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Psychological principles could explain major healthcare failings

A paper in the BMJ’s Journal of Medical Ethics breaks new ground by using psychological approaches and insights to review major health crises within the NHS.

Despite several complex and high profile inquiries into major healthcare failings in the NHS, mistakes reoccur and failings in patient safety continue. While inquiries describe what went wrong in each case, questions of how and why such failures happened remain unanswered.

In the research paper, Dr Michelle Rydon-Grange who has just qualified as a Clinical Psychologist at the School of Psychology, applies psychological theory to find new understandings of the causes that lead to catastrophic failures in healthcare settings.  She explains that the aspect often neglected in inquiries is the role that human behaviour plays in contributing to these failures, and hopes that using psychological theories could prevent their reoccurrence in the future.

The value of psychological theory in safety-critical industries such as aviation and nuclear power has long been acknowledged and is based upon the notion that certain employee behaviours are required to maintain safety. However, the same is not yet true of healthcare.

Though there may not be obvious similarities between various healthcare scandals which have occurred in disparate areas of medicine over the last few decades, striking similarities in the conditions under which these crises occurred can be found, according to Rydon-Grange.

Dr Rydon-Grange argues that common to all these crises are three contributory factors: a culture of fear, blaming and shaming; aversion control and negative reinforcement; and low morale.

Particular sets of circumstances unwittingly created cultures which lead to professional carers behaving in a less caring way. Behavioural, social, and cognitive theories from the field of psychology can guide a further understanding of what leads to poor care, argues Rydon-Grange.

‘Each high profile enquiry has cited a lack of leadership and confusion over job responsibilities and complex or unclear accountability arrangements as significant causal factors. What psychological theories offer are an understanding of why people do not intervene to do something, to clarify responsibilities or to question,” she explains.

The ‘bystander effect’ explains how an individual’s likelihood of intervening decreases when passive bystanders are present - in other words, if no one else does anything then you are less likely to act. The ‘commodification’ of patients within the NHS- viewing them as goals and targets rather than as individuals- could also add to the passivity of the bystander by reducing identification with the patient.

A culture of fear and blame also exacerbates the problem by inhibiting safe practice. Behavioural theory suggests that human behaviour is learnt. Employees working in hospitals where a culture of shaming and blaming exist are more likely to engage in behaviours to avoid the negative consequences of blame. However this does not encourage positive actions, such as transparency or openness. A culture that rewards positive employee behaviours and a culture of learning from mistakes and openness would be more beneficial.

Finally a culture of ‘learned helplessness’ may explain low morale. Individuals become passive or submissive in the face of difficulties. Not being listened to, disengagement and unattainable targets may numb staff into a feeling of helplessness and add to low morale.

Adding to an understanding of low morale, a further psychological theory can help understand why professional carers appear to have made decisions or taken actions that are seemingly at odds with their professional values. Psychological theory explains that when a person holds contradictory thoughts, or engages in behaviours that are inconsistent with their professional beliefs about a particular situation, this can lead to psychological discomfort. We all experience powerful motivation to reduce psychological discomfort in ourselves and we can manage this unpleasant psychological state in a number of ways, such as changing contradictory thoughts and behaviours so that they become consistent with one another. Applying this theory can potentially help explain lapses in care standards and explain why healthcare professionals appeared to have, under certain circumstances, made decisions that may have been unsafe and contrary to good patient care.   

Psychology has a clear contribution to make in better understanding the culture and behaviours that led to these crises. Recognising that certain employee behaviours that are embedded within a culture of openness and learning are required to maintain patient safety in our hospitals is the first step in helping to prevent future crises. By applying psychological theory, behaviours that may seem difficult to understand, can become more readily understandable. Once this understanding is in place, we are then in a better position to begin thinking about preventing future crises. 

Publication date: 15 October 2015