An ethnographic study of classifying and accounting for risk at the sharp end of medical wards

What is the Role of Individual Accountability in Patient Safety? A Multi‐Site Ethnographic Study

“…Deeply institutionalised norms and routinized forms of justification may be used both to promote excellent care and to legitimate or obscure poor practices that can harm patients (Dixon-Woods, 2010). Many norms of acceptability and excusability were functional for hard-working and over-stretched staff (Dixon-Woods, et al, 2009), but they were also sometimes implicated in allowing staff to externalise blame and to attenuate personal responsibility. Some norms rendered some problems -such as harm and assaults on dignity -as normal, natural troubles that were either invisible or inescapable given the circumstances of provision (Dixon-Woods, et al, 2011).…”

Whistleblowing Need not Occur if Internal Voices Are Heard: From Deaf Effect to Hearer Courage Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

“…In an examination of management and executive action in the United Kingdom's NHS, Dixon-Woods et al 37 found that while considerable time and resources had been invested into data collection and monitoring systems, the degree to which this was 'translated into actionable knowledge, and then into effective organisational responses' relied on the particular human responses of managers and or executive. DixonWoods et al 38 large mixed method research program involved 7 substudies which included data from 107 interviews with senior level stakeholders involved in quality and safety, 197 interviews with executive, board members and frontline clinicians, 715 surveys, 2 focus groups, and 10 interviews with patients and the public, patient and staff satisfaction survey data from 2005-2011 and 621 clinical teams assessed using Aston Team Performance Inventory. Dixon-Woods et al 38 classified senior management's responses into two categories of behaviour: 'problem-sensing' or 'comfort-seeking. '…”

“…DixonWoods et al 38 large mixed method research program involved 7 substudies which included data from 107 interviews with senior level stakeholders involved in quality and safety, 197 interviews with executive, board members and frontline clinicians, 715 surveys, 2 focus groups, and 10 interviews with patients and the public, patient and staff satisfaction survey data from 2005-2011 and 621 clinical teams assessed using Aston Team Performance Inventory. Dixon-Woods et al 38 classified senior management's responses into two categories of behaviour: 'problem-sensing' or 'comfort-seeking. ' Problem-sensing was thought to occur when senior managers actively sought out weaknesses in their organisations, using not only the formal incident reporting systems, but also 'softer intelligence. '…”

A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care.

“…A wide range of safety culture studies have adopted the ethnographic approach. 34,45,[118][119][120][121][122][123][124][125] Strategic immersion in the environment A major advantage of direct observation, in contrast with the questionnaire response, is that it enables researchers to see what people do and say rather than just what they say they do. 126 It can uncover how complex jobs are routinised together with 'the tacit skills, the decision rules, the complexities and the discretion' utilised in routine and marginal work (Smith,127 p. 221).…”

“…Possible explanations include that the care standards may not have widespread clinical support owing to considered professional judgement or lack of knowledge of the detail of the standard; staff may find the workload of making and/or recording multiple and repeated observations too high, signalling a need to prioritise those which are most important. Dixon-Woods and colleagues 125 discuss how rules in practice are so numerous that they quickly exceed individuals' ability to act on them. Staff then have to choose which rules to ignore, and may also ignore others without realising that they are doing so: partial compliance becomes the accepted 'normal-illegal' state.…”