In terms of risk assessment the emergency services are not special – they are different, because of the deeply embedded ethos and culture involved in the care and rescue of patients. George Dickson examines this difference as exemplified by the Scottish Ambulance Service and outlines the risk assessment approach taken to address occupational health and safety concerns.
The emergency services in general and the ambulance service in particular have a unique and sometimes disproportionate risk profile, characterised by a range of work stressors. As their care activities involve people (patients) the process can be full of uncertainty, emotion and organised confusion. It therefore needs to be built around a dynamic rather than strictly applied fixed design, but with an unbroken chain of diligence.
The Scottish Ambulance Service (SAS), like many other public services, continues to advance through periods of accelerated change prompted by external pressures, including political and public expectations, to become more outward focused on the delivery of health-care outcomes and performance in relation to health and safety standards.
Managers have a challenging, complex, and demanding role and have to adapt continually to a rapidly changing environment in which there exists “pressures and challenges of competition, legislation, regulation, social policy initiatives, senior management decisions, increasing sophisticated technology, and changing attitudes and expectations of staff, managers and patients”.1 Patients are more sophisticated and have higher expectations of quality and reliability of the service provision.2 This requires the creative use of professional knowledge and skill, where the Service must explore the use of different systems and processes to drive and advance change.
The Scottish Ambulance Service is at the forefront of pre- and inter-hospital care, providing the first response to clinical trauma, and the accidents/incidents/ disasters that occur every day. The health, safety and welfare of employees, in particular the management and assessment of risk, are increasingly key elements and part of the every-day life of the safety and health practitioner in an emergency service, where the 3Ps –’preservation of life’, ‘prevention of further injury’, and ‘promotion of recovery’ – are deeply embedded in the ethos and culture of staff involved in the care and rescue of patients.
The Service owes a duty of care to the public, as well as its staff. There are some occupations that can turn down a job involving a hazardous or risky situation, but the ambulance service cannot. Equally, it must not expose its staff to unacceptable risks. However, the question of what is reasonable has to be considered in the light of public duty. In measuring duty of care, the service must balance the risk against the measures necessary to eliminate the risk, but must also balance the risk against the end to be achieved within the tried, tested and well-established public and professional expectations expressed in the 3Ps ethos. The over-riding principle must be not to stifle the 3Ps but to provide a service that develops and implements good safety practice.
Demands of the job
The Scottish Ambulance Service is widely recognised as having a disproportionate risk because of the uniqueness of its work activities. Exposure to a range of environments and clinically defined infections are components of the risk profile. The work is considered physically demanding, stressful, and with a high emotional element. Musculoskeletal disorders are an obvious risk for nurses and pre-hospital care staff. Given the uniqueness of their patient care activities (clinical and non-clinical), however, the balance of risk is heightened and altered because of the adverse effects of human behaviour.
This unique risk profile is characterised by critical incidents and work-related stressors, such as job overload, shift work, and role conflict. Staff are often confronted with clinical trauma and can be exposed to the devastating impact of large-scale incidents/disasters, the distress of unsuccessful cardiopulmonary resuscitation, or they may have to deal with dead, or dying individuals. The work environment can also harbour threats to health, safety and welfare in the form of hazardous materials and processes (chemicals, hazardous substances, gases, sharps, electrical, plant and machinery, etc).
The delivery of health care by vehicle crew staff (VCS) encompasses much more than purely treating patients. Clearly, the risk profile of VCS (technicians, paramedics, non-emergency) is unique because they are exposed to unassessed hazards/risks in the delivery of the service. Risk “is a whole series of complex interactions and relationships between people”.3 We all work in a modern society, which has developed “an impressive arsenal of self-made potential hazards and catastrophes”.4 The emergency intervention of ambulance staff is sometimes as a result of professional or technical failure, arising from a combination of individual, group, social and organisational factors, including human error. “Outright technical or professional failure is rarely the sole cause of any accident/disaster”;5 it usually results from the cumulative effect of a number of shortcomings. Putting it more simply, the main problem with human error is that “we do not use the knowledge we have. Accidents with few exceptions are not caused by lack of knowledge, but by failure to use the knowledge which is available”.6
The delivery of the service is even more unique in that it brings together a diverse range of organisations: Fire, Police, air sea rescue, including the Royal National Life Boat Institution, military and mountain rescue. All these organisations have different priorities while seeking to produce the same outcome: the preservation of life. Consequently, VCS have to work and think of ways to continually improve and adapt to a dynamic environment.
Be proactive
The increased focus by the Scottish Ambulance Service on safety and health for all staff has required managerial re-orientation from lessons learnt from incidents and patient care practice, to new priorities that recognise the uniqueness of the working environment and the need to develop and implement a health and safety philosophy that is compliant with legislation and regulation.
The need to shift from a reactive to proactive approach to controlling and preventing error and system breakdowns is becoming more important. Employees who become more aware of their responsibilities for accident and injury prevention “show more interest in maintaining a safe and healthy workplace”.7 It is a management responsibility to inform staff of the risks involved, and motivate them to be proactive in devising solutions to reduce the risks. The impact of safety awareness will be short-lived unless there is an ongoing and innovative safety motivation programme for the workforce. Drucker noted that “management is first and foremost about the continuing development of the organisation and its employees. The demands and needs of the environment are constantly evolving and management is about adjusting the organisation according to the needs and demands of the environment.”
Risk assessment does not have to be complex. It is a systematic focus of thinking through the task, identifying the hazard and the potential for harm, and recording the best way of minimising or eliminating any risks. The aim of any risk assessment strategy must be to keep exposure well below a level at which harm is manifest. Individuals sometime see the process as an administrative impediment and do not always appreciate the value of carrying out a risk assessment before beginning a task, particularly when life is threatened. It is therefore important to have an understanding about the relationship between hazards, harm and risk.
The risk assessment process, coupled with professional and intellectual knowledge, skills and personal competency, is based on working experience of the operational activities derived from education, training and an intimate understanding of the tasks and issues. The simple process of translating knowledge into what the staff need to comply with safer systems of work will reduce/eliminate injuries. Facts are available to everyone and by having an intimate and deep understanding, staff can think about solving difficult issues. In combined services activities the development of good practice lies in knowledge exchange and knowledge sharing.
The air transport industry can be used to illustrate a framework in which individual freedoms and responsibilities within that framework are restricted.8 Pilots operate in a very strict system, following instructions from take off, on landing and while in flight. They do not have the freedom to stray outside the strictly controlled system yet, regardless of the restrictions, the crucial decisions about whether to take off, abort or land rest with the pilot. The point is that the risk assessment process is strictly applied, with clear components, but it also gives the assessor freedom and responsibility within a managed process, using an unbroken chain of diligence, in the application of therapeutic care and a safe system of work.
Conclusion
The approach is about discovery, involving people (patients) and, in some cases, a situation full of uncertainty and emotion. For emergency staff it is the external environment that creates most uncertainty. The situations and environment that confront the Scottish Ambulance Service are dynamic and require continuous evaluation to make provisions for any necessary changes, and to make the situation safer. “This is achieved by defining how a task should be done and communicate to everyone involved in the process the best way to accomplish it. Their creative energy, knowledge and skills, coupled with a strong element of duty of care, are used to design and construct processes, and to reduce risks and manage patients.
The key is to determine what problems can be tolerated without endangering the care process by taking the safe option. It is a continuous process of analysis of potential harm. It is strictly applied but, as in the pilot analogy, there is freedom and personal responsibility. A sound approach to problem-solving starts with the use of good risk assessment for ambulance-specific tasks, which is used as a basis for recognising any additional hazards and developing any necessary additions or modifications. Safer alternatives that ensure the safety of patients, staff and others that might be at risk should be identified and reviewed in the light of available information.
To restrict staff in their professional duties reflects an absence of confidence in existing professional relationships. In the Scottish Ambulance Service employees have freedom and responsibility within a highly developed system of accountability that employs self-disciplined people. The challenge is to create a service that recognises health and safety at the forefront of its operational activities by developing a culture that is effective and productive, and which supports the achievement of the operational imperative and strategic objectives.
Active learning will enable the development of skills based on the personal experience and education of staff. When every individual understands the impact their contribution has on the working environment they will be able to contribute to reducing risk. In an emergency situation the decision-making process as a result of a risk assessment needs to be sharper to recognise the operational imperative. In addition, existing, relevant good practice should be adopted and others with specialised knowledge involved. “The challenge is to select from best practice the best options.”10
Staff participation in risk assessment (dynamic evaluation) and prevention activities involving everyone can have a positive impact on the implementation of good heath and safety behaviour at work. This approach, to a degree, centres on competence, education, knowledge, understanding and training coupled with a chain of unbroken diligence of staff involved in the task.
References
1 Hiltrop Jean-Marie (1998): ‘Preparing people for the future. The next generation for HRM’, European Management Journal, Pergamon
2 Kald, M & Nelsson, F (2000): ‘Performance Measurement at Nordic Companies’, European Management Journal, Pergamon
3 Rayner, S & Cantor, R (1987): ‘How Far is Safe Enough? The Cultural Approach to Societal Technology Choice’, Risk Analysis
4 Clifton, J J (1990): Catastrophic Hazards in Society, Royal Swedish Academy of Engineering Sciences
5 Maryon K A (1998): ‘Clinical Risk Management’, Risk Management Bulletin
6 Kletz, T (1991): An engineering view of human error, Institution of Chemical Engineers
7 Angelica, M & Vecchio-Sadus Steven Griffiths (2004): ‘Marketing strategies for enhanced safety culture’, Safety Science
8 Collins, J (2001): Good to Great:Why some companies make the leap and others don’t, Random House Business Books
9 Edvinsson, Leif (2002): Corporate Longitude:What you need to know to navigate the knowledge economy, Prentice Hall
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