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Resilience has broad connotations and is often associated with emotional resilience and the ability to bounce back in the face of adversity – here we might say a person can be resilient to dramatic events or incidents. These qualities are important for medical professionals but when we talk about ‘resilience strategies’ we mean something quite different.
‘Resilience Strategies’ are the informal, unofficial and inventive ways that people choose to behave to reduce the likelihood of error and to improve their performance. We do not include those things people do when they are just following official rules. Resilience strategies should either be novel and inventive things that people do, or they might be assumed to be the normal way of doing something in some context but they are not part of the formalised procedures.
For example, I do a four-point check before I leave the house, this is fairly normal practice for me now and reduces the likelihood of me forgetting my wallet, keys, phone or travel card. I know some people do similar and others don’t. I also write lists and set reminders on my phone to reduce the chance that I forget something. I might leave something by the front door so I don’t forget it before I leave home. Other examples can be found in this stream: http://www.errordiary.org/?page_id=1258
When I was observing nurses give chemotherapy treatment as part of my research, they also did double-checking with each other to make sure that they had the right medication for the right patient. This helps reduce error but it isn’t a resilience strategy because this is written into their formal procedures – they are just following the rules.
There were other things that I saw them do which weren’t written into the rules, which I’ve tried to capture here:
Furniss, D., Back, J. & Blandford, A. (2011). Unwritten Rules for Safety and Performance in an Oncology Day Care Unit: Testing the Resilience Markers Framework. Proc. Fourth Resilience Engineering Symposium.
Some of the things I noticed included:
- Using the trolley and tray to organise work rather than just as something to carry mediation and equipment. This helped nurses check what medication they had and whether they had administered it all at the end of the treatment. The trolley and tray served to help bound a unit of work so it could be monitored more easily.
- The experienced nurses also monitored what people were doing that were new to the department, e.g. one healthcare worker was replacing equipment on a trolley and didn’t know that a certain brand of equipment was preferred to another because it had less chance of leaking.
- When programming two infusion pumps in parallel nurses would intentionally programme one and then the other so there was less chance of confusing numbers and medication.
Other things I’ve noticed since that study include:
- Sticking sample request stickers on patients’ doors when they are in their own side rooms, so when a clinician enters they are reminded of what samples need to be collected if an appropriate opportunity presents itself.
- Letting some patients know how to silence their own infusion pump alarms when it’s considered convenient and safe to do so. No patient is meant to interact with their own infusion pump unless it is a special PCA pump. Note that some patients who worked out how to control the devices themselves are discouraged from doing so when it is not safe to do so either because of their medication, condition or mental state.
Recently on Twitter I have noticed nurses sharing other tips, which aren’t part of the official rules or procedures, and other nurses have benefitted from this advice, e.g.:
- A nurse recently posted that her daughter was having a panic attack and wanted advice on what to do. A number of other nurses got back to this nurse with different pieces of advice. The strategy they used which helped was putting an elastic band on the patient’s wrist and flicking it and focusing on her breathing. The nurse that gave the advice said she had an arsenal of strategies to use in this circumstance but that is her favourite.
- On a #SNTtwitchat recently nurses were sharing advice for student nurses who were just starting. One piece of advice, which was well received, was to carry a small note pad around to note down conditions, treatment and medication so this students can see what they need to read up on later.
This sort of informal knowledge sharing is great. I wonder whether it would be possible to share these sorts of resilience strategies and tips more formally, or just find out more about how this goes on already. If you have thoughts on this please share them below, this might include specific strategies, how to share them, how to organise them and pick the best ones, or just whether this sort of approach seems promising or not.
We have started a line of research to investigate this and we want to talk to nurses and other medical professionals about this work:
Further reading on resilience strategies:
Furniss, D., Back, J. & Blandford, A. Cognitive Resilience: Can we use Twitter to make strategies more tangible? Proc. ECCE 2012.
Furniss, D., Barber, N., Lyons. I., Eliasson, L., Blandford, A. (in press). Unintentional Nonadherence: Can a spoonful of resilience help the medicine go down? BMJ Quality & Safety.