Constructing and re-constructing narratives of patient safety

Social Science & Medicine 69 (2009) 1722–1731

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Constructing and re-constructing narratives of patient safety Justin J. Waring* Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham, NG8 1BB, UK

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 31 October 2009

In the pursuit of enhanced patient safety, new forms of organisational learning have been introduced within healthcare services across the developed world. This paper examines how these systems contribute to the creation of knowledge about patient safety. The approach taken in this paper departs significantly from methods found within mainstream patient safety research. Rather than attempting to define clinical incidents through taxonomies or classifications, it considers how knowledge is socially constructed in clinical practice and through the processes of risk management. Specifically, it considers how narratives – the stories produced by staff in a large teaching hospital in the UK – about patient safety events are developed within the interactions of clinical practice, reflecting a dynamic mix of emotion and shared notions of responsibility. It then shows how these are re-produced as incident reports which transform knowledge through check-boxes and pre-defined categorisations leading to de-contextualised ‘narrow narratives’. The paper then examines how these accounts are further re-produced through risk management activities as they become de-authored and re-constructed to reflect managerial assumptions about learning. Through considering how patient safety narratives emerge through these processes, the paper highlights the contribution that ethnographic research, with a particular focus on narrative construction, can make to the study of patient safety. It offers an alternative to the current orthodoxy of policy and raises questions about the capacity of such systems to shape the production of knowledge to the determinant of service improvement and to act as a mechanism of organisational power. Ó 2009 Elsevier Ltd. All rights reserved.

Keywords: UK Patient safety Narratives Ethnography Risk management Hospital Surgery

Introduction Since the mid-1990s, ‘patient safety’ has come to the forefront of health policy across the developed world. This is illustrated by the publication of numerous reports and the implementation of organisational and regulatory reforms encouraging healthcare providers to become ‘learning organisations’ (Department of Health, 2000; Institute of Medicine, 2000; Wilson, Runciman, Gibberd, & Harrison, 1995). Supporting and developing policy, the last decade has seen an exponential growth in patient safety research, as demonstrated by the UK’s Patient Safety Research Portfolio and the work of the US Agency for Healthcare Research and Quality. It is possible to distinguish within this research a ‘measure and manage’ orthodoxy. By this, I mean that research often seeks to measure the scale and sources of clinical risk so as to inform the introduction of management ‘solutions’ that control for risk. A key feature of this approach is that knowledge about risk is widely treated as objective, established through

* Tel.: þ44 (0)115 823 1275. E-mail addresses: [email protected], [email protected] 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.09.052

scientific classification, and amenable to management exploitation in the pursuit of organisational learning. In this paper, I want to offer an alternative to this ‘measure and manage’ orthodoxy by illustrating the contribution that ethnographic and narratological research can make to patient safety. Specifically, I explore how ‘safety’ knowledge is ‘constructed’ by healthcare professionals and through the processes of risk management. This constructionist perspective explores how knowledge, rather than being objective, is embedded in social practice reflecting the experiences, language, interpretations and meanings of social actors (Berger & Luckmann, 1967). Developing this view, the paper takes a narratological perspective (Boje, 2001) to explore how actors ‘make sense’ of their experiences through story telling. The idea of collective sense-making is prominent within safety research, being linked to a positive ‘safety culture’ (Weick, 1995). In this paper, I take a less functional view and suggest that although sense-making is often collective, it can also be a source of conflict as different groups compete to establish particular constructions of knowledge. At issue, therefore, the stories that people and hospital systems construct about safety can act as a source of power through informing shared responses, delineating or reinforcing social boundaries or acting as a vehicle for control.

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To demonstrate the contribution of this perspective, I investigate how safety events are constructed in the everyday interactions of clinicians and through the newly established systems of risk management and organisational learning, such as the UK’s National Reporting and Learning System (NRLS). These systems are significant because they seek to share the knowledge and experience of clinicians with organisational leaders so as to inform safety improvements (Waring, 2005a, 2005b). Of significance, they introduce a series of organisational spaces and media through which narratives of safety are constructed and re-constructed. I show how knowledge is constructed, firstly, as verbal and interactive accounts, secondly, as formally documented reports and, thirdly, as management data. Although there are inevitable differences in how occupational groups give meaning to clinical risk, my analysis centres on the differences within these organisational spaces. I also suggest that as knowledge is re-constructed there are important implications, not only for how staff ‘make sense’ of and report incidents, but also for organisational learning as knowledge becomes filtered and transformed. Moreover, I highlight the implications for organisational power as the control of knowledge becomes contested between occupational groups. Constructing knowledge about patient safety The ‘measure and manage’ orthodoxy of mainstream patient safety research can be seen in three predominant areas. The first is concerned with determining the nature and level of clinical risk (Vincent, Neale, & Woloshynowych, 2001), often through developing incident taxonomies (Dovey, Hickner, & Phillips, 2005) and re-conceptualising safety to emphasise the systemic factors that frame error (Reason, 1997; Vincent, Taylor-Adams, & Stanhope, 1998). The second is concerned with measuring and fostering cultural change, through replacing a ‘blame culture’ with a more proactive ‘safety culture’ (Jensen, 2007; Neiva & Sorra, 2003). The third deals, more broadly, with the implementation and evaluation of safety improvement strategies, such as incident reporting (Coles, Pryce, & Shaw, 2001). Although such research makes a significant contribution to the field, its underlying epistemological foundations often make it myopic and uncritical of reform. In particular, in its conceptualisation of risk, mainstream research resembles what Lupton (1999) terms a techno-scientific approach, where risks are amenable to objective measurement and technical control. Such an approach fails to consider how clinical risks are given meaning within particular socio-cultural contexts (McDonald, Waring, & Harrison, 2005), how the management of cultures can neglect the taken-for-granted and tacit dimensions of healthcare (Waring, Harrison, & McDonald, 2007) or how the management of knowledge can be interpreted as a form of organisational surveillance and control (Waring, 2007). In seeking to go beyond the ‘measure and manage’ orthodoxy of patient safety research, this paper investigates how knowledge about safety is constructed and re-constructed through intersubjective story telling and through interaction with hospital systems. The constructionist approach is typically associated with understanding how knowledge and meaning emerge through subjective experience and social interaction (Berger & Luckmann, 1967), how it reflects shared cultures (Knorr-Cetina, 1981) and how it constitutes a disciplinary form of power (Foucault, 1980). In particular, it is shown how knowledge that is often considered to be universal, objective and scientific emerges within a highly relative social, cultural, technological and political activities (Holstein & Gubreim, 2008). The constructionist perspective has been developed and applied extensively in the study of healthcare work, including clinical error. For example, Bosk’s (1979) study of surgical training identified

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three distinct interpretations of error which were integral to the customs of professional socialisation. Similar research has further explored how issues of error and wrong-doing are interpreted by doctors, revealing how meaning is shaped by the inherent uncertainties of clinical knowledge, feelings of guilt and the need to establish shared coping and rationalisation strategies (Fox, 1975; Mizrahi, 1984; Paget, 2004). Drawing together these themes, Rosenthal (1995) explores how the construction and subsequent control of ‘problem doctors’ is shaped by wider collegial desires to maintain professional credibility and reinforce clinical autonomy. Of interest in this paper, research also explores the different ways healthcare professionals and hospital managers give meaning to clinical risks. Doctors are shown to deploy a discourse that simultaneously invokes scientific reasoning, as well as more ambiguous patient-centred specificities, whilst managers construct risks in ways that facilitate enhanced organisational control (McDonald et al., 2005). Waring (2007) also illustrates the capacity for patient safety systems to operationalise risk in ways that extends managerial surveillance over professional practice, whilst also showing how doctors interpret risk in ways that mitigates individual responsibility. Such work shows how knowledge about risk is constructed within clinical practice and interaction and how it reflects wider cultural and professional concerns. A particularly important way of exploring the construction of knowledge is through the study of narratives. This considers how individuals and groups ‘make sense’ of and interpret their experiences through story telling (Boje, 2001). Stories help actors to give meaning to often complex and emotional situations through developing plotlines, which are sometimes ordered and linear, but more often fragmented and complex. Importantly, narratives are normally woven together through social interaction, reflecting a high degree of inter-subjectivity and being influenced by wider cultural beliefs (Currie & Brown, 2003). Accordingly, narratives help to establish and reinforce collective sense-making, especially in situations of uncertainty (Weick, 1995). Beyond cognition, however, narratives also have a wider collective role in reinforcing social customs and identities (Rappaport, 1993). Like folktales, they articulate collective values and moral beliefs, which help actors to develop a sense of belonging through the shared interpretation of past experiences and the guiding of future actions. However, narratives can also overlap and compete as groups negotiate their divergent interpretations (Brown & Humphries, 2002). As such, the narrative perspective is attentive to the links between knowledge and power, recognising that story telling can provide a discursive basis for defining social reality, contesting alternate ‘truths’ and privileging particular forms of social action (Foucault, 1980). The analysis of sense-making and narrative is well-established in the field of organisational risk (e.g. Patriotta, 2003; Weick, 1995) and is increasingly applied in the study of healthcare reform and patient safety. For example, Currie and Brown (2003) show how hospital managers interpret organisational change through collective narratives that establish their occupational legitimacy. In the area of patient safety, Currie, Humpreys, Waring, and Rowley (2009) investigate how professionals construct narratives of their use of medical devices in ways that privilege situated clinical discretion over strict regulatory control. Similarly, McDonald, Waring, and Harrison (2006) analyse the narratives that doctors invoke when responding to hospital guidelines aimed at promoting ‘safe’ clinical practice, showing how medical identities are deeply opposed to rule conformity. Of particular relevance to this paper, Iedema, Flabouris, Grant, and Jorm (2006) examine narratives produced through critical incident reporting. They suggest reporting offers a new space through which events can be constructed via formal documentation, which in turn has an important teleoaffective role through the opportunities for self-reflection, self-

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evaluation and self-control. For them, incident reporting is portrayed as a post or soft bureaucratic form of governance as healthcare professionals are required to systematically document, reflect upon and monitor their own conduct. Like the concept of governmentality (Foucault, 1991), this form of control is associated with the internalisation of disciplinary or bureaucratic logics, such as risk management, and enhanced forms of self-surveillance, as an alternative to more direct forms of management or hierarchical control (Flynn, 2004). Drawing on the narrative perspective, this paper explores further how safety-related knowledge is constructed both within clinical practice and through interaction with new risk management practices. By focussing on the contribution that risk management systems make to the production of knowledge, further insight can be taken from Science and Technology Studies. This area of research illustrates how scientific ‘truths’ are constructed through highly social, cultural and technological processes (Knorr-Cetina, 1981; Pinch & Bijker, 1987), including highly enmeshed socio-technological systems (Bijker & Law, 1992). Here technologies are simultaneously constructed by and constitutive of knowledge and social action. In the healthcare field, for example, research has explored how clinical knowledge and professional roles are co-constructed through technological systems, such as evidence-based medicine (Timmermans & Berg, 2003). Specifically, questions have been asked about the capacity for ‘evidence-based’ procedures to standardise clinical practice and challenge professional autonomy (Timmermans & Berg, 2003). Of particular relevance to this paper, clinical record technologies, such as case notes, are shown to create new knowledge about and change expectations relating to clinical practice (Timmermans & Berg, 2003). Furthermore, Vikkelso (2005) illustrates how electronic record systems can refocus organisational attention (or learning) to the extent that more tacit and psychosocial issues related to clinical work are neglected. In addition, she shows how clinical roles, especially those of nurses, can be transformed through technological interaction to reflect the underlying expectations of ‘medical’ record keeping. This area of research highlights how human-technological interaction is central to the construction of clinical knowledge and also clinical practice, especially through forms of standardisation. Drawing on these perspectives, this paper builds on Iedema et al.’s (2006) work to look in more detail at the dynamic construction of safety narratives as they interact with new organisational systems introduced to promote learning and service improvement. I focus on the National Reporting and Learning System (NRLS) that has been introduced across the NHS of England and Wales (NPSA, 2003). This comprises a number of procedures for gathering and analysing information about the threats to patient safety to inform service improvement. First, healthcare professionals are encouraged to communicate their experiences of clinical risk through completing incident reports. These reports capture information about safety events enabling it to be shared with service leaders to inform service-wide learning. Cultural change is seen as integral to the success of reporting, especially the need to foster openness and communication amongst staff (NPSA, 2003). Through the collection and analysis of this knowledge, service leaders can then develop a more thorough understanding of incident trends and the sources of clinical risk. Following standard risk management procedures, policies describe how incidents should be stratified in terms of their severity and frequency to produce risk, scores, e.g., high, medium and low. This determines the relative importance of incidents and helps to inform management decisionmaking. For those deemed to be significant or critical, health policies recommend service leaders undertake a structured investigation to determine the underlying ‘root causes’ (NPSA, 2003). Reflecting the Human Factors approach, this looks beyond individual performance

to consider the contributory factors that produce error and patient harm (Reason, 1997). Through these inquiries, more detailed learning opportunities are generated, as well as the potential for more informed safety improvements (Rogers et al., 2005). Through exploring how safety narratives are constructed and reconstructed both in the interactions between clinicians and through participation in the NRLS, I aim to illustrate the significance of the constructionist perspective to patient safety research. In particular, attention is given to the way knowledge is transformed and translated as it passes through these new organisational spaces and media with the intention of understanding how changes in knowledge not only shape organisational learning, but also have the capacity to re-shape clinical work and present new lines of organisational power. The study approach and reflections The paper is based on an ethnographic study within a large English National Health Service (NHS) teaching hospital. Ethnography is concerned with developing a detailed understanding of how people experience, make sense of and structure their lives, taking into account the links between meaning (inter)action, culture and social institutions (Fetterman, 1988), in this regard, story telling, folktales and narratives are important because they articulate shared beliefs and convey notions of morality, ‘otherness’ and belonging. Ethnographic fieldwork is particularly suited to exploring these stories through direct observation of social life. This enables the researcher to study how people experience, interpret and react to ‘real world’ situations with the aim of developing what Geertz (1973) termed a ‘thick description’ of everyday life. As such, it offers a level of detail and insight that can be missing from more positivistic and scientific approaches to patient safety (Finn & Waring, 2005). This ethnographic study was conducted over a period of 18 months between 2003 and 2005 with a focus on the hospital operating department. This included over 300 h direct observations of management processes, clinical interactions, surgical procedures and informal situations, e.g., coffee breaks. Observations were supplemented by numerous informal conversations, over 80 semistructured interviews and the collection of hospital documents. Semi-structured interviews were conducted with a sample of surgeons (14), anaesthetists (12), theatre nurses and operating department practitioners (18), departmental managers and administrators (13), and corporate managers and executives (14), including risk managers. Participants were recruited through written invitation to all departmental staff and through opportunistic encounters whilst undertaking observations, with the intention of acquiring a representative sample across occupational and organisational groups. As a part of the larger study, attention was given to staff participation in new risk management systems. This included observing the activities that took place immediately prior to making a report, normally in the proximity of the Operating Department’s administration office. I also observed how staff formally documented their experiences through completing reports (over 50 reports were observed) and I undertook two weeks of continuous observations within the hospital’s Risk Management department participating in and documenting the processes of data analysis. Where possible, I endeavoured to track individual cases as they moved through these stages; in total only 10 cases were observed in this way. Throughout the study, staff were informed, both in writing and verbally, about the research design and consent was given prior to undertaking observations, interviews and collecting documents. All names given in the paper are pseudonyms. Ethical approval was also provided by the Local Research Ethics Committee and hospital management.

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Research data primarily comprised journal entries that detailed my observations and reflective interpretations. Where feasible, and with staff consent, conversations and interactions were recorded using digital audio equipment. In this paper, data is used to investigate how safety events are interpreted, given meaning and constructed as stories through interpersonal dialogue, the documentation of incident reports and risk management activities. Before proceeding, it is important to highlight a number of relevant issues. First, my analysis is concerned with the construction of narratives within the different spaces and media provided by the hospital’s risk management system. It centres on vertical change in the construction of narratives (between frontline staff and service managers); it does not deal with the horizontal differences between professional groups (nurses and surgeons). Second and linked to the above, the majority of observed instances of reporting involved nursing staff, with only around 10% made by surgical or anaesthetic staff. This variability reflects wider occupational differences and is discussed elsewhere (Lawton & Parker, 2002). Finally, it is worth considering that healthcare professionals inevitably experience many events they regard as ‘risky’ in their work, which are acted upon with little explicit recognition or recourse to reporting (Waring et al., 2007). It can also be assumed that those planning to report initiate their interpretation long before putting pen to paper. However, the focus of my observations was those interactions and actions that took place immediately before, during and after reporting. Findings The findings are presented in three sections. The first examines the way safety narratives develop in the everyday talk of clinicians prior to being articulated within reports. The second examines how these narratives are then re-constructed as written reports. The third explores how these reports are received and processed by risk managers leading to a further re-construction. I elaborate my observations with reference to three illustrative examples selected because they reflect the common themes found within the data, but also because of their diversity in terms of reporter, clinical focus and managerial response. Construction I: interpretation of experience How do clinicians construct their preliminary interpretations of safety events prior to reporting? An initial observation related to the difficulty individuals had in bringing some sense of order to what were disorderly situations. It was rare for clinicians to present unambiguous and linear accounts of their experiences; rather, they were typically more fragmented and confused. As such, these initial narratives were difficult to ‘read’. As can be expected, clinicians were initially concerned to reflect upon and ‘work through’ their experiences in order to develop a clearer understanding of ‘what’ had happened. Significantly, this often involved discussion with colleagues where interpretation began to coalesce into verbal sequential plotlines. This can be seen in the interactions preceding the completion of Report #919: Sister: What happened then? Reporter: Mr Smith [anaesthetist] went walkabout. Sister: What do you mean? Nurse: Was that in Mr Jones’ [surgeon] list? Reporter: We couldn’t find him anywhere.yes during Mr Jones’ second patient. The alarm was going off and everything. We didn’t know what was going on. Nurse: Really!

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Reporter: Yes the patient’s BP [blood pressure] was dropping. Mr Jones’ wasn’t happy and we were sent out to find Dr Smith. But we couldn’t. Sister: Where was he? Reporter: I don’t know. He said he went to make a start on the next case as we were running behind schedule. We weren’t told about it, well I wasn’t. Sister: Did you find him? Reporter: Eventually, but he said he had handed over the patient to Dr Woods and his reg [registrar]. It was a right mix up. This illustrates, how narratives develop through the intersubjectivity of co-workers. Interaction facilitates the recall of experience and the development of plotlines, and in turn narratives become co-authored and reflect shared experience and beliefs. In case #919, the sister guides the re-telling of the incident leading to a more structured sequence. This shows, in particular, how senior colleagues, especially for nurses, are important, not only in guiding, but also authorising narratives. This was particularly important where an event involved another more powerful occupational group; in this case a nurse reporting the activities of an anaesthetist, as it provided consensual agreement about a particular account. Dialogue between co-workers also had an emotional dimension. As highlighted by Iedema et al. (2006), emotion is influential in the interpretation of safety events and my observations revealed further how feelings of guilt, frustration and blame could shape interpretation. As illustrated above, the reporter was exasperated by the conduct of the anaesthetist, and felt resentment and anger about their conduct. In the case of report #1139, however, the reporter expressed feelings of their own culpability: Reporter: I still don’t know what happened to it [surgical swab]. It doesn’t make sense. Sister: Well we’ve checked the theatre, twice. Reporter: The count was correct before we started. Suzie made the count with me. I just don’t now what happened. I really don’t. Sister: Don’t worry these things happen. You still need to complete an incident report. Reporter: I know. That’s why I’m here. But I just don’t know what to put. I can’t put it just disappeared can I. Sister: Just give as much detail as possible. And put down all the steps that we took to find it. Reporter: Ok. During this observation, I was struck by the despair and helplessness of the nurse and the story that unfolded was equally characterised by feelings of responsibility and guilt. Such feelings shape how clinicians make sense of their experiences and, it can be expected, shape how events are communicated or shared with others. In this sense, the re-telling of an event will re-articulate these feelings, either explicitly with trusted co-workers or perhaps implicitly through other channels. It can also be speculated that such emotion remains with the clinician, shaping their future conduct and opinions of other staff, for example, making them risk averse. As discussed above, I observed how these emotional issues were also discussed and resolved through dialogue with senior colleagues who seemed to help staff identify alternate interpretations, justify actions taken and, in general, offer a cathartic outlet. Concern with patient harm featured in the verbal accounts of clinicians. As can be expected, reference to severe harm or poor outcomes escalated or enhanced the significance of an event, as well as exacerbating other feelings of guilt or responsibility. However, this was particularly the case when harm was in some sense unanticipated, for example in ‘‘routine’’ or relatively ‘‘low-

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risk’’ cases. On the one hand, it seemed that the inherent uncertainties of healthcare made patient harm an expected aspect of practice (Fox, 1975). On the other hand, clinicians saw some events as ‘out-of-the-ordinary’ and not to be expected. In such cases, narratives were typically more confused and disjointed, yet staff appeared to interrogate and discuss these events in greater length as a means of developing a better understanding. However, I also observed how instances of potential harm also concerned staff. This can be seen in my discussion with the surgeon who completed report #1102 following a gall bladder removal. Surgeon: It doesn’t bear thinking about really. Researcher: What do you mean? Surgeon: Well it could have been a lot worse.the table collapsed beneath me just as I was about to make the incision for the laparoscope. It just dropped to the floor. It could have been really serious. Imagine if it was a few minutes later. [Pause – looks for the incident report] I’m really quite appalled at what we have to work with. The patient could have been quite seriously hurt. R: So the patient is ok? Surgeon: Thankfully. Medical Devices needs to undertake a thorough audit of the equipment and instruments. It’s not the first time this has happened. R: So it’s happened before? Surgeon: Not to me. But this kind of thing happens a lot and nobody seems to listen. In this case, the narrative takes on a ‘what if’ quality: it was not only what did happen, but what could have happened, that characterised interpretation. These ‘what if’ events reflect the idea that healthcare professionals should communicate ‘near misses’. However, in these situations, uncertainty and doubt seemed more pronounced in the talk of clinicians as there was often little substantive experience, change or outcomes on which to develop a more detailed account. This may go some way to explaining some of the difficulties in reporting near misses. Looking across these narratives it was common to find that they articulated longstanding and deep-seated concerns about service organisation. In many instances, it appeared that interpretation reflected underlying occupational and organisational tensions, especially between doctors and managers, and nurses and doctors. This was frequently found in the way staff portrayed ‘others’ as threatening patient safety, whilst guarding their own professional credibility. For example, with event #1102, the surgeon’s frustration with working conditions implies that clinical quality is undermined by the management of devices. In the case of #919, the nurse is clearly touching upon more deeply engrained concerns about the relative contributions to safety made by certain anaesthetist staff. Given that these views are developed with colleagues it can be seen how they contribute to a collective image of ‘them and us’, and offer a shared means for redirecting or deflecting feelings of responsibility and protecting professional reputations. A number of important issues characterise how clinicians make sense of and give meaning to safety events. First, these initial narratives are embedded within clinical practice and reflect the complexity of clinical work. Second, narratives typically develop through interaction with senior or experienced colleagues, which has an important role in helping staff deal with confusing issues and works towards developing a more sequential and stable narrative. Third, these narratives are highly emotional, revealing feelings of regret and frustration, whilst also serving to allocate or mitigate responsibility. Fourth, they convey deeper values and beliefs about professional competence, identity and jurisdiction, especially as questions are asked about the contribution of ‘others’. Finally, these verbal narratives often seemed to be important for

individual reflection and collegial discussion, enabling staff to share information and develop collective meanings of risk. As such, these narratives are likely to be influential in supporting and fostering learning at the local levels of clinical practice. Construction II: narrow narratives How are these narratives re-articulated as clinicians participate in incident reporting? Paper-based reporting packs were issued to all clinical departments and wards within the hospital. These contained approximately 100 A4 carbonised forms, with an enclosed information booklet providing guidance on the six sections that made up the form: 1 2 3 4 5 6

Who is making the report? Where and when did the incident occur? Who was involved in the event? What was the incident type? What happened? What action was taken?

Of interest in this paper, are those sections dealing with incident type, the description of the event and action taken. For ‘incident type’ reporters, first rate the severity of the event with reference to a ‘severity table’ displayed within the booklet. This comprises a five point annotated scale for: (1) low, (2) slight, (3) moderate, (4) major, and (5) catastrophic. An event rated ‘low’ is described as ‘‘no obvious harm, minor cuts or bruises, no loss of critical services’’, whereas ‘major’ involves ‘‘permanent disability, multiple injuries, or failure to meet national standards’’. Another table describes the corresponding ‘litigation consequences’ including the likely costs and criminal actions associated with each level. Reporters then select (with a tick) whether the incident resulted in ‘Fatality’, ‘Actual Incident’ or ‘Near miss’. Again, descriptions are provided for each. The reporter then selects the incident ‘‘type’’ from a list including ‘diagnosis’, ‘pre-op assessment/procedure’, ‘anaesthesia/ sedation’, ‘operative/invasive’, ‘drugs, fluids and bloods’ and ‘case management’. Reporters then have the opportunity to give two ‘free text’ accounts of ‘what happened’ and ‘what action was taken’. The first asks for: ‘‘a brief, factual description that does not make any assumption or provide any opinion regarding the cause’’. The second asks the reporter to describe ‘‘the action taken by staff to make the situation safe, prevent reoccurrence and ensure the condition of anyone involved.’’ Five lines of text are available for each description. Some initial observations can be made about influence of form design on the re-construct of safety narratives. Unlike the processes described by Iedema et al. (2006), reporters are first asked to think about incidents as numerical values and types. This frames how experiences are re-interpreted with an emphasis on measurable outcomes and litigation costs, whilst the personal stories of staff are reduced to short descriptions. As such, the incident form, in keeping with wider trends in risk management (Power, 2004), emphasises standardised measures, but with little regard for clinicians’ experience or professional opinion. In turn, the more qualitative and complex aspects of sense-making are reduced to items that can be measured and quantified. The possible implication being that important contextual information could be lost as learning becomes dominated by a narrow range of issues, whilst staff may complete reports ritualistically as they feel their experiences are undervalued (Vikkelso, 2005). Illustrating the potential tensions between the more qualitative and quantitative approaches to narrative construction, I often found that clinicians had difficulty in re-interpreting their experiences when making a report. Specifically, it seemed their subjective

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experiences did not easily ‘fit’ with the required measures or scales of reporting. For example, when completing report #919 (see below), the nurse consulted the ‘severity table’ on four occasions. Each time she seemed puzzled, verbally comparing her account with the descriptions found within the table. Only through further discussion with the sister was a value finally given. When I asked about this, the nurse indicated that the descriptions within the booklet did not correspond with her experiences. It seemed, therefore, that there was a mismatch between her initial understanding and the need to provide numerical scores. The impact of this mismatch is that staff seemed to feel the forms were only concerned with basic or superficial information and not ‘‘what really happened’’. This might be seen as a further barrier to encouraging staff participation in reporting.

Report #919 Incident severity: 3 Type: actual incident Clinical: anaesthesia/sedation Description: Patient had seriously dropped blood pressure, critically, Emergency buzzer sounded. Patient’s anaesthetist unable to be found. Throughout duration of patients admission, anaesthetist, Dr. Smith, was reluctant to finish care of patient. He said he had to anaesthetise the next patient on the list. He told me he had handed all care to Dr. Allen and Dr. Tree. Dr. Allen denied this and Dr. Allen was unable to come and see patient due to his next case. Action taken: Kept asking anaesthetist to review which he did every so often.

As can be expected, the clinicians’ documented accounts were often more concise, sequential and linear in form, concealing the ambiguity and uncertainty that characterised their initial interpretations. This may reflect the lack of scope or space on the form to include this information or the desire of staff to make reporting quicker. It also showed how much of the complexity and contextual information that characterised the talk of clinicians was typically missed in reporting. Furthermore, these documented narratives exhibited a shift in focus and emphasis. Specifically, whilst their initial accounts were typically concerned to understand what had happened, reports largely tried to explain what happened. Highlighting this shift in focus and sequential ordering, reports were often imbued with technical detail about professional roles, perhaps indicating that reporters attempt to establish an unambiguous and authoritative explanation of events and by association their own conduct. This can be seen in the report #1130 where the narrative consists of short statements with technical detail, e.g., ‘‘4  4 swab’’.

Report: #1139 Severity 2: Type: [not entered] Clinical type: operation/invasive procedure Description: (4  4) Small swab was missing during the operation. The swab count was correct when I checked first (open) count, while closing Aorta Proximal stitch. When I check before closing the chest one swab was missing. Action taken: X-ray taken. Reopen and checked in again. I personally and all other members of the team checked everywhere to no avail.

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In these documented narratives issues of responsibility also appeared to change, often being re-cast in the way events were described. In report #919, for example, the reporter locates responsibility with the anaesthetist (Dr. Smith), whilst de-emphasising their own role in the event and making direct reference to two named anaesthetists (Dr. Allen and Dr. Tree) to substantiate their account. Similarly, report #1139 emphasises the reporter’s conformity to established swab-count procedures, thereby deemphasising any claims of deviation from established procedures. In this regard, reporting also enabled staff to describe actions taken after the event to further illustrate or justify their performance. This enables clinicians to reconstruct their version of events in ways that further allocates or deflect notions of blame, and in turn reinforces the boundaries of professional responsibility. However, highlighting the unevenness of reporting, some accounts seemed to avoid issues of responsibility altogether, such as report #1102 where the written account consists of a single line of descriptive information with little indication of the frustration or annoyance felt by this surgeon.

Report #1102 Incident severity: 3 Type: near miss Type: equipment failure Description: Patient was on the operating table approximately 10–15 min into procedure, when the operating table dropped to its lowest position. Action taken: The operating table was checked by the staff scrubbed at the table for steadiness and the operative procedure was completed. The operating table was removed from the theatre, theatre managers informed, incident form completed.

Through making reports, I observed clinicians re-telling their safety narratives in a particular written form. Shaped by the design of reports and the guide book, clinicians were required to translate and transform their complex, fragmented and emotive verbal accounts into more linear, formulaic and quantified accounts. As can be expected, standardised reporting results in the production of ‘narrow narratives’ that emphasise unambiguous explanation and standardised data so as to inform the management of knowledge and organisational learning. This shift in knowledge is significant because reporting captures, potentially, only a fraction of the detail and complexity that staff see as contextualising safety events, such as resource constraints and professional boundaries. As such, the subsequent focus of risk management may be limited to only those issues that easily fit within this framework of knowledge construction. More than this, the lack of attention to situational complexity and personal emotion may have the recursive effect of discouraging staff from reporting, in so much that their feelings are not considered or staff see reporting as a bureaucratic exercise. Construction III: managerial narratives How are reported narratives received, processed and reproduced within the Risk Management department? Upon completion, forms were normally left with the Operating Department administrators who detached the original and carbonised copies, forwarding the former to the Risk Management Department and keeping the latter for local records. In the Risk Management Department, two Risk Officers and a Risk Manager engaged in

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a number of interlinked activities that broadly corresponded with the approach recommended within policy (NPSA, 2003). Forms were received and processed by one of the Risk Officers. Initially, they were monitored for clarity and consistency, such as missing entries. Any such issues were clarified through telephone discussion with the reporter. All reported information was then entered into a specialised computer package, which played an integral role in storing and analysing incident data. The Risk Officer would systematically transfer the information into the database using interface menus. These broadly corresponded with form design, starting with the name and location of the reporter, before moving onto incident type and then the entry of free text. I observed, however, that data-entry did not match exactly the information presented within the forms. Specifically, the number of incident types listed in the database was considerably different than those on the form. This required the Risk Officer to re-code reported incident types. When asked about this, the Risk Officer said that ‘‘it didn’t really change anything as the data was morphed afterwards’’. As I later found, this involved aggregating that data into new categories, ignoring the specific codes entered by staff. This appeared significant in two ways. First, reported information is further transformed and modified by these Risk Officers to fit categories that do not necessarily correspond with those selected by clinicians, suggesting that there may be an additional mismatch between what staff experiences and what is eventually stored as data. Second, the Risk Officers believe reported information is readily open to manipulation and change. This illustrates how the re-construction of knowledge is a routine feature of risk management, and that risk managers assume control over this process. This was further evident in the way the free-text entries were processed. Rather than copying verbatim, descriptions were normally paraphrased into one sentence, with only a small proportion of information deemed as ‘‘relevant’’ for risk management activities. This re-processed information was produced as a ‘summary spreadsheet’ of all reports made within a given department over a given period (normally one calendar month). This was then disseminated back to the respective department as a part of the hospital’s feedback processes. These summaries revealed the extent to which the narratives communicated by staff, both between colleagues and in reports, are transformed through these risk management activities. Specifically, they were re-coded, re-ordered and translated into metric values that aligned with a set of management variables and expectations. This illustrates how the written narratives of clinicians are ‘washed’ of their technical and contextual detail. This can be seen for the three illustrative cases discussed previously.

Report #919 Type: clinical incident Classification: adverse outcome Description: patient had seriously dropped blood pressure and emergency buzzer was sounding but anaesthetist was unable to attend

Report: #1102 Type: other incident Classification: no adverse outcome Description: during operating procedure, the operating table dropped to it’s lowest position. Staff checked table for steadiness and procedure was completed

Report: #1139 Type: clinical incident Classification: no adverse outcome Description: swab was missing during operation. X-ray taken and staff checked theatre – swab not found.

As can be seen, the narrative accounts produced by the Risk Officers are even more distant and de-contextualised from the initial accounts produced by clinical staff. By focussing on pre-defined measures and categorisations, however, the potential exists for organisational attention and learning to be focussed on a narrow range of issues or risks and where the concerns of staff are neglected or marginalised to the detriment of more sustained or meaningful learning. This was observed further in the subsequent stages of data analysis. Here the second Risk Officers proceeded to ‘score’ each report using the computer software. This involved a 5  5 Risk Matrix that cross-referenced incident ‘severity’ and ‘frequency’ producing 25 risk categories. For example, those seen as low severity and low frequency were categorised as ‘low risk’. The matrix was presented as a means of establishing a more objective measure of risk, reflecting the techno-scientific rationality that characterised risk management, in general (Lupton, 1999). Despite being presented in this way, my observations of this process revealed that it remained highly subjective and shaped by the beliefs and experiences of the Risk Officer. For example, the Risk Officer described how the ‘frequency’ of an incident should be determined through comparison with similar reports involving a computer search of past incident types. However, as these were aggregated and the process was seen as time-consuming, they often based their estimation on an intuitive guess. When determining an incident’s ‘severity’ the Risk Officers openly re-classified the reported values if they believed it was not appropriate. The knowledge and expertise of the risk officers was, therefore, seen as more valuable and legitimate in the production of safety knowledge than the reported experiences of clinicians. Against this routine practice, however, those incidents graded by reporters as ‘major’ or ‘catastrophic’ were reserved for more detailed investigation. My observations reveal how the narratives of staff are further re-constructed as they pass through the routines and systems of risk management. A prominent feature was the de-authoring and re-authoring of safety knowledge. I use these terms to describe how reports were often ‘washed’ or filtered of their original content, especially the open-text description, before being produced as new incident types, scores and revised descriptions. This indicates how both the construction and control of knowledge is systematically transferred from the reporter to the risk manager, to the extent that some of the technical, contextual and emotional concerns of staff are squeezed out in favour of information that better aligns with the pre-defined risk categories, past experiences and assumptions of risk management. This can be seen further in the use of the risk matrix that seeks to redefine the ‘subjective’ and unscientific views of staff as more objective measures. Arguably, these activities neglect the detail and experiences of staff to the detriment of more contextual and embedded forms of learning as change becomes increasingly directed by the priorities and objectives of management. Discussion The findings illustrate three stages in the construction of safety narratives. First, clinicians engage in a process of ‘principal

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positioning’ where the interpretation of risk is embedded in context, inter-subjective in character, often uneven, and normally emotionally rich. These localised meanings of risk reflect wider cultural assumptions about professional responsibility, culpability and blame. Second, these verbal accounts are re-constructed as written reports where the medium of re-telling, with its emphasis on pre-defined scales and typologies, significantly influences story telling, to the extent that risks are constructed as ‘narrow narratives’. Finally, these narratives are re-constructed further through routine risk management activities, where they are ‘washed’, recoded and translated by risk officers. In short, the experiential, qualitative and culturally rich stories of clinicians are to a large extent transformed into the abstract, quantitative and explicit variables of management (see Table 1). On the one hand, it can be appreciated that such systems inevitably transform the production of knowledge in the processes of making it amenable to widespread application. For the advocates of risk management, this involves the use of standardised, rigorous and seemingly objective activities (Lupton, 1999). On the other hand, these processes remain highly uneven and, despite claims to scientific or technological rigour, knowledge is constructed in ways that blends the local experiences of clinicians with the assumptions and priorities of management. By recognising how narratives are constructed and re-constructed in this way, it becomes possible to identify wider implications for organisational learning and organisational power. In terms of organisational learning, two issues can be elaborated. The first relates to the reporting of incidents. Health policies internationally advocate reporting as a primary means of sharing knowledge about clinical risk, yet research suggests reporting remains inhibited by a range of social and cultural barriers (Waring, 2005b). As I have shown, reporting transforms how staff interpret and articulate their experiences of risk with an emphasis on predefined scales and typologies. It can be argued that this might in turn marginalise or devalue the affective and interpersonal knowledge of staff to the extent that they only report those events that more easily ‘fit’ within the prescribed model. As such, clinicians might be discouraged from reporting events that are more complex or ambiguous, because they are not easy to report, despite having important safety implications. This means that the mismatch between the verbal narratives of staff and the required narratives of reporting could deter reporting. However, reporting in this way could also have a recursive influence on how staff ‘make sense’ of risk. By requiring clinicians to think about and categorise risk along these predefine categorisation, a gradual shift may occur in how staff interpret events that aligns with the assumptions of risk management and indicates a wider cultural change at the level of collective sense-making (Weick, 1995). The second implication for organisational learning is found in the way knowledge is transformed and processed before being put to use. The systems described in this paper are highly centralised, to the extent that the experiences of staff are communicated upwards to the Risk Management department where they are then used to inform learning. As discussed above, the sharing of knowledge via incident reporting transforms knowledge, as the qualitative and ‘rich’ verbal accounts of clinicians become the quantitative and

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‘narrow’ metrics of management. Clearly, it is unfeasible for hospital systems to gather exhaustive and detailed knowledge about all clinical risks and, as such, they need to capture and handle information in ways that enable the most appropriate utilisation of resources. However, in seeking to be selective and focussed it could also be argued that these systems potentially neglect information that might be beneficial to learning. By re-constructing knowledge in this way, management attention and learning is likely to be based on a compressed range of de-contextualised and pre-defined issues that might not necessarily resonate with the experiences or concerns of clinicians. This might include information related to contributory or latent factors involved in the production of error (Reason, 1997). These centralised systems, with the propensity to re-construct the experience of clinical staff, might not, therefore, engender the level of learning as envisaged by policy-makers. As an alternative to this centralised approach, research shows that more de-centralised and ‘situated’ models of learning, for example within ‘communities of practice,’ are effective at both sharing knowledge and stimulating learning as they more accurately facilitate the translation of experience into change and improvement (Wenger, 1998). The second theme relates to the implications of knowledge construction for organisational power. As discussed above, the narrative perspective brings to the fore the underlying ideological influences on story telling and the way narratives articulate shared beliefs or reinforce group identities (Currie & Brown, 2003). As shown above, the verbal narratives of staff articulate collective attitudes about occupational responsibility, jurisdiction and tensions with ‘others’. For example, doctors cast doubt on the contribution that both managers and nurses make to patient safety; similarly nurses question the role of ‘problematic’ anaesthetists and surgeons. In this sense, narratives reinforce professional boundaries and identities through distinguishing the ‘safe’ from the ‘risky’ or ‘them and us’. In this way, professionals are able to protect themselves against feelings of blame through re-allocating responsibility with ‘others’ (Mizrahi, 1984), which reinforces feelings of competence at both the level of the individual and, more broadly, the profession (Rosenthal, 1995). Despite the promotion of a no blame culture, it appears, therefore, that issues of culpability run deep within the boundaries between healthcare professions. Despite clinicians being central to the production of knowledge at the local level, the study also shows how narratives are re-constructed as they pass through hospital systems, which in turn brings about change in both the authorship and authority (control) of knowledge. As with other information and technological systems (Timmermans & Berg, 2003), these processes are not only actively involved in the re-construction of knowledge, but also the reconstruction of roles. Elaborating this point, knowledge remains a powerful resource for expert groups, informing the design and delivery of work and contributing to the maintenance of jurisdictional boundaries (Abbott, 1988). This includes not only abstract knowledge, but also the indeterminate experiential knowledge of day-to-day practice (Jamous & Peloille, 1970). The special relationship between professional knowledge and power is exemplified by the inherent asymmetry of knowledge around health and

Table 1 Construction and re-construction. Verbal narrative

Incident narrative

Processed narrative

Embedded in practice Complex & fragmented Interactive interpretations Highly emotive Emphasis on responsibility Reinforce professional competence

Partially disembedded Linear with value Explanatory accounts Implied emotion Implied responsibility Reinforces professional competence

Disembedded Metric trends De-authored statistics No emotional content Reflects managerial assumptions Reinforces managerial utilisation of information

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illness that can been seen in the profession’s enduring claims to clinical freedom (Freidson, 1970). Should aspects of this knowledge become more open and amenable to control then it follows that claims to professional jurisdiction and autonomous working also come into question (Abbott, 1988). From this perspective, risk management systems that centrally accumulate, re-construct, and utilise clinical knowledge in the processes of learning are also involved in detaching this knowledge from clinical practice and control and making it, and clinical practice, amenable to external direction (Waring, 2007). As such, these systems not only illustrate a new medium for self-surveillance, as suggested by Iedema et al. (2006), but also an opportunity for external surveillance. In other words, knowledge is treated by managers as an organisational resource on which to base service improvements, for example, informing the re-alignment of working practice or identifying training needs. By re-constructing and managing knowledge in this way, new opportunities emerge to change, or indeed challenge, established ways of working. Like other forms of knowledge management (Willmott, 2000), these processes of de-authoring and re-authoring transfers authority over knowledge from clinicians to managers and facilitates managerial authority over clinical practice. However, it remains important not to over-emphasis this capacity. Although these systems present new opportunities for gathering information about clinical performance, the findings also suggest that they struggle to recognise, process or utilise the complex, technical and emotional aspects of this information that do not fit with management terms of reference. A final point for discussion relates to the contribution made by ethnography to patient safety research. This approach offers a depth of socio-cultural insight that can be neglected in more experimental designs. The focus on narrative construction brings to the fore how stories are repeatedly told and re-told with reference to different groups, media and organisational spaces. This study suggests that, rather than pursuing abstract taxonomies, we should look more at the interactive situations through which knowledge emerges and is subject to change. As indicated above, there is scope for more research of this type. For example, how do safety narratives differ between professional groups and why? How do investigation procedures produce further narratives and establish particular ‘truths’ about the need for service improvement? If research is to contribute to enhanced patient safety it needs to look more deeply and critically at the solutions being developed which, as shown, often neglect important socio-cultural and political dynamics of organisational life. We need to look more at how healthcare professionals understand safety from within, to appreciate how meanings and actions are bound together and how issues of power are central to service reforms. Conclusions The objective of this paper has been to demonstrate how knowledge about patient safety is constructed through social interaction, collective sense-making and through engaging in the technological processes associated with risk management. My aim has been to offer an alternative to the ‘measure and manage’ orthodoxy that characterises much of the mainstream research in this area, through demonstrating the value of ethnographic research and narrative forms of analysis. The contribution that this constructionist research brings to patient safety is through opening up the situated activities in which knowledge is constructed, re-constructed and put to use. Specifically, I suggest that incident reporting and risk analysis, which are common to patient safety reforms, introduce a series of spaces or media through which the collective verbal narratives of staff are reframed before being re-authored further by risk management. As such, knowledge

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