Objectives (1) To identify a range of safety skills (attributes of a safe practitioner) relevant across clinical specialities. 2) To obtain the views of clinicians regarding their importance and trainability.
Design We used a survey and focus group of 10 patient safety experts to extract a list of safety skills. 50 experienced clinicians rated the skills in terms of importance and trainability in an electronic questionnaire.
Setting A Clinical Safety Research Unit and its associated NHS Trust, within an Academic Health Science Centre.
Results 73 skills, in 18 broad categories, were identified from the focus group and survey. The majority of clinicians felt the skills were important (most important: technical skills (98%), crisis management (98%), honesty (97.5%); least important: open-mindedness (82%), patient awareness/empathy (81.7%), humility (81.2%)). There was less agreement about trainability (16/18 categories were felt to be trainable; most trainable: technical skills (98%), anticipation/preparedness (84%), organisational skills/efficiency (83%); least trainable: conscientiousness (56%), humility (40%), open-mindedness (30%)). More surgeons than physicians felt that team awareness and crisis management skills were trainable (p=0.0099, p=0.025, respectively).
Conclusions We have identified a preliminary set of safety skills, which with further refinement could form the template for the development of a formal taxonomy of the qualities and attributes of the safe practitioner. Experts and practitioners agree about the importance of the individual skills. The fact that the majority of these were felt by experienced cross-speciality clinicians to be trainable is encouraging in terms of the possibility of developing generic safety curricula.
- Patient safety
- safety skills
- health professions education
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Safety is a property of the whole healthcare system. Over the past 10 years, understanding the role of wider systems in the genesis and erosion of safety was a necessary counter to the tendency in healthcare to blame individuals for errors and harm. However, this has had unintended consequences: efforts to improve patient safety have paid insufficient attention to the role of clinicians on the front line, in terms of maintaining safety within imperfect healthcare systems.1 Although the actions of the government and senior management have an important role to play, the people who work in an organisation are also part of that system; each brings their own contribution to safe, high quality care.2 At the coalface, safety may be either eroded by the actions and omissions of individuals or, conversely, created by skilful, safety conscious professionals. People maintain safety by being conscientious, disciplined and following rules, for example, by washing their hands or adhering to prescribing guidelines. However, keeping patients safe, particularly those with complex and fluctuating conditions, also requires anticipation, awareness of hazards, preparedness, resilience and flexibility, the qualities that those studying high reliability organisations have sought to capture and articulate.3
To try and instil these qualities into the next generation of clinicians, patient safety is being incorporated explicitly into both undergraduate and postgraduate training.4–8 To aid this endeavour, there has been some work to identify the desirable knowledge, skills, behaviours and attitudes of a safe healthcare practitioner within the Safety Competencies Framework.9 Despite this, however, many current curricula comprehensively teach the role of systems in patient harm and error, but do not address in any depth the necessary skills that future frontline clinicians will need as individual healthcare professionals to maximise the safety of their patients.
Although the teaching of safety attitudes and behaviours is unusual in healthcare, it is deeply embedded in a number of hazardous industries (table 1). For instance, the Western Mining Corporation in Western Australia is an exemplar of creating ‘error wisdom’ within its organisation and frontline staff. Their motto is ‘Take time, take charge’ which aims to get workers to stop and think, to spend time assessing potential hazards before acting. Furthermore, trainee British Army officers are taught to carry out mini-risk assessments of their environment, resources, terrain, and contingencies by repeatedly cycling through a series of questions as they plan and implement a mission.1 Although such foresight skills are clearly important in medicine, they are seldom made explicit and are rarely incorporated into formal training curricula.
Within healthcare, training clinicians to be safe has always been a part of medical education in the sense that good clinical practice is the foundation of safe care. Moving beyond these basic clinical competencies, however, there has been an initial attempt to identify some of the important safety skills, most notably in the context of non-technical skills in anaesthesia and surgery. Pioneered by Rhona Flin and colleagues, non-technical skills can be defined as, ‘The cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.10 The identification of these non-technical skills has not only stemmed partly from direct observation of experts, but also from analyses of accidents where a lack of these skills has precipitated or failed to prevent disaster. Much of the current evidence on non-technical skills has focused on the operating theatre, expanding the repertoire of skills and training to include communication, stress management, teamwork, decision making and leadership.11 12 Importantly, evidence that these skills can be trained is rapidly emerging.13 14 Furthermore, interventions which range from simple briefings and checklists15 to complex, high fidelity full team simulations16 17 have been developed to improve teamwork and non-technical skills and consequently clinical processes and outcomes.15
Reflection on clinical practice and review of the literature, both inside and outside healthcare, suggests that safety skills might require a broader conceptualisation than non-technical skills. We therefore set out to describe and classify safety skills in healthcare without reference to any specific clinical environment. We aimed (i) to capture a broad range of generic safety skills relevant to all clinical settings/specialities and (ii) to assess whether there is a consensus among front line clinicians regarding formal training of these skills.
The study was carried out in two stages. In Stage 1, a list of potential safety skills was generated from a written survey and a focus group of patient safety experts and experienced clinicians. In Stage 2, the skills extracted from these processes formed the items of a questionnaire, which we used to determine skill importance and trainability.
Stage 1: generation of a list of safety skills
Survey of patient safety experts
A qualitative approach was used to elicit skills and behaviours, as it was felt that this would produce a wider range of skills than is described in the literature. An electronic survey was administered to 10 experienced patient safety researchers, purposively selected for their understanding of patient safety and diverse backgrounds (medicine, surgery and academic psychology). In the survey, we asked open questions designed to elicit participants' beliefs and perceptions of key safety skills (see online appendix 1). A reminder was sent to non-respondents 2 weeks later. All of the individuals selected for participation responded. Using standardised qualitative techniques in the form of emergent theme analysis, 58 distinct skills were extracted from the free text survey data by two independent coders.
Focus group of safety experts
After completing the survey, the same 10 individuals participated in a focus group where the list of skills extracted from the survey were presented and discussed (member-checking). This led to a dialogue during which participants were able to clarify and expand on their thoughts, adding skills that had not described in the survey. The focus group was recorded and transcribed, and the transcript was analysed using emergent theme analysis. An additional 22 distinct skills were identified from the focus group.
Generation of a list of safety skills
The 58 skills extracted from the survey results and the 22 skills from the focus group were combined to form a long-list of safety skills. The wordings used to describe the skills by the participants were left unchanged for use in Stage 2, as we did not wish to alter the underlying constructs in any way. This meant that there were some skills in the eventual list which were very similar to others; however, subtle differences between them were preserved. There were seven exact duplicates, which were removed. This left 73 skills for inclusion in the final questionnaire.
Stage 2: questionnaire administration and data analyses
The 73 safety skills generated in Stage 1 were collated into a questionnaire in which participants were asked to rate on Likert scales (1–5) how important each skill is to being a safe practitioner and whether it is trainable. Prior to being deployed, the questionnaire was piloted with five clinicians to ensure comprehension and usability.
45 physicians and 45 surgeons were selected from a University Teaching Hospital in London using stratified random sampling. We sought to obtain the views of experienced clinicians, so the study population was restricted to speciality trainees of year 3 or higher, specialist registrars and consultants.
The questionnaire was administered an online surveying tool (http://www.surveymonkey.com). Between January and May 2009, clinicians were sent an email that outlined the purpose of our study and contained a link to the questionnaire. Subjects were informed that questionnaires were anonymous, that their responses would be kept confidential, and participation was voluntary. No incentives were offered for survey completion. Non-respondents were given two reminders via email.
Categorisation of safety skills and data analyses
Although respondents were presented with the 73 individual skills in a non-categorised manner, for the purposes of data analysis we subsequently categorised the skills using an iterative process with the agreement of two investigators (SL and KM). Table 2 shows the 18 categories generated (column 1), and the individual 73 skills (column 2), with illustrative quotes from both the initial scoping survey and the focus group (column 3). Importance and trainability data for each of the individual skills were grouped into these categories and cross-tabulated according to the respondents' specialities. Finally, any difference in perceived trainability between specialities was examined for significance by calculating the z ratio and associated two-tailed probabilities.
Of 90 potential respondents, 64 started to complete our questionnaire, and 50 fully completed it, giving an initial response rate of 71% and an analysable response rate of 56%. Of analysable respondents, 33% were speciality trainees year 3 or 4, 22% were specialist registrars and 45% were consultants. Regarding specialities, 45% of respondents came from General Surgery, 39% from General Medicine and 16% from Emergency Medicine.
Respondents felt that the majority of skills were important (4 or 5 on the Likert scale) to patient safety (figure 1). The highest scoring skills in terms of importance fell into the following categories: crisis management (98%), technical skills (98%) and honesty (97.5%). The skills felt to be least important were those in the categories open-mindedness (82%), patient awareness/empathy (81.7%) and humility (81.2%).
Participants exhibited lower agreement regarding skill trainability than importance (figure 2), although in the majority of categories (16/18) more respondents felt that the skills were ‘trainable’ than ‘not sure’ or ‘not trainable’. As might be expected, virtually 100% of the sample felt that technical ability was trainable. The next most trainable categories were anticipation and preparedness (84%) and organisational skills/ efficiency (83%). Conscientiousness (56%), humility (40%) and open-mindedness (30%) were felt to be the least trainable categories of skills.
Physician and surgeon participants largely agreed on the trainability of the safety skills (table 3). The only obtained differences were that that significantly more surgeons than physicians perceived that skills within the team awareness and crisis management categories are trainable (p=0.0099, p=0.025, respectively).
This study has identified a set of 73 safety skills within 18 categories, providing a template for a broader exploration of the skills and attributes of the safe practitioner. We have demonstrated congruence between the views of experts and practitioners about the importance of the individual skills. While some of these skills (eg, decision making18 or teamwork19) have already been the subject of considerable research in medicine, others (eg, conscientiousness or humility) are less well-explored. One might expect skills such as team working, leadership and anticipation to have been ranked higher in terms of importance, as might be the case in other high reliability industries.
The skills that we have identified are broader and more comprehensive than those alluded to in current patient safety curricula. As these curricula evolve further, we suggest that consideration should be paid to the possibility of including explicit training of these skills. Some of the skills identified might be considered to be attributes of character rather than skills, but are nevertheless thought to be potentially trainable.20 While such attributes cannot be taught in the lecture theatre, the training, enculturation and ‘hidden curriculum’ of medical practice can be a powerful determinant of the development of safety attributes.
The only significant differences across specialities in terms of perceived skill trainability were that significantly more surgeons felt that team awareness and crisis management skills were trainable. This may reflect the increase in team training and crisis management training available to surgeons,21 but not yet to physicians, and implies that involvement in safety-related activities can change the attitudes of individual clinicians, in turn enhancing safety. The obtained consensus among physicians and surgeons that the majority of skills are important and trainable is encouraging in terms of creating a generic cross-speciality safety training curriculum. Clearly, the skills identified overlap to some extent with those identified in other studies9 and with some skills currently being taught in undergraduate medical curricula (eg, communication skills and professionalism).22 Careful consideration, however, will be needed on how best to teach the other skills which might be considered to be inherent personality traits, such as honesty, humility or conscientiousness.20 These skills are not only desirable in doctors, but also in allied healthcare professionals, and it may be beneficial to consider the possibility of multi-professional safety training curricula in the future.
The main limitation of this study is that the sampling frames were relatively small. However, when generating the initial list of safety skills, although we surveyed 10 individuals, we obtained a wide range and large number of safety skills, and preserved the richness of this data by not reducing the number of items for inclusion in Stage 2. The large number of items generated in Stage 1 may have hampered the response rate achieved in Stage 2—the questionnaire containing 73 items may have been too time-consuming for busy clinicians. Having said that, our analysable response rate of 56% is comparable with other internet-based surveys of clinicians.23 The fact that we used experts in the field and experienced clinicians in both parts of the study allows us to be confident with the face and content validity of the questionnaire items.
We regard this list of 73 skills in 18 categories as a template for the development of a formal taxonomy of the qualities and attributes of the safe practitioner. This preliminary study, part of an ongoing research programme, has produced a list of safety skills validated by experts, which we intend to further explore and refine into a clearer hierarchical framework, that may be of practical use to designers of patient safety curricula. Further work is needed in other clinical settings and in other countries to refine and formalise these skills and to examine their relationship to safety outcomes and clinical performance. Ultimately, we believe that the identification of these safety skills and their successful incorporation into training curricula can be the catalyst to creating the safe clinicians of today, tomorrow and of the future.
Funding The Clinical Safety Research Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust, which is funded by the National Institute of Health Research. The research described here was supported by the National Institute of Health Research and the Health Foundation.
Competing interests None.
Ethics approval This study was carried out with REC approval, reference number: 07/H0712/113.
Provenance and peer review Not commissioned; externally peer reviewed.