. So, yeah. Awesome that you've set that up. 

31:03 Helen: Yeah. Absolutely. And essential. [laughter] I wonder if we might just bring it back in a little bit to the sort of system features that we talk quite a lot about in the program. And the issues of this of the things that we touched on initially. We've naturally and I think importantly focused on what we do about culture in the workplace and support for individuals and teams. But the physical work environment and the equipment that we use is also massively important and very little focused on in healthcare. I've heard plenty of surgeons say to me that they the female surgeons saying things like well 

31:37 Helen: most of the equipment that's designed has been designed for men so for bigger hands and for taller people and so forth. And then other issues of design which I know we touched on in a light-hearted way in this slide. Which actually would not be that difficult to fix, would not be that hard to fix. And this issue of co-design, which we never pay attention to. And if you think about the new infusion pumps that arrived in our hospital during the pandemic without so much as a, oh, what do you think of these guys? They turn up and you just Yeah, we love we love them. Not the design flaws were so obvious to us that we're going to be using them in immediately obvious that it felt like such a an own goal for the company not to have talked to the clinicians that were going to be using the equipment. Think about hospital beds. The beds that we brought into the organization that are really difficult to access the brakes, the side panels are impossible to keep up without banging them really hard. If you want to put an ICU stack on the end, 

32:41 Helen: We've had to make something to attach it to the to the new beds safely. So, these sorts of design flaws tell a story in the program about the original design of a water-birth bath in maternity. It's the most hysterical thing. It it was an enormous oval high-sided pool basically. No steps, no handrail, nothing. So, women in labour were expected to get in and out of this thing. Midwives couldn't access the patients easily. And it took a hold on a minute, let why don't we talk to the midwives and the mothers about what this should look like before they realized, oh yeah, we should have we should really have thought of that. And those aspects of designing things, and it might not be the design of a physical thing. It could be the design, for example, of a checklist. So, checklists are everywhere in healthcare, but they are used very variably I think is is the way I would describe it and it's only become apparent in the recent past with all the research that's been done the importance of design in Checklist and perhaps first and foremost is co-design. Get the people that are going to be using the checklist to go through safety critical steps in a procedure to think about what those are and how they want to ask the questions which is exactly what you do iterative process  

34:10 Laura: And go from the workers imagine to the workers actually like well this seems like a good idea exactly we're now going to try it in practice and we're going to reflect and we're going to adapt rather than just exactly. 

34:24 Helen: A nd I think again just on the on the simulation theme. Obviously when you say simulation to people in healthcare, they tend to think of plastic people, and we do use a lot of plastic people in simulation. They're very they're very helpful. And if you ask the general public whether they think it's a good idea for doctors and nurses to practice on plastic people before they get to real people. Not surprisingly, all of them say yes, that's a great idea. And yet we don't do it often enough in that sort of low-dose, high frequency model that 

34:51 Helen: we've talked about. But whilst everyone gets why simulation is good for workforce development and training the workforce in healthcare, we don't think about it often enough as a method. So as a tool for understanding latent risks in healthcare and the sort of thing I'm talking about is the work, for example, that you guys did in critical care. Yeah. When you were moving from the old intensive care unit that we used all the way through the pandemic into the new fancy pants unit just outside here and you thought very carefully about what it was going to mean to transfer all your critically unwell patients individually into that new space. Yeah. And came up with all sorts of issues similar to the work we did with an electronic anesthetic record.  

35:52 Laura: Yeah. And it gives you a chance to try it out, make mistakes, learn from those mistakes and make adjustments rather than it being with a ventilated actual patient.  But in the same at the same breath, if you have designed a space with patients through an iterative process with an ergonomic perspective and a human factors approach, what you then can't do is then just repurpose a space. And I know we've talked before about the way that you'll have a broom cupboard that then hangs these procedures. We're just going to shove them in there. And actually, then you're just exposing huge risk to staff and patients, both physical risk to staff and to patients and safety risks, but also efficiency problems. And I think, if we do think systems design and environmental design is important, then we can't just go changing it willy-nilly and expect it all to be fine. Because it's just paying lip service to it.  

36:44 Helen: No, I completely agree and it's why I've kind of moved us onto this slide saying, look, what can we do to achieve this this sort of state of happiness at the end of again this this is this is my maxillofacial gang on a Tuesday and this was I did not I promise I did not make them 

36:53 Helen: smile. It was the end of a busy day, and we'd managed to squeak in an emergency as well as the elective work, and it felt good. So, so how do we achieve this on a on a day-to-day basis in healthcare and some of the things we've touched on back to Maslow's food drink coffee at night looking after your people training them properly in that in that low-dose high frequency model are some of the relatively simple steps and these are questions that have been asked of us that that we could be taking I think it might be quite good because we've got a number of questions that came in before this session that I think it would be worth going to right now and one right at the top that cropped up is of course AI is everywhere in healthcare at the moment. We're being scatter bombed with different devices that we're being asked to use as a way of reducing our cognitive burden and making our work easier. And in actual fact, it's failing fairly routinely when they're implemented 

37:56 Helen: Because, funnily enough, we're not thinking about the ways that we implement them. And I think if you look at those documents that came out of the IHI and out of the Chartered Institute in the recent past on how we implement AI in healthcare successfully, they point to the importance of several things. So, there are three probably three areas in which they think, arguably AI is going to be most useful. So firstly, as an admin tool. So, things that could capture your ward round, for example, and record them accurately. This kind not [laughter] letters and so forth in clinics where ambient voice technologies could be useful. Okay. So there's that. Then there's clinical decision support. It's a little bit more tricky. And I'm going to come on to why that is in a second. And then finally that they're talking about the importance of chatbots for patient information. Right? That that could be very helpful. But I think the three core areas where we're not getting it right yet is perhaps first and 

38:57 Helen: foremost we're not thinking carefully enough about where in the healthcare system it is most appropriate to put these tools. All right. So that's the human factor system thinking aspect of it. We're then not thinking about what it takes to ensure that our healthcare professionals trust these devices, have confidence in what they're telling them. And then let's bring the engineers in and say what we need to understand about the devices is the interpretability and the explainability of how they're working, why they've come to that answer so that we then do trust and have confidence in them. And I don't know, I know that you guys in ICU recently had an experience with ambient voice technology, and I wonder whether you have thoughts on why that perhaps wasn't as successful as it might have been. Yeah, again I think partly it was because we were just sort of given it to try and like with all of these devices everyone is going to operate in different ways. So, my approach to a ward roundund for example is very different to a colleague's approach 

40:04 Laura: and I think again trying out a new device it you want to be able to understand how the different people are working and therefore help them get the best out of that device and in the end my feeling was oh this is just going to slow me down and I actually I was worried it was going to miss some of the things I was saying or misinterpret and actually from an efficiency point of view I therefore just abandoned it whereas got I've got other colleagues who are a bit more bought into this kind of thing who found it more readily implementable. I think there is a concern about governance as well as isn't there with patient data.  

40:41 Helen: I think yeah people were very worried about what was being recorded and some of the anecdotes I heard were when it came to having those sometimes very difficult conversations with families it was switched off. Yeah. Because they were worried about what exactly was going to be captured and where it was going and this sort of thing, which isn't entirely understandable. So, I think there's a lot of work to be done on how we harness AI to that particular question. I'm going to I'm going to move us on to one that we discussed a little bit before this started and maybe come to Lily on this and think about this issue of what we do when there might be a disagreement between colleagues and how you avoid that when you're discussing a patient's treatment in the presence of the patient and or their family. So, we talked a little bit, didn't we, about transparency, honesty, and so forth. Lily, you had some interesting thoughts on the way to approach this.  

41:36 Lily: Yeah. Well, I think my first thought was why remove it from them? Yes. There are lots of situations where there are multiple ways to approach the same problem and genuine clinical equipoise and having been a patient myself and recently with one of my parents I think I really appreciated being given and I appreciate that I as well that I'm saying this from the point of view of a medic and perhaps it was easier for me to weigh things up but the basic principle of autonomy states that patients should certainly be heavily involved in the decision- making and every as far as possible be given the tools to understand the decision that they're making and my view is that as clinicians we should facilitate that process and that clinical debate is actually incredibly helpful to hear I think it it helps in understanding the disease it helps in feeling enrolled in the process and it gives an opportunity to state health beliefs that can be very deeply held and I think are very important to reflect in the decision making. 

42:54 Helen: Completely and I think that's perhaps even more obvious when it comes to safety incidents being honest something's not gone according to plan here's what's happened we're sorry it's happened and we're going to take a step back and try and learn from the events as they've evolved and I've certainly over the course of the past decade or so when I've been investigating safety incidents I've had some what you might call courageous conversations, Lily, with patients and their families because you you've quite simply got to be very open and it can mean quite heightened emotions are expressed and managing those is it's a big part of our jobs no matter what role we're in.  

43:37 Laura: I think just slightly related to that, Lily, there's there is some quite good evidence as well from surgeons that the better the communication is with from surgeons to patients, the lower the chance of complaints then from patients when complications do happen. And for me, we were talking a bit about this beforehand. From my own experience, I've always found patients to be very grateful for very explicit information, and I know everyone varies in how much information they give. For me, I'm talking particularly in reference to anesthesia before an operation, and I often find people are very thankful for the explanations that are given. And I think if people feel informed, it helps them feel empowered. And then if things don't go quite to plan or there's a complication and you've communicated so well and in kind of engaged that trust and that shared, accountability, you're more likely to have a situation that can be managed well afterwards or in the event of something less good happening.  

44:53 Helen: That's such a nice point. I think it goes very much to what we discuss quite a lot in the online program we run in this hospital and in the module. The importance of compassion, right? Surely, it's barn door obvious why do we need evidence that compassion is important in healthcare and yet it's there in spades and if anyone's interested there's a great book called compassionics you could just Google it you you'll find it which explores very beautifully all of the evidence that points to and exactly what Laura is saying there's very clear evidence of reduced litigation for example from the United States where surgeons are more open and honest about what to expect about what has happened and about situations where complications have occurred and I think the value of compassion is not only obvious from the standpoint of team performance. We all know what it feels like to go into a work environment where you feel that people have got your back. Where you're going to have a good day when you see a certain group of people in the work environment. And the flip side of that is how it feels when it's not like that. When you don't you're not seeing the kind of people that are on the screen there. You 

45:48 Helen: don't know them. It's the middle of the night, it's an ad hoc situation, it's an emergency, and you don't know anyone. And that's where all of the important non-technical skills around good communication with your colleagues, around introducing yourself, around wearing a hat with your name on is hugely important and being kind to each other, being polite, being civil, makes a massive difference. And the evidence is not just around team performance as we're saying; it's very much around patient outcome as well. So yeah, I think hopefully that's answered that question on patient engagement, and I think always goes back to the issue of honesty. There was another one that interested me because rather fortunately this morning one of the DM students in the OxSTaR research group was speaking on the call and she was talking about her research in Kenya on how anesthesia providers in Kenya which is a very different context you can understand from working in this country cope with 

46:55 Helen: the very obvious pressures they have where workforce capacity and so forth is concerned. And the question that we were asked is, what lessons on clinician well-being can high income systems learn from low-income low resource settings? And so, I put that question to Hillary this morning and she was saying it's exactly the kind of thing I'm asking. But perhaps not surprisingly, that very human aspect of connectivity of knowing who you can go to for help is at the heart of it. And those lessons are the same whether you're in a high income or a low to middle income context. And that actually of course the nuances are going to be there in the way that anesthesia for example is practiced because in Kenya certainly a very broad range of individuals. So, you can have doctors, nurses, and I'm going to forget the title they give them now. It's like our ACCPs. Yeah. Our advanced clinical care practitioners. Exactly. Physician associates and so forth can practice anesthesia. And so, they come from 

48:01 Helen: different clinical cultures already and that presents an interesting difference in the way they cope under pressure and who they turn to for help. But I think where the differences are concerned at the heart of it, it's more of a similarity. It's more about the importance of human contact, of feeling free to speak up, free to put your hand up and say, "I don't know." Can you help me? That's so important. I don't know whether either of you have any more thoughts on that, whether indeed Lily, you've got any experience in low to middle income context.  

48:45 Lily: I think well just to really echo what you've said and I think also and I have limited experience but enrolling families as well and really connecting with the support structures of patients themselves which often plays a much more practical role in very under-resourced set or lower resource settings but I think is a really important lesson for us here too. 

49:06 Helen: I'm going to move us on to the question around debriefing after sudden traumatic events these sort of moments where everyone has had a stressful experience in a team and perhaps the patient has survived perhaps, they haven't. What do we do afterwards? How do we establish a culture of debriefing after these incidents? And it seems quite obvious perhaps to turn to Laura. I think both of us have had experience of the so-called hot debrief. But you this is something you feel quite strongly about and the psychological safety around setting those conversations up. 

49:32 Laura: Yeah. And the timing of them, which I think is really important. I do think that as we have become more experienced and more comfortable about analyzing safety incidents and how we learn from them in a productive and compassionate way. There is something of a risk around debriefing that they become a learning discussion and something to do with kind of anal analyzing this incident from a kind of safety point of view. But it's really important to recognize that the importance of firstly a a sort of temperature test making sure everyone's okay either immediately afterwards or at the end of a shift which is not a full psychological debrief but a kind of supportive sense check. But then actually that when you do organize a formal debrief, which shouldn't be too long after the incident, but should allow time for people to have had the chance to go home, decompress, for some of their feelings to emerge, and for them to process some things and have questions. That should be structured as a psychological debrief from which some learning may come, but it should not be the focus of it. And people shouldn't feel that they can't be present and can't open up in the way that they might because it's a safety incident analysis and those things need to be separated.   

51:18 Helen: And so I think that's really important. Yeah. Yeah. Yeah. And I don't know in your coaching practice, Lily, whether you've come across issues that have arisen as a result perhaps of poorly managed post-traumatic stress in surgeons. 

51:17 Lily: Yeah, absolutely. I think and again teams differ, departments differ but broadly speaking there is not a robust and reproduced system for dealing with for instance an adverse event, a complication or an error for surgeons and Kevin Turner who I mentioned earlier published a paper with his team around the experience of surgeons after an adverse event. And they're fascinating findings. 36% of them had the clinical symptomatology of PTSD. I think from memory 48% were experiencing anxiety, 43% sleep disturbance, 11% using excessive alcohol. And 43% of them had not spoken to a soul, not a colleague, not a partner, and less than 3% to a professional. And I think this again, right. I'm on my soap box, I know, but talks about having a culture where it's fine to be affected, and it's fine for things not to go as planned and they do. In the same survey, 80% of surgeons had experienced an adverse event of some kind in the last year. They happen. 

52:45 Helen: Interests me Lily because we just recently did a piece of work because a trainee in anesthesia came to me and said, "I've had this awful experience, after a safety incident. I don't think we've got adequate structures in place to support people after these sorts of events. Can we have a look? So, we did a survey and got a lot of responses, very interesting responses from anesthetists and thought, well, great, let's replicate this in the surgical cohort and very interestingly no one replied. So, this went out to resident surgeons only, not to consultant surgeons. So maybe there would have been a difference, but it really it kind of worried me a bit, and this was a repeated request. We sent it out a few times. And we did get some responses, but I think maybe five and three of those five said, "Oh, no, no, I've never been involved in a safety incident." and I found that quite hard to believe. So, it's clearly happening, right? We all know it is because as an anesthetist, if I'm in a safety 

53:44 Helen: incident, I'm usually in it with a surgeon. So, [laughter] it's going to be it's out there and it's happening and I worry that that culture of being able to talk about it is perhaps not as obvious as it as it should be in surgery.  

54:18 Helen: We have a hand up. So, Anu, I see your hand up. I'm going to allow you to come off mute if you want to share your question with us. You're on mute right now. We can't hear you but sometimes Zoom takes a little minute doesn't it to if you speak go ahead and chip in otherwise please if you if it's difficult to speak you just pop the question in the chat I think we've got a few minutes to hear you yeah hi Anu sorry I didn't mean to have my hand up I was having no problem no problem at all I'm resisting though [laughter] no problem at all yeah I think this this issue of what we do after safety incidents is one that gives me still great cause for concern and it surprises me to this day as someone that's been an educational supervisor for a long time 

54:56 Helen: that I'll come across people that don't know what steps you take educational supervisors that don't understand if a resident doctor has been involved in a safety incident this is how they should be supported because there are actually structures in place but I just don't think people are aware of them as they should be and I think that certainly for consultants again I'm just not sure that people are aware and there's still too much of a feeling of being a bit worried it's definitely better than it was don't get me wrong since I started in this since we started teaching human factors maybe over 15 years ago now the feeling was very different than it is now and that's a good thing that's a really good thing and I think the advent of things like PSIRF and much more systems approaches to thinking about safety incidents the evolution of HSSIB has always been has also been tremendously helpful. But the messaging around learning from safety incidents rather than blaming when a 

55:53 Helen: safety incident has happened still needs a little bit of work, I think. Good. So, I am a little bit mindful of time. I think we've got four minutes left until the end of the session. Livia, I don't know if you wanted to come in and say a little bit more about the master's programme to finish off with. 

56:12 Olivia: Just first a big thank you to Lily, Helen, and Laura. I think we have time for one more question, and it looks like we have a hand up. So, Walter, I'm going to allow you to come off mute and then I will go ahead and close us out. Go ahead, Walter.  

56:39 Walter: Thank you so much, Olivia. Can you hear me? Yes, we can. I just had a question about these type of psychological stressors and has there been much research done on how it affects clinical performance and if so, in what way does it affect it? 

56:54 Helen: So, the answer is yes and badly if I'm going to put it very simply. And I and I think that the kind of stresses that we've been talking about all the way through this this program and the thing the anecdote as she calls it that Lily Lily spoke about in her own experience of performance anxiety are very obviously the things that we're talking about the concern we all have and if you just look at the HSSIB report on fatigue and the impact that has on performance both physical and mental performance . And indeed, in the compassionics book that I mentioned, there's quite a lot of literature around, the way people feel and how it impacts their performance. It's very clear that we're not doing enough a to understand it or b to support people who are struggling in the workplace, whether it's through mental ill health or physical ill health. Lily, I don't know if you wanted to say anything else about the impact that things like 

57:51 Lily: Coaching might possibly have on this sort of problem. Yeah, I think that coaching is one of many avenues to develop self-awareness and self-management strategies to learn to carve out time for and learn how to self-reflect. And I personally have found it really useful obviously well not obviously, but that's I appreciate my bias. I think therapy is also a really helpful modality amongst many others. And I also don't think that you need to go and see a coach. I think there are lots of ways that you can reflect on your own and lots of AI tools now around coaching which can be more affordable. But the advantage of seeing a physical coach is that it holds you socially accountable and financially accountable, and it can be very difficult to prioritize self-development work in a very urgent job otherwise.  

58:46 Helen: Yeah, absolutely. Walter, I hope that's answered your question. 

58:48 Walter: Yes, thank you so much. It seems it very much reflects the research that we've done on practitioner fatigue here in the States. Yeah. Yeah. absolutely. I think you'd find the HSSIB report. It's free to access quite compelling. Thank you so much. I really appreciate it. Not at all. 

59:13 Olivia: Wonderful. Well, with that, we are right at time. A huge thank you to Lily, Laura, and Helen for an excellent topic that we don't talk enough about in our day-to-day work. So, thank you for being here. Thank you all for joining the audience and submitting some quite thought-provoking questions in the registration and here live with us. As I mentioned, if you are interested in learning more, this Oxford Open Grand Rounds session is a taster of some of the concepts that are featured in the Master's and PGCert courses. If you would like to see some of the previous Oxford Open Grand Rounds, you can head over to our website. We did one in September about what's next for AI and surgery. So, you'll see a library of different topics that feature concepts from the course. And of course, if you are interested in staying in touch with us, please scan the QR code on the screen here. You can also find us at the link at the bottom of the screen. And if you have any questions, please email us at ssp@nds.ox.ac.uk. 

1:00:09 Olivia: Thanks everybody for being here and we will close out the session.