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The Human Issues :. -Why Exposures Happen -Responding to Reduce Distress Barbara Wren, C.Psychol. Occupational Health Psychologist Royal Free Hampstead NHS Trust. Why Do Exposures Happen?. Individual Level Explanations: Knowledge Confidence Skill/Competence Stress/anxiety

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the human issues

The Human Issues:

-Why Exposures Happen

-Responding to Reduce Distress

Barbara Wren, C.Psychol.Occupational Health PsychologistRoyal Free Hampstead NHS Trust

why do exposures happen
Why Do Exposures Happen?
  • Individual Level Explanations:
      • Knowledge
      • Confidence
      • Skill/Competence
      • Stress/anxiety
      • Internal factors- inattention, forgetfulness, carelessness
      • Fatigue
      • Solution=teach, train, motivate, (punish)
      • Person – centred approach suits management agenda (isolate cause=no change)
problems with individual level explanations
Problems with Individual Level Explanations
  • The best people can make the worst mistakes
  • Errors are not random but fall into recurrent patterns
  • Local human error = last, least easily managed part of casual sequence
why do exposures happen 2
Why Do Exposures Happen? (2)
  • Team/group level explanation
    • Communication
    • Leadership
    • Modelling safe practice
    • Team-working
    • Role clarity
    • Learning Culture of team
    • Solution= teach, train, motivate,( punish)
why do exposures happen 3
Why Do Exposures Happen?(3)
  • System Level Explanations
    • Errors = result of “upstream systemic factors”

Organisational strategy, culture, management attitudes to risk and uncertainty

    • Organisational Culture: safety vs. blame
    • Information as a Learning Resource
    • Integration of risk management into management structure
how human error contributes to system failure
How Human Error Contributes to System Failure
  • All organisations create barriers btwn source of hazard and potential victims/losses
  • Human elements weaken or strengthen by
    • Active failures “unsafe acts”
    • Latent conditions arise from fallible decisions often taken by those not directly in the workplace, lie dormant, combine with trigger event = incident.
latent conditions
Latent Conditions
  • High workload and fatigue
  • Inadequate knowledge, ability,experience
  • Poor equipment design
  • Inadequate supervision & instruction
  • Rapid change
latent conditions ctd
Latent Conditions (ctd)
  • Poor morale
  • Macho culture
  • Poorly expressed rules
  • Lack of integrated safety culture
active failures and latent conditions
Active Failures and Latent Conditions
  • Active failures hard to predict
  • Latent conditions are always present, can be identified and removed


  • Call for change in culture or management attitudes and beliefs
culture change to reduce error
Culture Change to Reduce Error
  • Raise awareness of cost of risk
  • Educate clinicians about their role in risk management
  • Focus on near misses as well as actual incidents
  • Ensure concerns can be reported without fear
culture change to reduce risk ctd
Culture Change to Reduce Risk (ctd)
  • Use external input to stimulate learning
  • Effective communication & feedback to frontline staff
  • High profile lead and personal commitment of senior clinicians
  • A strong organisational culture for dealing with the findings of reviews of adverse events
the way forward
The Way Forward
  • Unified mechanisms for reporting and analysis of mistakes and near misses.
  • A more open learning culture
  • Mechanisms to translate learning into practice
  • Wider appreciation of the value of the systems approach

An Organisation With a Memory, DoH, 2000

factors influencing distress after exposure
Factors influencing Distress after Exposure
  • Whose responsibility?

(guilt, anger with self/others)

  • Immediate/longer term consequences for self:
    • anxiety
    • uncertainty
    • health,
    • career,
    • relationships,
    • the “hoped for” future
factors influencing distress after exposure ctd
Factors influencing Distress after Exposure (ctd)
  • Immediate and longer term consequences for others:



  • Ability to manage anxiety & uncertainty
  • Tolerance of side effects of prophylaxis
providing initial psychological support
Providing Initial Psychological Support
  • Listen to fears
  • Communicate understanding
  • Normalise reactions
  • Check for information needs
providing initial psychological support16
Providing Initial Psychological Support
  • Prepare for emotional impact, & for physical side effects of treatment
  • Challenge thinking e.g, catastrophising
  • Discuss stress/anxiety management
possible emotional impact
Possible Emotional Impact
  • High emotion – eg tearfulness
  • Hyperarousal
  • Rumination
  • Nightmares
  • Shock and disbelief
  • Irritability
  • Emotional numbing
  • Avoidance
  • Guilt
  • Anger
issues to consider in planning support
Issues to Consider in Planning Support
  • Current life situation
  • Previous coping style
  • Social support
  • Personal and social resources
  • Psychological resources
  • Current psychological state
  • Impact on, and likely reaction of, partners, family etc.
factors influencing coping
Factors Influencing Coping
  • Understanding and interpretation of the threat (appraisal, assumptions and beliefs)
  • Ongoing stressors
  • Coping strategies used
  • Availability of social support
  • Self-efficacy
what helps
What helps?
  • Providing information sensitively
  • Supporting problem solving, positive re-appraisal, & information-seeking coping
  • Promoting self-efficacy
  • Help to access opportunities to discuss fears and feelings
  • Linking support provided to “the meaning of the exposure” for the individual