I have written previously about the use of A Just Culture Guide (NHS Improvement, 2018) to support systematic thinking when faced with patient safety incidents and how it can be useful as a tool when dealing with complaints against nurses or midwives in a fair and just way.
In 2018 the review by Professor Sir Norman Williams was set up to conduct a rapid policy review into the issues relating to gross negligence manslaughter in healthcare. This review supported the thinking in the development of the just culture guide:
‘A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’
And also:
‘In a just culture investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours.’
I recently spoke at a conference, the subject of which was ‘managing nurses in difficulty’. One of the themes throughout the conference was ill health, both as a contributing factor in why individuals had acted in a certain manner, and as a result of individuals going through a formal process.
The just culture guide states its purpose is to support conversations between managers and individuals to determine whether an individual requires specific support or intervention to work safely. It asks a series of questions to assist in clarifying whether there is something specific about an individual that needs support or management as opposed to a wider issue, in which case singling out the individual could be unfair and counterproductive. The guide also aims to reduce the role of unconscious bias when making decisions to ensure that individuals are consistently treated equally and fairly no matter what their staff group, profession or background.
The first question in the guide asks ‘was there any intention to cause harm?’ which in my view is the easy one to answer. However, question two, the ‘health test,’ is where I feel we need to consider our approach as this is the area that needs informed, consistent handling: It asks:
Substance abuse and mental health are the areas that I feel have the potential to leave both individuals and managers highly vulnerable, without the right knowledge and skills. I have never been given awareness or skills training to recognise the answers to these questions. Although I am not proposing that we become competent to diagnose these issues, with insufficient awareness and confidence to refer on to experts at this critical stage of early fact finding, many individuals will instead progress on a pathway of investigation that all too frequently can lead to suspension or a period of sickness absence and significant personal impact.
NHS Employers (2019) considered the knowledge that mental health will affect one in four people at some point in their life, and that employees with mental health problems frequently suffer discrimination in the workplace. It cited figures from the mental health charity, Mind, showing that 30% of staff disagreed with the statement ‘I would feel able to talk openly with my line manager if I was feeling stressed’ while 56% of employers said they would like to do more to improve staff wellbeing but didn't feel they had the right training or guidance. So, what can we do to improve this? A good start in my view is to use the NHS Employers (2018)Workforce Health and Wellbeing Framework. The framework considers the key organisational enablers required for improving staff health.
The framework also considers health interventions, informed by research on the leading causes of absence due to poor health from NHS organisations. The focus for all three areas—mental health, musculoskeletal and healthy lifestyles—includes prevention or promotion and self-management, in addition to psychological interventions. The aim is that working practices and conditions that are identified as contributing to poor mental health are managed, workplace support is available for staff to maintain good mental health and manage mental health conditions, and connections are made across mental and physical health. The toolkit enables a delivery plan to be built that considers three key areas:
The framework, with its best practice examples, appears to me to be a good starting point for a plan to improve our understanding and to approach how we support staff in the workplace with mental health issues.