Safer Cultures of perinatal care
In the last five months, three hugely important and impactful reports have been published, summarising wide-reaching inquiries into neonatal and maternity care in England. The stories and assessments shared by the teams led by Donna Ockenden, Baroness Valerie Amos and Lady Justice Thirlwall make for harrowing reading.
Harm occurs in our perinatal services, to babies and families, and to healthcare staff too. And some of this harm is avoidable.
Although the scope of these three inquiries was quite different, we are struck by two things. Firstly, the common themes that we see in each. And secondly, the value that psychological thinking could add to the proposed solutions. In this blog post, we share some of our thoughts on how psychological and relational thinking must be the foundation of any sustainable approach to improving safety in perinatal services.
Common themes
In all three reports, an absence of listening stands out as a common thread. There are countless stories of women, families, and clinicians repeatedly reporting concerns that were not heard, leading to avoidable harm, with tragic consequences.
Related to this, a psychologically unsafe organisational culture is repeatedly identified as an inhibitor of both sharing and hearing concerns. Defensive practice, coupled with a lack of truly authentic accountability, is widely described. This is the worst of all worlds: the finger of blame gets pointed (with all of its painful, disconnecting consequences) without clear, fair consequences being attached to the other end of that finger.
The Ockenden, Amos and Thirlwall reports all converge on the idea that safety is not only about technical reliability. It depends on relational conditions: whose voice carries weight, how distress is met, whether challenge is safe, and whether inequity is actively recognised and addressed.
A framework to understand
Given the clear psychological underpinnings of the problem, it is striking that none of these three influential reports engage with a psychological approach to a solution. This is very disheartening, but perhaps to be expected. Public inquiries are positioned within the public and political context to require clear, decisive, auditable solutions. Therefore attempts to operationalise culture-change by these broad national inquiries are almost destined to become tick-box exercises. Their paradigm requires that they conceptualise culture as a single, unitary Thing, that can be directed and shaped by top-down directives.
But cultures are not single, unitary Things. They are intersecting networks of different ideas, some of which are pretty abstract and hard to understand, let alone actually directly influence. They respond to top-down directives, most certainly, but rarely in predictable or controllable ways, because cultures are also patterns that emerge from bottom-up relational interactions between human beings.
We agree with Donna Ockenden, Baroness Valerie Amos and Lady Justice Thirlwall, that the culture of the perinatal system is at the heart of the problem of - and solution to - avoidable harm. We also think that, until the system spends a bit of time engaging meaningfully with the complexity of what culture means, and how to work in it (and with it), nothing will change.
To help keep hold of the nuance here, we find it helpful to recognise that culture is a multifaceted thing. We use an acronym, "CULTURES", to remind us of some of the different components that contribute to culture, in the perinatal context:
Contract: These are the social contracts we have with our employing organisation, with our colleagues, with our service users and with society: agreements about what we are here for, and how we accomplish that. How are these contracts negotiated, and how is power managed? Do we feel trusted and valued in our work? Do we feel that we have a voice?
Understandings: These are the beliefs that shape our culture. How do we make sense of the tasks we are here for? What do we believe about the challenges that this brings, and about each other?
Language: What words do we use in our setting? How does our language shape the way we are with each other? How does language get used in different ways (spoken/written, formal/informal)?
Traditions: What are the unspoken customs and 'ways we do things around here'? How are these traditions perpetuated, how are they learned? To what extent are we mindful and aware that these traditions happen?
Underlying Values: What are the values that organise us? Do we have a clear sense of what we care about - both as individuals and as a team? What happens when our values are in opposition to each others?
Relationships: How do relationships work in this setting? What does the map of relationships look like, and how do we tend to them? To what extent do we prioritise relationships when we think about safety?
Expression: How does this all show up in how we act? How do these contracts, beliefs, words, customs, values and relationships get expressed? What patterns of behaviour do we see? What patterns of behaviour do we not see?
(Stories: This is a bonus letter. For us, cultures can be seen through the idea of a story: what story do we tell ourselves and others about who we are, why we are, what we are doing, and how we are doing it?)
Safety
We believe that the psychology of human experience has a huge role to play in understanding the problem of avoidable harm – and in moving to a truly meaningful and practical model of safe perinatal care.
On the one hand, it is easy to think of 'safety' purely through the lens of harm-avoidance. This is certainly a key outcome, but it is only one half of the equation. People also need to feel safe to identify potential harm and learn from it. And when our mindset is focused on risk-of-harm (or 'threat mind', we might call it, which the human brain does pretty well), this is not a conducive place from which to engage in wise judgement and learning.
In fact, the idea of 'safety' has some quite distinct meanings, each linked to different human motivations. There is a very well evidenced science of the human mind behind this and if you're interested, check out what we have written elsewhere on this subject here and here. We think about:
Safety 1: This is the harm-avoidance mindset. Our brain's threat system is vigilant to danger and takes steps to reduce it (e.g. increasing surveillance)
Safety 2: This is the positivity mindset. Our brain's drive system motivates us to pursue success and replicate the things that work (e.g. learning from excellence)
Safety 3: This is relational safeness. Our brain's soothing system taps into safe relationships to help us settle, sooth, and connect with people and creativity.
A successful, responsive and sustainable model of safety needs to find a balance between all three of these motivations. We must act to reduce danger, and we must attend to and grow the things we do well. But crucially, we need to build this on a foundation of trust, connection and compassion. When we approach safety solely in a threat-based mindset, the focus of our minds narrow. Our ability to stay curious about different meanings and explanations is constrained. Our consideration of the internal worlds and intentions of other people becomes more rigid and less open. We close down ideas, stories, people, and signals (of both what is strong and what is wrong) unless they fit with our particular view.
This is what our brain has evolved to do in the face of threat and danger. It served us well, once upon a time (when we were a hunter-gathering species, for example). But threat mind does not increase clinical safety in a perinatal system. Quite the opposite: it inhibits all the things we need to do to promote safety.
Instead, we can start from a point of relational connection. This means we:
notice distress and vulnerability
listen to understand
hold uncertainty together, with curiosity
use power to protect, not silence.
This means using our courage to face and sit with discomfort, establishing respectful challenge, allowing:
staff to raise concerns early
families to be heard and believed
dissent and difference to be welcomed
learning to replace defensiveness
harm to be recognised and responded to helpfully
needs to be addressed and safeguarded fairly.
Creating safer cultures
Lady Justice Thirlwall rightly points out that one cannot simply bring about a particular culture, such as a "no blame culture" or a "learning culture" by describing it and expecting behaviour to follow. It is unfortunate that her suggestion to act according to a "patient-centred culture" falls foul of the same pattern. But it is understandable. The notion of culture is complex and multifaceted. Especially in NHS perinatal systems, which have overlapping cultural patterns at various levels of the interprofessional, local, regional and national picture. Conveying a single approach that will influence culture at all these levels in a helpful way is a mammoth task.
But it is one that we think is possible. We've started to outline our practical ideas here. These are the things we think will start to move things in a helpful direction.
Space. Spaces to think are prioritised. This means slowing down, noticing and reflecting what is happening in our team. Spaces to think are important for individuals but they really bring value when we can share those spaces together with our teams.
Accountability. Recognition and clear communication about everyone's responsibility is key. Is everyone clear about what is expected? What helps to scaffold the courage to have difficult, connected conversations when things go wrong?
Frame. Clear agreements and supportive processes. It is helpful to have explicit, shared agreements within a team, about how we do our work, how we take care of service users and each other, and how we check in when things are going well and when they are not.
Enquiry. An open and curious stance. This is key. A lack of openness and curiosity about other people (service users and colleagues) was at the bottom of every story from the Ockenden, Amos and Thirlwall reports. The conditions to maintain curiosity are hard to sustain in the face of overwhelm, without adequate support.
Relationships. These are the cornerstone of safe care. Relationships, between teams and families, and within teams, should be prioritised in any conversation about safety.
(If you would like to, you can download an A4 print-friendly pdf of the SAFER acronym here. You might like to display it as a poster).
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These ideas have been around for a long time. The system continues to fall at the final hurdle, though, which is recognising that this requires investment, concerted effort, and a lot of hard work and difficult conversations. The 2023 UK Neonatal Partnership Board "Supporting the perinatal team to implement recommendations related to Neonatal Care" report stated that "Compassion and Listening to Families... comprise the basic tenets of all patient care and should not per se require any additional resource." It is only at the most superficial level that this is accurate. It is true that individual acts of compassion and listening rarely require additional resource at the point of delivery, and would have huge benefits for patient safety. However, we know from research and extensive experience that compassion and listening require much additional resource in its groundwork and scaffolding. Our acronym "SAFER" doesn't happen overnight. It requires structure, space, facilitation, training, adequate staffing, appropriate skill mix, manageable workload, time for teams to come together, time for multiple teams to join in dialogue. This cannot just be for managers, it needs to be both a top-down and a bottom-up effort.
But more than anything, it needs to start with understanding.
