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The followers have roles that are as mission critical as the leader. Followers are expected to work within their scope of practice but also take the initiative. No one would expect to turn up at a ward emergency and have a neat row of staff against the wall waiting for instructions. It is important to think about the level of communication required between the leader and followers. If it is obvious we are doing a task, this does not need to be communicated. There is a risk that followers can overwhelm the leader with verbal communications where, in fact, the key is to communicate concerns or abnormal things. In the Formula One pit lane during a tyre change, the crew communicate (visually) as tasks are completed; they also signal if they have a problem, they do not communicate verbally at every expected step.
Hierarchy
Within the team there needs to be a hierarchy. This is the ‘power gradient’; the leader is at the top of this as the person coordinating, directing and making the decisions. However, this should not be absolute. There is much discussion in the literature about the degree of the hierarchical gradient. If it is too steep the leader has a massive position of power, his or her decisions are unquestionable and the followers blindly follow the orders. This is not safe because leaders are humans too and also make errors – their team is their safety net.
Safe practice is achieved where the followers feel they can raise concerns or question instructions. This must always be understood by the leaders as much as by the followers. One way to reduce the hierarchy gradient is for the leader to invite the team’s thoughts and concerns, particularly around patient safety issues. It is also important for the follower to learn how to raise concerns appropriately. This is often referred to as ‘flattening the hierarchial pyramid’ – the leader is ‘nearer’ to his/her team, actively listening to concerns raised, whilst team members undertake allocated tasks effectively and feel empowered to ‘challenge’ or raise concerns.
One acronym that is sometimes used to raise concerns in a format which escalates appropriately is PACE (probe, alert, challenge and finally declare an emergency). The probing question allows diplomacy and maintenance of the hierarchy whilst raising the relevant concern.
| Stage | Level of concern |
|---|---|
| P Probe | ’Do you know that …’ |
| A Alert | ’I’m more concerned now …’ |
| C Challenge | ’Please stop what you’re doing and consider …’ |
| E Emergency | ’I need you to stop immediately because …’ |
These stages are described with examples below:
Probe – this is used where a person notices something they think might be a problem. They verbalise the issue, often as a question. ‘Have you noticed that this woman is bleeding excessively?’
Alert – the observer strengthens and directs their statement and suggests a course of action. ‘Dr Brown, I am concerned, the mother is still bleeding more than I’d expect – shall I give ergometrine?’
Challenge – the situation requires urgent attention. One of the key protagonists needs to be directly engaged. If possible the speaker places him‐ or herself into the eye line of the person they wish to communicate with. ‘Dr Brown, you must listen to me now, this patient needs more action now as the bleeding is not slowing down.’
Emergency – this is used where all else has failed and/or the observer perceives a critical event is about to occur. Where possible a physical signal or physical barrier should be employed together with clear verbalisation. ‘Dr Brown, you are not acting on this woman’s significant ongoing bleeding. Please move aside and I will assess directly myself.’
The PACE structure can be commenced at any appropriate level and escalated until a satisfactory response is gained. If an adverse event is imminent then it may be relevant to start at the declaring ‘emergency’ stage, whereas a much lower level of concern may well start at a ‘probing’ question.
Some industries have also additionally adopted organisation‐wide critical phrases that convey the importance of the situation, e.g. ‘I am concerned’, ‘I am uncomfortable’ or ‘I am scared’. In an effective team where the leader actively listens to concerns raised by his/her team members, progressing beyond the ‘P’ or ‘A’ step should rarely be needed.
4.8 Situation (or situational) awareness
A key element of good team working and leadership is to be fully aware of what is happening; this is termed situation awareness. It not only involves seeing what is happening, but also captures how this is interpreted and understood, how decisions are made and ultimately involves planning ahead.
Typically, three levels of situation awareness are described:
Level 1 – What is going on? Collecting information
Level 2 – So what? Interpreting the information
Level 3 – Now what? Anticipating the future state
Level 1 – the basic level (What is going on? Collecting information)
We are prone to errors even at this level: the risk is that what is seen or heard is what is expected to be seen or heard, rather than what is actually occurring. Figure 4.2 shows the similar package design of two different medications, making errors more likely. It is important to really concentrate on seeing what is actually there.
Figure 4.2 Similar package design of two different medications
Distraction
Within healthcare, distractions become the norm to such an extent individuals are often not even aware of them. The risk is that mistakes are made and information is missed. It is important to try to challenge interruptions when doing critical tasks, and when they do occur, restart the task from the beginning, rather than from where it is considered the interruption occurred. Some organisations are looking at specific quiet areas for critical tasks. Whatever the local set up, the key is to develop and maintain everyone’s awareness of how distraction greatly increases the chance of error.
Level 2 (So what? Interpreting the information)
This encompasses how someone’s understanding forms from what has been seen. To minimise level 2 errors consideration is needed as to how the human brain works, recognises things and makes decisions and choices. This level of detail is beyond the scope of this introductory chapter (for those who are interested in pursuing this further Safety at the Sharp End by Flin et al. (2008) is an excellent learning resource for the whole field of human factors in healthcare). Therefore this section will focus on a part of this – the decision making that leads into level 3.
On the face of it the practice of decision making is familiar to everyone. However, to understand the factors that can compromise this process it is important