Andrew S Al-Rais: The art of shared learning—it’s good to talk

Opportunities for shared learning are increasingly being lost in NHS hospitals, but we need them now more than ever

Cast your mind back to your most recent clinical mishap. Remember the sickness rising from your foregut as the realisation of your error bathed you in fear. Reflect back on those nights of introversion when your world fell apart and the prospect of a broken career loomed large as you slept fitfully. We have all been there. If it hasn’t happened to you yet, it will. Healthcare is a complicated beast whose progression continues to punch holes in the defensive layers of Swiss cheese. For someone, somewhere, those holes are lining up right now. 

Look on the bright side—you’ll never make that mistake again, will you? But what about your colleagues? What about the folks on your rota? Or your departmental lead? Could they make the same mistake?

It is perhaps an unfortunate marriage that the most frightening moments in our working lives are also the most profound learning events. Yet I can’t help thinking that we miss a trick when it comes to the effective dissemination of this powerful form of learning. A trust I previously worked for temporarily abolished the departmental governance programme under the premise of improving service delivery when pressures were at an all time high. We went from meeting as an entire department every other month to never. The clinical work continued. A lot of that work was excellent, but some of it was not. Processes continued to need improving. Near misses needed scrutiny. Individuals’ experiences needed debriefing. Yet all of these are impossible undertakings if the forum to do so does not exist.

In my more junior years I would hear the words “seven pillars of clinical governance” and succumb to a cold sweat. This was the talk of interviews and career progression. This was swiftly followed by cursing and rote learning. Now, after 12 years of doctoring, I have finally been exposed to the wonders of a robust system of governance.

Anyone who has ever been to a clinical governance day at a helicopter emergency medical service base will attest that the world of pre-hospital care has mastered the art of governance and shared learning. Teams meet with reassuring regularity. Hierarchy is nowhere to be seen. Case after case is scrutinised in minute detail in an open forum. People are questioned. Systems are questioned. Decisions are questioned.

At first sight it can appear openly hostile. But it isn’t personal. It’s about patients, and being better for them. It’s about marginal gains. It’s about revelling in a shared commonality of wanting to provide the best possible care for people. It’s about making sure that everyone learns from what you saw, how you felt, what you did, and how you responded. Does the system work? Can it be better? Can we pour our collective learning into the Swiss cheese and fill up all the holes so they never line up again? Quite frankly, it’s cathartic and I’m looking forward to taking this model of governance back to my hospital practice.

There are barriers, of course. The lesser caseload and smaller organisational size in pre-hospital care lends itself well to this type of governance. Yet an anaesthetic department in a teaching hospital may number nearly 200 individuals—meeting every fortnight for a whole day is impractical. However, I suspect we can all still do better than the status quo.

I also suspect that the tentacles of a well oiled governance machine reach even farther than one imagines. Loneliness and isolation prowl our hospital corridors. Gone is the traditional “firm” with its sense of belonging and apprenticeship. The haphazard nature of the new contract means that opportunities for shared learning have been decimated. Now, more than ever, we need the opportunity to meet regularly as a collective. To discuss what we did and how we did it. What went well and what could have gone better. To share stories and troubleshoot our own insecurities.

Our duty of candour extends beyond the admission of poor care and an apology. In order to properly discharge that duty, we must have robust governance and systems for continued improvement in place.

Remember, we are all ultimately chasing the same goal: excellent care for our patients that mirrors how we would want our family to be cared for. It’s just a lot easier to do if we do it together.

Andrew S Al-Rais is an anaesthetic registrar and a helicopter emergency medical service doctor. Twitter @andrewalrais.

Competing interests: None declared.