I am sharing my experiences of leadership and the journey of a healthcare entrepreneur. I hope that this will inspire others into following the same journey and create opportunities for all!

The Maslow Foundation aims to ensure social inclusion, using the voice of lived experience to create services that meet their ambitions and I am proud to be Chair of Trustees creating hope, joy and meaning in our lives. Our services include creating safe spaces to ensure meaningful conversations, being able to connect individuals into wider services with a model of trauma stabilisation and connection. We are pleased to be offering housing to those who cause harm from domestic violence and enabling their partners to remain in their local community. This has revealed the challenges with employment and our move to creating an entrepreneurial laboratory and microbusiness support. We are champion the Child Impact Assessment to support mothers who may be sent to prison and their children to inform judges and provide a robust plan for the family. To support the charitable sector I have launched Urban Nest Housing Solutions to access housing with safety at our heart.

Nurture Health and Care Ltd has been co-founded by myself and my team to nurture workforces across the public sector. This is built on a model of Psychological Safety and recognises the need for connection, sense making and action. By creating sense making structures through our supervision model or decision making groups in our investigation team, we can enable people to make sense of risk and uncertainty. We are proud to be offering services to the NHS for investigations and the Prison and Probation Ombudsman/NHS England for clinical reviews. In addition, we are providing sexual offence examiners to sexual assault referral centres, with a unique workforce strategy which includes the accredited Sexual Assault Nurse Examiner programme (SANE) and our inspection ready governance delivery. We use our four ways of knowing to help provide understanding, equality of voice and values based decision making to create new insight for our services. We provide post graduate preceptorship programmes and enjoy the contribution of our Nurse Ambassadors and run a Nurture Ripple and Cultural Architect Programme generating psychological safety to embrace the ambition and creativity of our workforce enabling success.

I am interested in how language can represent culture and be measurable through artificial intelligence and have set up a new organisation, the Centre of Artificial Intelligence Interface (CAII), with the launch of our new website and first product which acts to create different perspectives as a basis of decision making: https://www.3friends.ai/ and looks how ethical AI solutions can contribute to healthcare.

As a Trustee for Survivors In Transition, I continue to support my passion of providing services to those who have experienced sexual violence and am lucky to work alongside Fiona Ellis, who as CEO has created a values based innovative organisation to provide therapeutic interventions.

I am also exploring setting up a microgrant funding system to create financial support, coaching and an incubator of change recognising how passion, entrepreneurialism and the agency of people can support change in our services. I look forward to sharing this journey.

Alexis Hutson (https://www.alexishutson.com/) facilitated the Faculty of Medical Leadership and Management course – Tomorrows Strategic Leader which I attended and highly recommend. She was an excellent resource and identified the concept of ‘Taking a Thought for a Walk’ which I have named this blog after. Simon Bennett (http://www.simonbennettcoaching.com/) is my personal coach and I advocate this support, It enables us to explore the journey that we are all undertaking in a psychologically safe space.

I believe that without aiming for the impossible, miracles cannot happen and through authentic leadership, we can enable every person to be able to reach their own potential.

As some-one who values justice and fairness as one of my core beliefs, I feel it is important to explore how justice and fairness links to our understanding of healthcare.

Co-operation is evolutionarily important for our daily lives and social norms have become part of human nature. The rulebook identifies from these social norms, our frameworks for justice. Social justice encompasses the relationship between individuals and their society and considers how rewards, opportunities, and wealth should be distributed among individuals.

Our perception of fairness and justice is a socially constructed concept and therefore different for everyone and how we apply this to the real world setting of health and care is not simple.

Our preference for fairness has been proposed as a basic human impulse and therefore when we perceive unfairness, we experience a negative emotional response whereas fairness is associated with positive feelings and we build from these our sense of ‘Justice’.

Some people consider that fairness is the belief that we should be rewarded for our efforts, which may lead to the thought that those who ‘may not be able to work’ are less deserving than those who are ‘hard working’. Alternatively, we may consider fairness to be that we apply the same procedures to everyone, which can be seen in tax systems or as part of human resources and equality practices.

Fairness does contribute to our need to feel safe, as it allows a sense of control over the unknown.

Fairness is protective, as the alternative is to accept the fact that life is unpredictable and that negative things can occur to us at any time.

The unintended consequence of the concept of fairness, is that when bad things happen, the person is considered deserving of a negative outcome. This ‘victim blaming’ is an unconscious bias so when we notice this in ourselves, we need to sense check our cognitive distortions. Equally, for those who experience bad things, we blame ourselves, feeling shame and guilt and this should also be challenged.

As many of these traits are seen in healthcare settings and form part of the basis of disproportionality, we need to talk more about our true thoughts and feeling and be able to sense check and challenge.

Justice for Patients: Personalised Care and Population Health

We know that the burdens of ill health are unevenly distributed both within and across populations, and that the benefits of health care are not always available to those who need them.

A Community-Powered NHS

Avoiding discrimination and ensuring fair distribution of effective treatments is required to achieve greater justice in health and social care. In addition, we need to respond to the barriers created by the social determinants of health and that diversity is represented in our models of service delivery.

The care of an individual patient needs to be our top priority as part of our professional duty of care, however in order to achieve justice, we need to juggle these individual requirements against the need for equity at a population health level.

In order to achieve this:

• Clinical training must go beyond history taking, clinical examination, differential diagnosis and treatment towards judgment and shared decision making skills.

• Policy makers need to consider an agenda which is broad, interdisciplinary, embracing the experience of illness, the psychology involved, negotiation and sharing of evidence, and how to prevent harm from overdiagnosis.

• The co-creation of a shared understanding of needs at an individual and at a population level will be required to ensure everyone can access care, meet the wider social determinants of health and move away from the traditional medical model.

Justice for our Staff

The Equality Act and wider workforce legislation protect our labour markets yet we still have differential achievement and lack of representation across the landscape of employment and the concept of social justice builds on this.

https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a-collaborative-and-inclusive-future

In our NHS and wider social care settings, we need to work together to improve the experience of work for everyone and should be committed to equality, diversity and inclusion reinforced through role modelling psychological safety within a trauma informed organisation,

Well-being should be prioritised.

Mentoring and coaching opportunities for individuals and their teams should be available to help meet the ambitions of all.

We would like people to be able to identify with the statement “I feel free to be my authentic self at work.”

Justice for our Organisations

How does justice and fairness work within the landscape of organisations that contribute to social and health care systems?

Businesses traditionally engage in competitive practices within a capitalist market place and even in our statutory organisations, have capitalist principles embedded to gain market share or to be the best in relation to the provision of services.

Justice tends to take the form of legal challenge, where organisations have failed to meet their legislative obligations.

Competition between organisations may provide comparison information, which can lead both organisations to set higher standards and motivate them to greater achievement or create cost savings.

Competition also leads to behaviours such as self-enhancement and self-preservation. Although competition does not necessarily create overt hostility, it does sow the seeds for potential problems.

So moving from competition to collaboration is a transformational shift in culture.

Seeing the Individuals in our Boards as People

We need to see our Board level members of staff as people who are subject to emotional responses, unconscious bias and will see themselves or others as victims. This is crucial to transformation rather than assuming that Boards are a single entity that can absorb all impacts.

My belief is that our Boards are exhibiting trauma responses which is translating into signs of organisational fight/fright/freeze/compliance with defensiveness, tunnel vision, lacking creativity and being unable to form connections as typical signs of trauma.

So how do we move to collaboration in our social and healthcare landscape.

Judgment not rules

Currently the health and social care landscape is bound by rules.

• Is this decision legal?
• Is this decision an evidence based process?
• What is the right way to progress?

These back and white rules need to shift to conversation and shared understanding with an appreciation that most complex problems have multiple solutions in which different groups or outcomes may be amplified or compromised.

Beware of the Unintended Consequence of Regulation

Despite the importance of external scrutiny as it is impossible to mark your own homework, the regulatory framework of proxy measures, black and white thinking, reward and punishment is not fit for our new world.

Our regulators need to be trained on organisational psychological safety and trauma informed inspections, creating shared understanding and moving to measuring progression not comparison.

Our current regulatory bodies cannot function safely within the current statutory and legislative frameworks in which they operate where rigid measurement and benchmarking is the mainstay of assurance.

Informally, even where organisations, boards and registered managers have a good rating or an outstanding rating, they do not believe the inspections to be a positive experiences. Many believe the time taken to be compliant detracts from patient care, with process being more important to evidence than culture.

History has revealed that patient safety appears not to be improved as significant events including our current maternity scandals are not identified by our regulatory framework.

Many believe these inspections to be variable, lack objectivity and are often found to be traumatic for those involved. Most worryingly, areas of deprivation or diversity of professionals appear to receive poorer inspections outcomes. Our regulatory frameworks therefore feel unfair and appear unjust.

Although inspectors may demonstrate insights into the systemic challenges faced by organisations, the consequences of their actions have led to further staff depletion, burn out, closure of community beds and focus on process improvement. There is a lack of independent appeals process and disagreement is considered, defensive rather than valuable. This lack of system level oversight has meant regulatory action on one part of the pathway impacts on another.

We need to urgently review how we can have external scrutiny that is independent and robust but allows organisations to feel supported. I believe that we should walk along side our organisations to create change ensuring that all decisions related to risk is managed at a whole system level and that a shared approach to risk and consequence is adopted.

Justice in Evaluation

We therefore need to adjust our perspective on how we measure outcomes and evaluate progress in evidence based medicine, our workforce strategies and from regulatory and commissioning infrastructure.

Models can be found that fit a whole system approach.

Logic modelling is one methodology for representing various components and how they are expected to fit together to achieve outcomes.

A logic model is designed to:

• Assess the strength of the assumptions being made about how your programme will achieve change

• Identify cause-effect relationships

• Build an in-depth understanding of how a programme is intended to deliver results

• Raise awareness and build common understanding amongst stakeholders Identification of outcomes should happen at an early stage of the process and ideally not be retrospectively fitted to a predetermined and funded set of activities or interventions.

Alternatively a Realist Evaluation as part of a Context: Mechanism: Outcome evaluation model could be used.

Realist methodology is based on the assumption that the same intervention will not work everywhere and for everyone. The focus is on “what works, for whom, under what circumstances and how”. The key questions in realist evaluation concern causation (the act of causing something) and attribution (the act of attributing something). The term ‘realist evaluation’ was first used by Pawson and Tilley.

This evaluation methodology considers non-observable entities and processes such as culture, class and economic systems that can have a real effect on whether programmes work. Social systems such as the family, schools and economic systems have dynamic boundaries in terms of the flow of people, resources and information. These social systems interact with each other and the interventions themselves are open and dynamic systems. These can interact with other social systems, and so causation is not a simple linear process. They can be the result of changes in, and interactions between, different social systems.

Realist approaches are appropriate for evaluating complex interventions such as community based public health programmes and are particularly useful for those that produce mixed outcomes to better understand how and why differential outcomes occur.

By changing our Perspective and Unlearning our current method of assurance and evaluation, we should be able to shift to creating a health and social care system that can respond to our current challenges.

Considering how ‘fairness’ and ‘justice’ are created is key to this new way of looking at the world.

In moving from our traditional model of evidence based medicine (EBM) to Personalised Medicine (PM) and ensuring that greater participation and inclusion is built into our service designs, we are going to have to move away from the conventional statistical analysis to a new way of generating measures to identify best practice.

We live within budgets and have limited resources so delivering value and being cost effective, both with our finances, but also with our staff and environment is a challenging balancing act.

We know that our current mindset has led to bias and created systemic disadvantage, so we need to shift to expand our quantitative approach to include qualitative research methodology. We need to learn the skill of interpretation through an inclusive lens, understanding the limitations of our data sets and being prepared to adopt the principle of ‘unlearning’ that which has not worked.

Importantly, we are missing the process of looking back and ‘marking our homework’ so we can check that our assumptions and ensure our direction of travel is positive.

No doubt our ‘family GPs’ built their knowledge through true understanding of families over time. Our hospital staff used to be a permanent fixture and generated wisdom for the community. We have lost this capability, through early retirement, rapid career progression and staff turnover, short term outcomes and service evaluations with ‘in the moment’ decision making.

This shift from outcomes and meta-analysis to triangulation through mixed methodologies, using a diverse perspective to interpret and create insight which is reviewed over time as well as in the moment is our next step.

Our traditional model of evaluation is based upon: Input – Intervention – Outcome and we need to move to: Experience – Conversation – Understanding but what new measurements are needed to demonstrate success.

As we drown in information, how should evidence be generated and disseminated?

How can evidence generate evidence-based policy that is flexible to changing context?

How can we educate our front line workforce on the best options and be confident in using their intuition and judgement?

What does consumer led services look like in the eco-system of health and social care?

What are the current research methods that are available?

Healthcare research is a systematic inquiry intended to generate robust evidence however many of us, have limited experience in critically reviewing evidence, analysing statistics and are even less familiar with the field of qualitative research and its validity and we are not practiced at the skill of reviewing evidence with others to create understanding.

I have summarised the common qualitative methodologies, as healthcare professionals, we should become more familiar with all our models of research and understand the problems and how statistical analysis has led to misunderstandings.

The major types of qualitative research designs are:

• narrative research
• phenomenological research
• grounded theory research
• ethnographic research
• historical research
• case study research

The qualitative method of inquiry examines the ‘how’ and ‘why’ of decision making, rather than the ‘ ‘what,’where, ‘ and ‘when.’ Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena making sense of complexity and does not test a hypothesis but discovers emerging themes.

Narrative research

Narrative research focuses on exploring the life of an individual telling their stories of individual experiences. Data collection include interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences and developing themes to gain greater insight.

Phenomenological research

Phenomenology defines the ‘essence’ of an individual’s experiences regarding a certain phenomenon. Data collection is through Interviews with individuals, examining documents and observations. Data analysis involves the researcher interpreting the phenomenon, based on their judgement, rather than simply describing it.  

Grounded Theory Research

Grounded theory comes from the ability to induce a theory grounded in the reality of study participants. Data collection involves recording interviews from many individuals until data saturation. Data analysis includes analysing data through ‘open coding,’ ‘axial coding,’ and ‘selective coding.’ Open coding is the first level of abstraction, and refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory. Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings.

Ethnographic research

Ethnography is used for understanding culture-specific knowledge and behaviours. Ethnography focuses on narrating and interpreting the behaviours of a culture-sharing group. To understand the cultural patterns, researchers observe the individuals or group of individuals for a prolonged period of time. Ethnographers collect data by observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group.

Historical research

Historical research creates insights from the past and involves interpreting past events in the light of the present. The data is collected from primary and secondary sources such as diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The written report describes ‘what happened’, ‘how it happened’, ‘why it happened’, and its significance and implications to current clinical practice.

Case study research

Case study research focuses on the description and in-depth analysis of the case or issues illustrated by the case. Observations, one to one interviews and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived and a written case report constructed.

Lens of Philosophy

If our data, regardless of qualitative or quantitative origins, is only interpreted through the lens of a scientist, it is likely that we will continue to attempt to build rules and fail to take account of the complexity of the problem. Through the lens of philosophy, we can build on our concepts, explore possibilities, embed time and consider domains of spirituality, connection and allow other alternatives to be revealed.

Through understanding the patterns of health behaviours, illness experiences and context, we can design health interventions and develop healthcare theories which includes a person-centered way of discovering and uncovering thoughts and actions for us all.

Our current position

Evidence-based medicine (EBM) currently is defined as the optimal integration of the best research evidence, clinical expertise and patient’s unique values for clinical decision-making and for optimising patient care.

NICE has published evidence across:

• Conditions and Disease
• Health and Social Care Delivery
• Health Protection
• Lifestyle and Wellbeing
• Population Groups
• Settings

Although, NICE is increasingly widening the perspective of their stakeholder engagement and including qualitative research they still prioritise:

• Systematic Review and Meta-analysis
• Economic Evaluation in Health Care
• Quasi-experimental Evaluation of Health Care Programs and Policies
• Randomised evaluations

As healthcare professionals it is important we consider the following challenges of evidence based medicine.

Publication bias

Publications tend to publish statistically significant results which are positive proving the hypothesis which generally is that the intervention works. Many trials are never published and those with negative findings, even if significant are left unseen.

Small trials are often considered not worthy of publication as their results are not statistically relevant and yet often these ‘hint’ at important findings. An example includes the delay in adoption of thrombolytic treatment for acute myocardial infarction where as early as the 1950s, small trials showed reductions in mortality rates, but we had to wait for a trial which involved the enrolment of 48,000 patients before it became national best practice.

Poor quality research

Researchers may use the wrong methodologies, collate data incorrectly, use surrogate outcomes, misinterpret results and often came to unjustified conclusions. Under-representation and lack of reflection through fixed mindsets mean that misunderstanding in conclusions may be seen.

Discredited Trials

Discredited trails often continue to be cited as best practice as papers remain accessible. If a busy health practitioner does a quick ‘google’ search, the discredited paper may be the first to appear, with no identification of its flaws.

Under reporting of harms

Harm outcomes are often incompletely reported which leads to overestimation of efficacy and  underestimation of safety.

Conflicts of interest

Conflicts of interests are widespread amongst academic institutions and researchers and associated with pro industry conclusions. Ghost authorship where there is a failure to declare conflict of interest or publish an advertisement with the appearance of a robust publication can mislead.

Trials stopped early for benefit

A significant number of trials stop earlier than planned due to apparent benefits that overestimate their true effectiveness. These trials receive great media attention and then affect clinical practice.

Statistical heterogeneity (how different we are)

As pharmacokinetic and pharmacodynamic mechanisms are fairly similar across all humans, patients appear to be relatively homogeneous (the same) in drug response. However, heterogeneity (differences) still occur, even if they are more likely to be due to the wider eco-system of social determinants of health and behaviours rather than variations in biochemical mechanisms.

When dealing with outcomes, EBM assumes that the “reality” of the drug or intervention response as statistically homogeneous (the same); so we all react in the same way thus an average response represents individuals well.

However we see heterogeneity (differences) in trials:

1) between-patient variability (the differences between patients)

2) patient-by-intervention interaction (the extent to which the intervention response differs between patients) 

3) within-patient error (the variability that the same intervention given to the same person on different occasions may alter)

The more different we are, the more difficult it is to calculate the anticipated linear correlation between cause and effect and this leads to misinterpretation of the data.

Future research methods must find ways of accommodating clinical reality and that we may not behave the same, as currently the sad truth is that the more complex a situation is, the less evidence is available to treat them.

What are Outliers and why do we care about them? 

The paradigm of EBM, through the use of statistics has created a world seen through averages.

The presence of outliers can lead to error in interpretation and tend to be removed through statistic analysis, with the consequence that systemic bias has formed amplifying the mean.  Casual observation of the literature suggests that researchers rarely report outliers or seek to understand them.  Given that we know that analysing our assumptions to ensure accurate interpretation is crucial, this is an unintended consequence which requires urgent review.

In the future, the entire Bells Curve should be analysed, with the understanding that the outlier rather than being a ‘contaminant’ to ignore should be considered as a source of insight.

Outliers from data errors. 

Outliers are often caused by human error, such as errors in data collection, recording, or entry. 

Outliers from intentional or motivated mis-reporting. 

There are times when subjects purposefully report incorrect data to researchers, often from the act of trying to please rather than sabotage. Data is often sensitive (e.g., teenagers reporting drug or alcohol use or sexual behaviours) and therefore reporting may not be accurate. Motivated over-reporting can occur when the variable in question is socially desirable such as income, or educational attainment and the Placebo effect and Hawthorne effect are well studied.   

Outliers from sampling error. 

Another cause of outliers or is sampling.  It is possible that subjects are inadvertently drawn from a different population than the rest of the sample such as studying nurses and inadvertently, a paramedic is interviewed but the study is about nursing views. 

Faulty or non-calibrated equipment is another common cause of outliers. 

Finally, it is possible that an outlier can come from the population being sampled legitimately through random chance and this therefore is a valid subject to understand!!!! 

When researchers in Africa discovered that some women were living with HIV for years without treatment, these rare cases formed a source as inspiration for inquiry:  what makes these women different or unique, and what can we learn from them? 

So what are we going to measure to ensure we have services that meet the needs of our populations.

What do people probably need to know?

• Was the intervention accessible?
• Was it delivered to the standards required?
• Did it make a difference to the person?

What do those responsible for population health need to know?

• What does the whole system look like to those who use services?
• From this jigsaw, is it accessible by all?
• Which elements are measurable and how can these be measured?
• What difference does it make to the population and is it inclusive?

Does looking back over time give greater insight?

We have an exciting opportunity with integrated care systems to provide a systems approach to health and social care and to relook at our key performance indicators, national audits and other benchmarking tools to ensure that we are not reinforcing bias and review our existing evidence base with the eye of inclusion.

The transition from ‘outcomes that matter to organisations’ to ‘outcomes that matter to patients’ is an important step forward.

• Our demographic data needs to more than protected characteristics reflecting heritage, culture, geography and socio-economic status.
• Our goals should align with our values creating measures for our organisations and communities.
• Resource utilisation needs measures which demonstrate whole system utilisation.
• Patient experiences of shared decision-making and narratives need to be recorded.  
• We need to understand how our patients, staff and organisations feel and change from the current position of stress, fear and failure to feeling safe, trusted and motivated.
• We should analyse our insight using multiple perspectives creating thought leadership which stimulates innovation providing a catalyst of change.

Dr Gethin Rees has a mixed methods research project through which I will enjoy learning about qualitative research and building a new skill set. https://research.ncl.ac.uk/equivalence-in-custody-healthcare/

They are using:

• Ethnographic approach – fly on the wall to observe interactions
• Semi structured interviews to deep dive and explore
• Review of risk assessments and consideration of continuity of care and information sharing

I am also working alongside Dr Steven Suckling who is introducing philosophy into the review of health and care services. NHS Staffing Crisis and The Art of Life – Maslow Foundation (wordpress.com).

Triangulation of results should form the new gold standard, blending quantitative and qualitative research with a lens of science and philosophy. I would propose that the current landscape, rather than being the Gold Standard, should be considered the minimum standard and we can build on this to form a New Paradigm which includes co-creation, distributed wisdom and situational awareness.

Although this is a long video, it challenges our approach introducing philosophy, new language and constructs. I found this a motivating video that shows there is another way providing hope and inspiration for the future.

This excellent report captures how we might think about healthcare in the future.

https://www.mckinsey.com/mhi/our-insights/adding-years-to-life-and-life-to-year

Healthcare includes physical, mental, social and spiritual domains and the influencing factors, such as genetics form a small part of our health outcomes. Personal behaviour, social constructs and environmental factors are the more critical part of the eco-system for health.

I love new learning so am excited by the times ahead, with the use of technology to create new ways of thinking about our health.

Our SMART devices are being rewarded for steps achieved, 23andme.com creates consumer led health information and positive words create nudges for change and this type of online presence may be far more impactful than our traditional health care models.

So my personal development plan for this year, includes Personalised Medicine (PM), Digital Therapies (DTx), Artificial Intelligence (AI), Gamification and Machine Learning (ML), Robotics, Smart Devices and understanding the power of Google search which we all use before seeking advice elsewhere.

Developments like cloud computing, blockchain, telehealth, and health apps are now routinely used. Like every change, the unknown feels uncomfortable as we grapple with clinical medicine, within a context of psychology, neurosciences, linguistics, computer science, artificial intelligence, emotion and behaviour alongside genomics, neural networks and pharmacy in a landscape of culture, history and ecology. Increasingly complex care plans, involve multiple organisations, polytherapy and polypharmacy and will require innovation to create shared understanding.

Digital recording already captures physical measurements, experiences, and social media narratives and has set the stage for a revolution in individual health and medical management, population-wide health strategies, and real-time generation of new knowledge and insight.

Chronic disease management and preventative medicine occurs in our own homes so we need to shift to understanding how to meet people in their own context to achieve better outcomes, improving quality of life, but still recognising systemic disadvantages such as accessibility including distance to be travelled to the service, access to technology, time off work, language fluency, health understanding, reading and digital literacy, numeracy and cultural beliefs all need to be addressed. Financial barriers force individuals to choose between household expenses, other priorities and can impact on healthcare and often leads to stigmatisation of individuals who use services ‘inappropriately’.

The social determinants of health (SDoH) are “the conditions in which people are born, grow, live, work and age that shape health,” with these conditions including “socioeconomic status, education, neighbourhood and physical environment, employment, and social support networks, as well as access to health care” and traditionally have been out of scope for the NHS however with Integrated Care Systems and digital technology, we have a unique opportunity to have a meaningful effect on these wider inequities.

I have listed below – from my own research what new terms as clinical practitioners we should be familiar with.

Personalised Medicine

PM can be explained by advances in clinical pharmacology, genetics and neural networks and the recognition that behaviour and the SDoH all impact on an individuals and their families.

We are shifting from being diagnosed with an illness, where the decision about which treatment you’re offered is based on average results through traditional random controlled trials and meta-analysis to PM, where we tailor medical decisions and interventions to an individual person.

We are all unique, our genetic makeup is very slightly different and the “genomics revolution”—advances our understanding of the health implications due to the human genome. There are common risk factors for many diseases, such as age, exercise, cholesterol levels, excess weight and smoking. Our genes, then affect how much difference these risk factors make to each person. This means that some people develop diseases, while others don’t and the same disease will progress differently in different people, and people react differently to treatments.

Through PM, we could minimise side effects, and improve outcomes through a precise diagnosis based on your unique situation, and even be able to predict and prevent illnesses developing in the first place.

PM isn’t just about prescribing, it about a person centred opportunity to address multiple factors including the SDoH.

Pharmacogenetics

Pharmacogenetics has described how people may metabolise drugs differently due to the genes and our unique biochemical processes which influence our drug response. This has led to the concept of a “personalised prescription” by “tailoring drugs to a patient’s genetic makeup”.

To choose the correct drug response and dose, we use genetic information in the context of environmental and personal factors; furthermore, these other factors may be more important than genetics in determining drug response.

From an industry perspective, there has been a lot of promise in terms of PM, however, the larger shift from the pharmaceutical industry is generating collaborations of organisations to increase engagement of individuals, alongside medical or surgical interventions creating support communities rather than a unique drug for an individual.

Artificial Intelligence

Utilising collections of data which arise from electronic health records and other sources, means that any aspect of medical practice such as patient characteristics, symptoms of specific diseases, diagnostic criteria, medication doses and abnormal signs on radiographs or other technology can be reviewed and aligned to our decisions on diagnosis and treatment. This data can be used to construct algorithms to create action.

AI can use computer vision to interpret visual information such as images and videos, to which it can then react based on its algorithms. Natural language processing (NLP) is how AI can understand and interpret human language, whether spoken or written.

However algorithms only work where there is a concrete answer rather than emotion, intuition, subjectivity, perception, memory and human cognition which all influence the decisions we make and currently AI and ML cannot mimic the human connection with others, our resilience and flexibility in response to experience.

Medical applications of AI have focused on diagnostic decision support, often in a specific clinical domain such as radiology and pathology, using algorithms that learn to classify. Examples include diagnosis of malignancy from photographs of skin lesions or from radiography, prediction of sight-threatening eye disease from tomography scans and prediction of impending sepsis from a set of clinical observations and test results.

Systems could autonomously triage patients or prioritise individual’s access to clinical services by screening referrals. Subcutaneous insulin pumps could be driven by information from wearable sensors, or automated ventilator control driven by physiological monitoring data, are all part of our future.

While AI-based systems are currently unable to connect with a smile, notice pain in an expression, or hear distress in a patient’s voice—skills at which humans excel—these systems offer the unique opportunity to augment our performance by creating order and transforming vast amounts of data into clinically actionable information to support optimal care. This should enable us to spend more time on explaining choices, discussing worries and anxieties and creating a shared understanding.

Digital Therapeutics and Gamification of Serious Play

Digital Therapeutics or DTx is one of the latest buzzwords in the digital health ecosystem.

DTx deliver evidence-based therapeutic interventions that are driven by high-quality software programmes to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimise patient care and health outcomes and build on PM utilising a variety of techniques.

Examples include:

• Daylight and Sleepio from UK based Big Health for anxiety and insomnia respectively
• Action For Happiness
• gameChange from Oxford Virtual Reality for Mental Health
• Velibra for adults with social anxiety disorder, panic disorder and general anxiety disorder
• BDD-NET for adults with body dysmorphic disorder
• Minddistrict for adults with depression
• Regul8 for adults with irritable bowel syndrome

Other areas of development are chronic pain management, oncology support programmes, substance misuse interventions, lifestyle changes including health coaching, meditation and health behaviours such as exercise and diet.

DTx solutions are typically delivered through smartphone apps however this requires digital technology so although is very accessible, can also create inequity if these resources are unavailable or not understood.

SMART devices

Healthcare professionals are very familiar with blood sugar technology and substantial improvements in diabetic management, such as normalising blood sugars through SMART technologies however we need to upskill ourselves in understanding SMART data and their link to health outcomes.

Our devices, smart watches and phones measure our heart rates, count our steps, understand our sleep patterns and are part of Microsoft teams:- Headspace to help in stress management.

This march of health sensors and wearables is expanding exponentially and now is interwoven with our clothes, can appear as digital tattoos and possibly digestibles or in our blood vessels as nanobots.

Digital health technologies can identify environmental factors, including air pollution and UV light, pollen and may lead to new ways of management of asthma or risk of malignancy and population health strategies. Food scanners could alert users to one of the constituents in their meal ensuring those allergic to certain foodstuffs are informed.

Although consumer demand for interventions that support behaviour change is high, many programmes such as weight management elicit only marginal and temporary changes in weight, with participants often experiencing weight regain. In their ideal form, evidence-based digital health tools will focus on health behaviour improving self-awareness, provide on-demand health information and education, support self-care, and promote accountability with social support networks, health coaches, and providers. They will utilise real-time data to provide personalised feedback and messaging to support change in a way that is more compelling than the traditional patient education however success of these models is still evolving.

Facilitating Off-Site Patient Management through Telemedicine

COVID-19 drove many health consultations to a virtual technology and we then have been increasingly utilising the model of hospital at home, virtual wards and virtual consultation utilising remote devices to share information and provide services in a more effective and often more acceptable manner.

Robotics

Robotics, now are part of many surgical procedures and support simulation and learning, however the technology exists for robots that could undertake phlebotomy and other technical skills, disinfect environments and even be social companions. Toy robots have been utilised as educational resources for children with ASD and other disabilities and artificial limbs have become unique and admired. We recognise how empathy, communication and the importance of human relationships underpins our therapeutic relationships but we could see robotics as partners in care.

However with every great opportunity comes unintended consequence

The bias cascade starts with the data collection process which is part of information gathering and research. Disparities are known to exist in the recruitment of subjects and health data sets, where certain populations are underrepresented, decisions made by systems that are subject to bias and fragmented services all perpetuate biased clinical performance and can be amplified by AI and ML.

We therefore need diverse and well balanced study populations, paying particular attention to racial and ethnic diversity, gender balance, socioeconomic equity, and other social, as well as social determinants of health including access. Decision making should be scrutinised for bias and wider systemic disadvantage represented. Electronic health records, and any other documents and sources of data used in AI algorithms need to use neutral and fair language to retrieve data records. Data needs to be accuracy, have identity matching capability, and privacy protections of individual data as part of the governance requirements for successful technology transformation.

Algorithm bias has already been identified in kidney function assessment (glomerular filtration rate) with age, gender, race, and levels of creatinine. The tools categorised the race of the patient as Black or not Black. When the calculations were created, black people were falsely perceived to have higher muscle mass on average, which often resulted in a higher kidney function score and triggered a delay in necessary treatment. This has been mirrored in other measures related to bone density and urinary tract infections as examples.

Recently it was noted that pulse oximeters are not accurate across different skin tones leading to altered management plans. Assessment of jaundice, pulmonary function and other parameters have been subject to incorrect data analysis in relation to ethnicity, gender and other characteristics.

The big technology giants such as Apple, Microsoft and Amazon are able to mine their health data creating more data points than traditional health services and may use AI models to create market opportunities in a lucrative lifestyle and wellbeing market place so understanding their own approach to bias is critical as part of the future of population health.

Systems can be designed to take action when explicitly rules are identified, however in healthcare, there is complexity and an ever changing environment so caution needs to be manifested before accepting digital transformation.

Our traditional model of Input – Intervention – Output should move to consider whether  Experience – Conversation – Understanding is more appropriate therefore priorititising human interaction.

Other challenges in technology include:

• Distributional shift – where a system is poor at recognising a change in context resulting in the system continuing to make errors. Examples could include a change in manufacturer of a technology which alters parameters related to radiology images but the AI is unaware of the change so may misinterpret data points. Another example might be the introduction of a drug safety alert and the failure to adopt the changes needed.
• Automation complacency – Automation bias describes the phenomenon where we accept the guidance of an automated system and cease searching for confirmatory evidence, transferring responsibility for the decision to the machine. This is already seen in automation of blood pressure and oxygen saturations, believing the machine and not the presentation of the patient.
• Negative side effects – Systems can reinforces an incorrect decision and create a positive feedback loop. An example might be that an autonomous ventilator derives a ventilation strategy that successfully maintains short term oxygenation at the expense of long-term lung damage.
• Unsafe exploration – An actively learning system begins to learn new strategies by testing boundary conditions in an unsafe way, such as a continuously learning autonomous heparin infusion starts using dangerously large bolus doses to achieve rapid aPTT control.
• Interoperability – Significant progress on interoperability has occurred, but the broad interoperability of health care data platforms is still lacking including access to records, terminology standards, and concern about data management across organisations. The move needs to be towards patient owned information rather than organisation owned data.
• Cybersecurity and privacy concerns – are major obstacles to digital health adoption, continue to erode patient trust, and reinforce health systems’ reluctance to share data so leveraging the opportunity to share, aggregate, and analyse health data to improve individual health and to advance the learning health system is significant, but this has to be balanced against the risk of loss of privacy for individuals sharing their most sensitive data including through the expansion of the use of apps. Cybersecurity requires special attention to avoid intentional corruption of AI/ML training datasets (training data poisoning), use of AI by attackers, or anti-privacy designs in digital health.
• Identify Confirmation – Understanding the identity of the person is critical as many interventions have side effects alongside benefits so being correctly allocated is important alongside monetarisation capability and information sharing protocols.
• Current unclear standards and lack of regulatory guidance – has created a marketplace where promising digital health solutions that provide superior quality, impact, and value are difficult to distinguish from poor quality services.

Governance Frameworks in a Technology Centric Evidence Based Medicine

The public has routine exposure to digitally facilitated convenience based on their experience with other industries and now expects the same from the health care ecosystem. As the understanding of what creates health and well-being grows, it is important to engage patients, families, and communities in the design of new structures, processes, and solutions to support health and well-being.

An immediate priority is to ensure access to digital solutions as digital exclusion can reinforce inequity so ownership of devices, understanding of technology and broadband access is essential across all economic groups and all regions of the country and as a clinician this should now be part of our medical history.

Eliminating bias and creating fairness and equity in AI means being conscious of bias at every potential entry point but there will be the unintended consequence of being missed in design and implementation stages. We need to be alert to this and as a clinician be part of the constant review and ensuring a diverse team is present to explore any systemic disadvantages that may be created.

Quality control questions that we need to be able to ask are:

• Has the system been tested in diverse locations and populations?
• How can we be sure the training data matches what we expect to see in real life and does not contain bias?
• How can we be confident of the quality of the ‘labels’ the system is trained on?
• Do the ‘labels’ represent a concrete outcome or a clinical opinion?
• How has imbalance in the training set been addressed?
• How is the system going to be monitored and maintained over time?
• Does the system adjust its behaviour (‘err on the side of caution’) where there are high impact negative outcomes?
• Does it produce an estimate of confidence?
• How is the certainty of prediction communicated to clinicians to avoid automation bias?
• How can it accommodate changes to clinical practice?
• What aspects of existing clinical practice does this system reinforce?

Stewarding Evidence Based Medicine for Our Future

By its nature, EBM regards disease at a population level with minimal consideration to the role of the individuals. As one size does not fit all, the move towards PM, especially if we take into account the SDoH will be positive. By altering the paradigm of EBM to understand what kinds of interventions improve health outcomes, and which ones do not, there is no reason why appropriate and applicable evidence cannot be gathered about the effectiveness of interventions for everyone.

The transition from ‘outcomes that matter to the industry’ to ‘outcomes that matter to patients’ has the capacity to transform EBM and will be driven by the technology companies and our own interactions with apps, SMART devices and consumer led initiatives however it is also dependent on a highly-skilled digital health workforce, and the training challenge for leveraging digital health is our next learning journey.

So in conclusion, I will continue to enjoy learning about technology and its opportunities, alongside the responsibility to ensure that the limitations are understood. I look forward to the time saved through AI, leaving me the ability to communicate and create shared understanding with others on how to navigate the complex eco-system of healthcare.

The evidence base of the future for health and care needs to integrate psychology, sociology, linguistics, neuroscience, computer science, artificial intelligence and philosophy, alongside traditional clinical practice taking into account culture, history and our environment.

Key to this is the understanding that although we can introduce processes and measurements for the predictable, when we are looking at human behaviour, complex dynamic systems and uncertainty, we can no longer use a process or an algorithm so our current model of health and social care needs to value skills such as experience, empathy, instinct and shared decision making.

From Dr Steve Sucklings blogs – https://themaslow.foundation/category/steves-thoughts/

I have been able to explore that we have four types of knowing;

• Procedural
• Prepositional (facts)
• Perspectival
• Participatory

In health, we have focused on policies, procedures and facts rather than wisdom considering life experience, reflection, active open mindedness and situational awareness to enable the balancing of view points, appreciate context and provide the aspiration to improve through mastery.

INSANITY – Doing the same thing over and over again and expecting different results. Albert Einstein

We discuss understanding our patients but have not recognised that our staff need the same support. We all move away from danger to safety and towards others and the need to belong, so understanding the principles of psychological safety and trauma informed practice underpins how we all respond as individuals, in teams, as organisations and systems.

When we are stressed and feel unsafe, we have tunnel vision, impaired memory and processing capabilities, with a survival response which leads to fight (aggression and defensiveness), flight (withdrawal), freeze and compliance.

When we are thriving and feel we belong, we can collaborate, innovate with creativity and insight and utilise our experience to best effect.

We appreciate that we work in constraints, both financial and of resources including staffing but we also need to understand how we build our own constraints. We should value aspiration and ambition. We need to discuss our feelings and emotions and how these interweave with our decisions.

Power dynamics are rarely discussed however are critical in appreciating decisions and feeling safe. Imbalances of power, naturally happen through roles, professional identity and cultures but if misunderstood can lead to individuals, teams and organisations that feel like bullies, often driven by their own insecurities.

So remember:

• Inclusion safety – means we are all valued, we appreciate and respect.
• Learner safety – enables us to experiment, fail and share our learning journey
• Participation safety – ensures that everyone is empowered to contribute
• Challenger safety – creates an environment where we can speak up and challenge the status quo.

For patients, we need to identify a new way of delivering personalised case which will take into account; clinical medicine, genomics, neural networks and biochemisty, understanding emotion, motivation, perception alongside sociology and the social determinants of health with an appreciation of power and equity alongside how and what interventions are delivered.

For organisations, it is critical that we understand patient safety and have high quality services but we need to move from fixed mindsets and goal orientated  behaviours to growth mindsets and continuous improvement. Rather than fearing feedback and aspiring for approval, we need to understand mastery and activation and ‘being better than we were last year’.

We have recognised from The Francis Report about Mid Staffordshire NHS Foundation Trust to the latest Ockenden Report about Shrewsbury and Telford Hospital NHS Trust and their maternity services, that we have consistently delivered some areas of poor care. We have identified the importance of culture and that this is the bedrock of good practice, but we seem unable to move to a new way of working.

I would propose that attempting to systemise the unpredictable and not value uncertainty and the opportunities that this brings, will lead to the reinforcement of a failing system, in which people feel scared.

Our organisations have grown up in silos delivering care for single diseases and lack the structures, culture, systems, and routines needed to support a democratic, collaborative, and interdisciplinary approach to self-management in patients who have more than one chronic condition and live in a complex eco-system. We have not created holistic services which respond to the needs of patients.

Our partners have their own traditions, with significant differences between health, care and the voluntary sector which are not understood. Challenges such as accountabilities between multiple stakeholders and historic relationships also need to be considered in the new Integrated Care Systems.

Our regulators including the CQC, have tried to simplify the complex, basing its reviews on ‘fallible’ measures and creating an unintentional consequence of feeling that you are being bullied where you have no options but to follow their drumbeat of activities even where it is causing detriment to your organisation and staff.

Our strategic leaders, and politicians often implement new policies and transformation plans with a disconnect on how these will be delivered, with optimism bias, where the politicians can over estimate the benefits, and local leadership having the bias of negative framing believing that nothing will change the current position.

Greater levels of shared understanding would bridge these gaps across our health and care systems, from co-creation with patients, to a shared vision across strategic leaders.

Finally, we have forgotten the most improvement element which is the change over time. Snapshots are not helpful, although comparing trusts and organisations provides an opportunity for insight, I think the real measure is to see self-improvement removing the stress of being compared to others.

With a lens of new understanding, we can build on the foundations of EBM to form a new model of best practice which we have called Participation Centred Care where we merge personalised medicine and participation, organisational development and distributed wisdom and systems theories and philosophy with greater understanding of the totality of the statistical bell curve and celebrate our outliers narrative to inform our practice.

I am sharing my insight into evidence based medicine (EBM), as I recognise that we have all believed this to be the gold standard and when we followed the guidance, we were doing good things. Yet, bias has led to unintended consequences.

As a follower of evidence based medicine, I had not appreciated some of the detriment that may occur but I also believe that we should be kind to ourselves as our brains are designed as high performance pattern recognisers to cope with all the information that they are exposed to. This leads to thinking short cuts and using strategies such as EBM enabled us to function in a world where it is impossible to be effective without some systems to help.

Bias at a system and organisational level can lead to systemic disadvantage, culture and impact on functioning of organisations and communities.

This is a long blog but I believe understanding more about bias is critical to the solving of the wicked problems that we currently face in health and social care.

In research, the concept of bias is well defined and has led to scrutiny of the methodology and analysis of bias. We have trusted that Random Controlled Trials (RCT) and EBM should be able to give clear, definitive and reliable responses to questions.

A good-quality RCT must fulfil the following:

(a) the clinical question must be clearly stated,

(b) the statistical methods must be accurately chosen,

(c) the target sample must be carefully selected,

(d) the randomisation must happen in a clear, unbiased and blinded way,

(e) the collection of data must be rigorous and thorough,

(f) the analysis of data must be blinded and statistically correct,

(g) the evaluation of the results must be unbiased,

(h) the conclusions of the work must be a direct consequence of the statistical analysis and no room should be allowed for personal beliefs and unsupported opinions.

Wider evidence based practices mirror this process utilising national audits, benchmarking systems and evaluation of key performance matrix to inform best practice.

However, critical to these assumptions is that:-

• the research question is appropriate for the problem
• the statistical method is fit for purpose
• the sample population is inclusive and representative of the real world
• that analysis utilises multiple perspectives to consider what the outcomes mean

Our approach is to use simplistic measures, which do not take into account the complexity of ecosystems.

We use a narrow choice of participants and measure with demographic datasets that are not fit for purpose.

Then we analyse through a fixed mind set, often utilising the medical model and efficacy of medicines.

New ways of framing evidence and generating innovative solutions requires a fundamental change in perspective, abandoning deeply held principles and assumptions, and introducing ideas and methodologies from disciplines beyond EBM.

This will feel scary as we have to acknowledge that we have practiced medicine in a manner which has may have caused harm – this causes me anxiety and distress as I believe in the ethical principle of ‘Do No Harm’.  

There are examples of positive outcomes through the use of EBM such as the British Thoracic Society’s asthma guidelines, developed through consensus but based on a combination of randomised trials and observational studies. Subsequently, the use of personal care plans and step wise prescription of inhaled steroids for asthma increased, and morbidity and mortality fell.

However there are other negative outcomes where research has misled practice, such as the breast cancer risk in Hormone Replacement Therapy, wrongly revealed risks that outweighed benefits in postmenopausal women. Use of opiate medications as first line analgesia led to a global epidemic of dependency as we believed that ‘when pain was treated, the person could not become addicted’ and the number of people that have died in relation to addiction is a travesty.

Research Biases

In research there are always biases that need to be considered.

The study design can be poor, statistical bias. There can be systematic differences between groups, selection bias, or between the care the patients receive as performance bias. The outcome can be determined differently in the groups, known as detection bias or the experimental and control groups can get mixed and lead to contamination bias. Within the trial, interviewer bias can influence results, chronology bias is where timing of trials can impact on results, recall bias, exposure misclassification or outcome misclassification can all influence results. Bias after trial completion can be seen with citation bias, confounding and confirmation bias all influencing how results are interpreted.

However the most influential bias of all is that of the “conflict of interest bias”.

RCTs are run or sponsored by the pharmaceutical industries, which have the money, the means and the knowledge to design and conduct wide trials and to publish their results in influential journals.

EBM’s acceptance of industry-generated ‘evidence’ leads to bias in the choice of hypotheses tested, manipulation of study design and selective publication, little scrutiny of the outliers and lack of inclusion. Organisations are penalised for not following these artificial norms and systemic disadvantage has been embedded.

Professional organisations can also perpetuate “conflict of interest bias” utilising their professional power to reinforce the status quo and further champion industry generated evidence.

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. As part of the intelligence-driven approach to regulation, the CQC works closely with national clinical audit bodies to identify key metrics which reflect quality of care and track the performance of providers against these metrics however we rely on the evidence base metric being correct and Shrewsbury maternity services are an example of caesarian section rates being used as a measure of quality.

KPIs, benchmarking and achievement of standards measure success of organisations and are linked to performance and payment mechanisms. Therefore, work around practices develop so that financial penalties and reputational damage is avoided and does not lead to public health gain. Examples such as introducing a first point of contact rather than the an assessment, or that patients are moved to a medical admissions unit rather than a specialist ward are mechanisms introduced to ensure targets are met.

Assuming that the trials are conducted rigorously and the analysis of data is statistically correct, negative results are often omitted, cherry-picking those that can optimise the sale of medicines and products or show case success.

Negative results, are as worthy of publication as the positive ones but may be hidden. Therefore, medicine based on such evidence is likely to be less effective if not unsafe and focuses on medicines rather than wider interventions or systems.

This is a serious problem for the overall evidence base underpinning practice and we need to re-analyse this to take into account these flaws.

The Complexity of Patient forms a bias

Teams deal with people with real life circumstances that provide context. Chronically ill patients usually take multiple medications over many years in a different manner to which they are prescribed and comorbidity is a fact of life for our patients often combined with socioeconomic deprivation and other personal experiences which include culture and identity.

Thus, the application of EBM to real life means that we are building on a flawed foundation.

Biases are caused by:

(1) the lack of patient input to the design;

(2) the low status given to experience (‘anecdote’) in the hierarchy of evidence;

(3) the limited attention given in EBM to power imbalances in healthcare;

(4) the over-emphasis on the clinician-patient relationship which overlooks how we self-management our conditions and the influence of wider social networks; 

(5) the primary focus on people who seek and obtain care rather than on the hidden denominator of those that do not seek or cannot access care;

(6) the avoidance of understanding how the ‘google effect’ is impacting on decisions;

(7) Presence or absence of comorbidities within RCTs by excluding people with more than one disease, by studying the effect of a single intervention on a single disease state;

RCTs derive proof of effectiveness through strictly controlling as many variables as possible, so that any differences between the intervention and control groups may be attributed to the intervention rather than some other factor. The presence of multiple diseases and their various treatments, alongside altering the parameters in which they are taking their medicine, weaken this process, hence the exclusion of people to achieve statistical significance.

Similarly, service evaluations, only include those that use services and rarely explore the hidden opinions of those who do not access services, once again reinforcing bias.

Many diseases such as hypertension, diabetes and epilepsy are multifactorial and not a single entity with a single variable, yet we apply the same principles as a simple disease. Even our treatment of ‘an enlarged prostate’ is illogical, with the large fleshy prostates receiving the same treatment recommendations as the tight muscular prostates which we note from clinical examination.

Most published research has minimal patient input and the evidence gathered relates to options and outcome measures that patients themselves would not have chosen. The available menu of evidence-based choices reflects a biomedical framing and omits options that might be more acceptable and effective. The lack of study of exercise in relation to many diseases, is an example of the favouring of medicines as the intervention of choice.

EBM’s hierarchy of evidence tends to devalue the patient experience. The patient is effectively ‘regressed to the mean’ and offered the option that the average patient would benefit most from.      

Qualitative evidence, even when robust and relevant, is rarely used to its full potential.

Patient and public input to setting research priorities, study design, choice of outcome measures, and interpretation and dissemination of findings must be prioritised and effectively resourced.

Lack of Diversity as a bias

Much of the information about the research participation reports either under representation or lack of data about ethnicity.

The most represented group in these trials are white, middle class, highly educated men. The characteristics of trials is that the subjects are often younger and may vary significantly than the groups they are trying to treat. This misses ethnic diversity or more accurately genetic ancestry, children or the older populations, those with poorer socio-demographic markers to name a few.

This lack of reporting precludes the possibility of any subgroup analysis to identify any significant differences. More importantly, the lack of participation means there is a paucity of research evidence about which interventions are effective in disadvantaged groups.

The generalisability of the findings is limited to people who are sufficiently similar to the trial participants and assumes that the outcome will be the same missing physical, cultural, and structural issues which may not translate to our wider populations.

Creating trials with lived experience as part of the research team is important and using strategies such as Diverse and Inclusive steering groups may help address these issues.

Age, ethnicity and gender variations may lead to changes in responses to drug treatments. These variations, due to differences in the metabolism of drugs, results in variable circulating concentrations, so that the same doses of a drug given to different people can have variable effects.

More difficult is the task of unravelling cultural and structural issues to do with engaging in health care, but this is a crucial part of generating good evidence. Distrust of white dominated institutions is a key factor after the impact of ‘being experimented on without their knowledge or consent’ or being ‘denied services’ has created different perspectives of accessing services, which include the public sector vs private services and other commercial incentives which impact on choice and behaviours, alongside outcomes.

We need to know, not only that an intervention works in ideal trial circumstances with a well defined population, but also works in the context of routine care, within the widest community.

Bias in diagnosis

The human brain is a complex organ with the wonderful power of enabling man to find reasons for continuing to believe whatever it is that he wants to believe. – Voltaire

Errors in cognition have been identified in all steps of the diagnostic process, including information gathering, interpretation of test results and in clinical reasoning and diagnosis and treatment.

The causes of bias are varied, and include learned or innate biases, social and cultural biases, a lack of appreciation for statistics, and even environmental stimuli competing for our attention.

Our brains respond automatically move away from risk and towards others who create a feeling of belonging. We have type 1 thinking as a fast, intuitive, pattern recognition driven method of problem solving, which places a low cognitive burden or type 2 thinking, which is slower, more methodical and a thoughtful process. Type 2 thinking places a higher cognitive strain on the brain but allows appraisal of data more critically and looks beyond patterns. Our left and right sides of our brains lean towards process and empathy, neurodiversity and our character all creates differences in our perceptions. In addition, situations of stress, fatigue, environment and cognitive overload affects our decision making. This has formed part of our new Patient Safety Strategy with Human Factors being critical to understanding how decisions were made.

Examples of bias include the availability or likelihood of the event, leading to a favoured choice, diagnostic anchoring occurring when a plan is conceived before receiving all the necessary information about it. Confirmation bias, interprets information to fit a preconceived diagnosis. Overconfidence bias and diagnostic momentum reinforce following a course of action, without considering the new information available and changing the plan if required (particularly if the plan is identified by a senior or we have heavily invested in that plan).

Group decision making can be seen as group-think, where people agree and fail to challenge the status quo. Our alignment to our professional identify or cultural groups can impact on our decisions and wider influences, mean that intoxicated patients, repeat attenders or those who challenge may receive a different level of care.

We must use reflection and gain insight into our own thought processes and discuss openly human factors, patient safety and review the relationship between healthcare professionals and the systems with which they interact. By understanding our diversity of perspectives, we can co-create new shared understanding with our patients, colleagues and in the systems we work.

Meta-analysis reinforcing bias

Despite the risk of bias, RCT remains the most reliable research design, provided that the size of the sample allows statistically significant conclusions. If they have ‘low statistical power’, several small sized RCTs can be combined with an advanced statistical procedure called meta-analysis.

A meta-analysis consists of a systematic review of different studies in order to gather all the cases together and perform statistical tests on the pooled population. The main difference between a “simple” systematic review and a meta-analysis is that the former is a collective interpretation of the available studies, whereas the latter allows a proper statistical analysis with evaluation of the probability that the null hypothesis is true (p-value).

Meta-analyses are powerful studies that constitute the basis of many of our guidelines.

The risks of meta-analysis may be that they wrongly estimate statistical effect and do not appreciate differences between populations, unclear quality of included studies and inclusion of only published results.  Restrictions such as only reviewing articles in English can give different results from those that could be obtained if no linguistic restriction has been applied.

Therefore, meta-analyses cannot be completely trusted as regards their significance and may amplify problems with less effective, harmful or more expensive treatments being identified and wider public health or social investment poorly understood.

The Impact of Bias

Bias is depicted negatively as something that distorts the truth as a cause of systematic error and that can potentially be eliminated using technical procedures and checklists however bias can also be defined in terms of a value-driven perspectives which leads to beliefs and behaviours. This kind of bias cannot be eliminated and is unavoidable as is part of humanity. It is, however, potentially productive if we share our perspectives which can lead to creativity, empowerment and innovation.

Healthcare needs to build from statistical analysis and causation, towards shared understanding and co-production of next steps where empowerment and exploration of options are prioritised.

More investment in independent research is required with shift from the RCTs and datasets to include narrative and qualitative perspectives. Independent bodies, with a diversity of opinion and voices, need to set research priorities that are co-produced with the whole population and reflect public health opportunities rather than organisational commercial priorities.

A sensible addition is to ensure the registration and reporting of all clinical trials should be published including those with negative findings so we can learn from all insight.

What do people probably need to know?

• Was the intervention accessible?
• Was it delivered to the standards required?
• Did it make a difference to the person?

What do those responsible for population health need to know?

• What does the whole system look like to those who use services?
• From this jigsaw, is it accessible by all?
• Which elements are measurable and how can these be measured?
• What difference does it make to the population and is it inclusive?

As a nurse in the nineties, training as a doctor in the noughties, Evidence Based Medicine (EBM) was my truth. I was a believer that we should follow the processes and guidelines that flowed from research and our analysis of data. I felt that the statisticians and researchers, knew more than myself, with their T Values and Confidence Intervals and were experts, building standards from which the foundations of policy and guidance emerged. These made us feel safe and we were part of a community that shared a common understanding.

I now recognise how EBM underpins my feeling that I face complexity every day.

We have built ourselves fixed mindsets and rabbit holes which have trapped us. People and systems do not fit into these boundaries. When we describe complexity, we are describing the feeling of panic when something does not fit this paradigm and when our decisions are outside this norm and creates a fear of rejection.

 These publications give insight and I would highly recommend a read to gain a feel for the paradox of EBM and I love the story of The Emperors Clothes.

The Emperor’s New Clothes: a Critical Appraisal of Evidence-based Medicine – PMC (nih.gov)

Evidence based medicine: a movement in crisis? (ox.ac.uk)

The following blogs will review this interesting topic

• Bias in EBM
• The Challenges of EBM
• Lies, Damned Lies and Statistics
• Personalised Medicine, Artificial Intelligence and EBM
• Justice In Healthcare
• Understanding Power, Complexity, and Influence

Evidence-based medicine (EBM) emerged as a ‘new paradigm’ for improving patient care. Yet there is currently little evidence that EBM has achieved its aim.

EBM is defined as the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.

EBM become popular, due to the need for patient safety, inconsistencies in clinical decision-making and to control escalating costs, although the science of ‘best research evidence’ has paid less attention on how to capture the subjectivity, uniqueness, and real-world messiness of individuals.

The question of what might constitutes ‘best evidence’ is addressed in levels of evidence tables such as the one produced by the Oxford Centre for Evidence-Based Medicine.

Like most other evidence-ranking schemes, systematic reviews of randomized trials are placed at the apex of the evidence pyramid with mechanistic reasoning and ‘expert opinion’ ranked at the bottom. The flaws in analysis ignores outliers and the biases of research have potentially created real harm.

Qualitative research that describes the patient experience, including the perspective of carers and significant others, can add granularity and meaning to research findings. Nevertheless, this is viewed as less robust than quantitative evidence, rather than complementary to it and addressing different questions.

The individual case report sits at the bottom of EBM’s hierarchy of evidence and we are asked to discount anecdotal findings. This might be appropriate however, the outlier, provides a real opportunity for insight and for individualised management plans.

In a world of only biochemical processes and reactions, EBM may be the answer however our chemistry is contained within a living person, who may experience poverty, disadvantage or be struggling to cope with life. Trying to create simplicity out of huge complexity is a mistake.

Literature evidence has then been collected into “guidelines” for a specific clinical situation. I am sure, they are valuable instruments, however, they have become unchallengeable, and the “absolute” truth. They constantly increase in number, cover virtually every aspect of medicine and restrict the “freedom” of healthcare staff. We are gradually becoming passive executors of someone else’s decisions and have lost the skills to apply judgement, with people fearful of making mistakes in a black and white world rather than being confident with risk and uncertainty.

If EBM were the revolution it aspired to be, we would expect population-level health gains, such as those that occurred after the introduction of antibiotics, improved sanitation and smoking cessation. The Black Lives Matter Movement, covid outcomes and our knowledge of the social determinants of healthcare inequity teach us that disparity and disadvantage may have been amplified by EBM.

The current evidence about health care outcomes suggest that the cost of health care continues to rise, improvements are plateauing, systemic disadvantage is embedded and trust in professionals decreasing.

The future of healthcare will challenge population focused EBM, through understanding our genetic code, our neural networks and the rise of personalised medicine. We need to find confidence in managing systems with artificial intelligence, algorithms and robotics changing the face of healthcare.

I am not suggesting that we throw away EBM and guidelines, but there are serious problems to consider.

The changing landscape of medicine will create a new environment:

• This must include valuing those with personal lived experience and being inclusive.
• Philosophy alongside science can help us consider a different lens to manage complexity.
• Alongside knowledge, systems and policies, we need to understand each other’s perspective and be able to develop ways of creating models of shared understanding.

Our teams need to think laterally, explore how we think ourselves, how we co-create meaning with others and how this manifests in a wider eco-system, going well beyond the rigidity of the EMB and other structured formats. Clearly, we need to preserve and guarantee the safety of our patients but to improve clinical outcomes, we need to have a shift in mindset away from EBM.

We have discussed culture, creating a vision, bringing together a team but what is it that can catch us out?

Most of us, feel “If only I work harder, learn more and perfect my skills, with the combination of passion and work ethic, I can be an expert and will feel good enough.”

As discussed previously, the concept of patience and exploration are important skills of leadership. We need to shift from experts, competency and doing it alone, to mastery, wisdom and achieving things collectively.

Children naturally practice mastery, uninterested in their performance when they are young enjoying experimenting and having fun but as they become oriented toward performing well, children who meet a challenge, often feel that they are not good enough and abandon learning.

We know there is a whole range of knowledge, skills and competencies that people need to develop in order to succeed in a role. But, if we focus on growth and development and life long learning, we could find joy in the work we do, even when we are not good at it yet!

I would like to address the myth that work needs to feel impossibly hard and a destination to be achieved. Where there is challenge, which requires effort and learning, often with conflict between people, through mastery, we could enjoy the process, connecting with our colleagues and problem solving together.

The path to mastery

While we are exploring and working towards an end result with others, the process transforms who we are. We grow and develop, connect and share our ideas and knowledge.

Mastery requires endurance, dedicated time and continuous effort. It takes hundreds and thousands of repetitions, trial and errors alongside community and celebration.

As a leader myself, there have been times when panic has set in. Imposter Syndrome undermined my efforts and I found myself frozen with anxiety, unable to be creative or share my guilt, that I was letting everyone down.

By opening up, using a coach who created a reflective mirror, I could explore new opportunities, stop competing and put aside my short term goals and find a new direction.

Inspiration has come from understanding psychological safety, servant leadership, values led systems, distributed wisdom alongside the joy of empowering others and problem solving as fun but it involved change in myself.

Although we need to understand who we are, we have to shift our mindsets to believe and discover our untapped potential.

Why is mastery out of vogue?

At an individual level, our pull for perfectionism, gathering knowledge, creating correct systems and success projection tend to get in the way of being flexible, adaptable and always learning.

We feel guilt and shame for failing and letting people down. Rather than ask for help when we hit a barrier, we often feel we are stupid for not being able to solve the problem and make mistakes.

Organisations learn when individuals learn.

It is not through endless policies, processes and systems that real transformation occurs.

Real mastery requires us to become lifelong learners and coaches, facilitators and mentors for other’s journey.

• Purpose gives us the energy of pursuing a path
• Wisdom gives us energy when we are open to new understanding
• Belonging creates energy when we are deeply connected with people, so that we can take joy in other people’s joy and find success in their success.
• Growth generates energy when we are growing from every experience.
• Self-actualisation provides inner peace that allows you to engage with your responsibilities with focus and self confidence.

How do we develop mastery?

Although Benner: From Novice to Expert: Excellence and Power in Clinical Nursing Practice Novice is a good model of educational progression, we need to build on this foundation.

When we start a job, we acquire knowledge and develop skills, meaning we can follow a task to an end.

Then, we perform group of tasks with understanding, growing capability and confidence in the role. As our intuition develops, we become truly competent.

When we are competent, we grow the capacity to do more and find space available for us to help others. This is when we become an actual contributor to the broader team and meet the proficient criteria.

By contributing, others start seeking us for ideas, opinions and we become able to create solutions, connect the dots or bring teams together and may appear experts however I would include that we should grow our own personal insight, becoming an influencer and modelling adaptability rather than the fixed mindset of the expert.

In our own academy we believe that is mirrored in our model:

• Acting a Ripple of positivity – our thoughts, actions and words have the power to affect great change far beyond ourselves. The small decisions we make every day – to laugh, to smile, to share a kind word – create an impact that spreads far and wide, impacting much more than our own lives.

• Acting as a Change Agent, Social and Cultural Architect consciously role modelling values and behaviours to lead change in others and transform teams, systems and organisations.

• Alumni – Our mastery requires us to become aware of our latent power and grow trust in our collective ability to overcome hurdles and we can act as influencers to create ongoing transformation.

In conclusion, in mastery, we will be both a leader and a follower in our individual and collective transformational journeys, igniting and inspiring change to create a journey of discovery.

You can change an organisation to adopt a new culture through celebrating followship.

You can change people in organisations to be cultural architects.

You can create whole systems change through culture.

We know that this is achievable as we watch social influencers, technology companies and their leaders. We adopt the latest craze and see transforming communities across the world.

We know change is true as we now use technology, phones and self driving cars. We have a computer on our wrist and communicate virtually.

So transformation happens and is achievable.

So why has changing organisational culture been so challenging.

I have had some lightbulb moments recently exploring how we make decisions and experience the world with Dr Steve Suckling: https://themaslow.foundation/surviving-storms/.

This led to some thoughts which I believe have undermined our efforts.

We have put systems, policies and processes in place, hoping these will enable us to implement change however

• Culture is about people, with a shared mission

The social influencer movement has captured this through creating experiences and messages uniting us into communities. Sharing our lived experience can be a joyful exchange of ideas and inspiration.

In achieving change, we need to celebrate followship as well as leadership and unite to achieve a goal.

• We have ignored Philosophy over Science

‘Quite often we focus on what we know and what we can do. This focus, taken too far, can lead to a defensive approach which shuts down active open mindedness. Focusing too much on procedural and propositional knowledge can pit our knowledge against the knowledge of others’                                                                                                                             Dr Steve Suckling

• Underestimating the dynamic of power

To create a wave of change, we need to harness all the energy of our workforce, empowering the marginalised alongside SWOT analysis and the stakeholder influence matrix.

Cognitive Dissonance and Domicide

Leon Festinger published his theory of cognitive dissonance, the distressing mental state that arises when people find that their beliefs are inconsistent with their actions. Recent decades have seen a rise in “deaths of despair” which cognitive science researchers have situated within a wider “crisis of meaning” (Vervaeke 2017).  Increasing amounts of people are experiencing domicide (literally, the death of home), a process by which an individual, or group, comes to experience a lack of grounding or connection to society.  In Health and Care and many other environments, we believe we should be making a positive difference to the people we serve however many of the actions we undertake do not align to this purpose creating a feeling of distress.

Aligning to our culture is important to recreate a sense of belonging and shared purpose.

What are the first steps?

To create a different culture, we need to share a common vision. This vision needs to make sense and be logical. Even where individuals, are sceptical, they can be followers and build the foundations as a legacy for the future.

The flip side of leadership is followership.  It stands to reason that if leadership is important, followership must have something to do with it too.  But curiously, followership is not spoken about and will be negatively framed as ‘sheep’ and ‘being easily led’.

Followership is the ability to take direction well, to get in line behind a plan, to be part of a team and to deliver on what is expected of you.  Yet, who gets gold stars when they are described as an excellent follower.

Good followers have a number of qualities:

• Judgement

Followers have an underlying obligation to follow only when the direction is ethical and proper.

• Work ethic, competency and being a team player

Followers are diligent, motivated, committed, pay attention to detail and make the effort to participate.

• Courage

Good leaders are grateful for constructive feedback and followers need to have the courage to be honest and share wisdom and experience

We need to understand how to include, not exclude individuals, and create a momentum of change.

We need to build trust, to ensure that people know when they do something, the reaction and that this is consistent and authentic.

Although organisational change theory is helpful and we are aware of Pavlovs dog and Skinners experiments on rats, demonstrating behaviours generated by reward and punishment, is ignoring the great sense of community, peer to peer engagement and our own insight and perspectives.

Creating a Community that Identifies with the Vision

To build your change agents and cultural architects, you need to engage with people and listen.

Our workforces need to be involved in conversations, applying culture to create a framework for shared understanding and providing opportunities for bridging professional differences of opinion.

A new model of peer supervision is needed, where when we have the ability to explore events, experiences and our policies and processes through the lens of active open mindedness.

• What is the context in which we are working?  This will be often overlooked, but in a COVID world, with AI looming and a systemised, regulated service, understanding how we apply culture is critical.

• How is culture perceived by different individuals and groups – the word psychological safety which feels a positive shared cultural value may have different meaning to different people and it is important to explore the words generated by culture together.

• How can you develop a strong and engaging narrative and set of key messages? These again are often dull, but look to social media for inspiration, the power of storytelling should not be underestimated.

• Ensure that you fully represent the people affected and ask them what is needed?

• Strengthen the agency and action of people to achieve change themselves.

Distributed Wisdom

Using this strategy of enabling people to step back and see the wider picture, identifying threads and relationships, a new common vision, goals and behaviours can be achieved with shared understanding.

Do not underestimate the dynamic of Power

Power lies at the heart of change and understanding where power is held or who is experiencing marginalisation is critical to success.

Power in organisations is often captured through professional identity or department identity but can be economic, political, social, cultural or symbolic. People’s experiences of power depends on their identities, related to age, gender, race, class, ethnicity, religion, sexual orientation or disability status.

A common conception of power is control over others, having authority and control over individuals, groups or institutions which can be backed up by action – often loss of a job.

Visible power is when decision making is observable and leads to formal and recognisable rules, laws, structures and procedures.

Resistance is a form of power often influencing of the agenda from behind the scenes.

However, power is subtler and can be positive.

• Collective Power is the strength and capacity gained from joining others in working towards a common goal.

• Power within is personal self-confidence and role modelling can be a form of power.

• The norms, values, attitudes, beliefs and ideology that shape a person’s way of thinking can influence decisions and form a powerful opportunity.

So looking into the organisation to identify how power can be understood and utilised to create a positive optimising effect is important.

What is Needed to Build a New Culture across Systems?

To create whole system transformation, organisations need to share a common vision, role model successful application and create win:win changes recognising the value we all bring to the whole community.

We can apply the same principles at an organisational level.

• A shared mission
• Including Philosophy alongside Science
• Leveraging the dynamic of power

Developing a powerful message and narrative that will engage, motivate and resonate with your audiences and key stakeholders to make a change is a critical element of effective influencing.

Finding Inspiration in a Journey

With cultural change, embrace the journey and focus on making small, incremental steps and work closely with your workforce to create a movement of change.

Even when you are struggling, walking creates a pathway of footsteps and others can follow.

Listening to Steven Bartlett’s podcast: The Diary of a CEO, he discussed how time is more precious than gold and diamonds and yet we do not think about time as a precious resource.

If you google the qualities of an ‘inspirational leader’, you will rarely see the word patience.

Patience means having time to ask questions, explore answers, and going with the flow. Patience helps you resist the tendency to create urgency when there is none, allowing space and time for creativity, insight, and judgment. It is more than time management.

Patience has contributed to many great leadership successes. Gandhi demonstrated extraordinary patience in working for a free and independent India. For more than thirty years, Gandhi worked, never varying from his commitment to non-violence. His patience resulted in a free India.

This reminds us, big ideas might take years to achieve.

This made me think about my own relationship with time.

• I am often impatient, achieving goals and feeling a positive energy of ‘doing’

However, this leads to poor decision making, without considering the consequences of quick decisions. In addition, completing the actions yourself, prevents others from achieving these opportunities and finally is a short term fix.

• I have practiced being patience, both as a strategic leader and entrepreneur. This means focusing on the long term vision.

We need to have the ability to wait for our longer term goals, staying calm in the face of disappointment and creating space to think when we are processing urgent decisions especially in face of risk and uncertainty.

• Time Management, is something I feel I have become an expert at. This requires understanding what to prioritise, how to delegate and consider when, what and where we schedule our attention. We need to use every minute wisely.

 My view is that you can only juggle 3 big actions at any one time.

We should end our working days positively so doing the hard things in the morning and fun things later.

Strategies such as do, dump, delegate or delay for the to do list are a good way to manage your list.

• Then work-life balance for a workaholic, is not an easy goal to achieve but it is important to be present when you are at home for your family and own wellbeing.

With our world quickly becoming a place where we can get everything instantly, is this creating a false urgency?

In leadership, the expectation is to take action quickly and decisively, creating action plans and targets to measure compliance. Patience is often thought of as a weakness and considered as being slow and sometimes even incompetent.

Split-second decisions and moving on to the next problem becomes the norm but this means that often the incorrect actions are taken and there is not time to reflect or alter the direction of travel.

People demand action and the greater the crisis, the greater the push to act! A leader endures rather than flourishes and often feels under pressure, if they make a decision to wait.

However, patience doesn’t mean ignoring the interim milestones but to keep them in context. It should not to be confused with inactivity – far from it, patience requires overwhelming effort, not to jump in and react.

Many of the roles and responsibilities associated with leadership require patience!

• People Management and the ability to continuously notice the small things, celebrate achievement but manage poor performance takes enormous energy and patience.
• Strategic planning and the understanding of a wicked issue requires thought and patience and may take years to resolve.
• Collaboration, building the wider community or networks of people and organisations takes time.
• Changing Behaviour and organisational culture is not a quick fix.

So despite the importance of patience, many senior leaders, especially those whose careers are in rapid ascent, need results for their portfolio and become distracted for short term glory over long-term results.

Self-awareness and giving yourself permission to wait, is the start of being able to improve your patience. The more self-aware you are, the easier you will recognise the warning signs of impatience, such as quickened pulse, growing irritation or a sense of jumping in. You will also be able to counteract your physical reactions by using strategies to delay decision making and by taking some deep breaths or mindfully adjusting unhelpful behaviours and destructive thought patterns.

Time Management also forms part of this journey and allows calm and control of our ‘doing’. Good time management is the partner of patience and allows to plan for inactivity as well as make the decision to do!

So in conclusion, time should be treated like gold and patience an important leadership skill.

Our current landscape of organisations is that they are unable to change, overwhelmed by the unpredictable: COVID, regulatory oversight and significant pressures in workload and service delivery.

Toxic culture continues to feature in serious case reviews and through wider feedback.

The latest opportunity for change is the Patient Safety agenda which champions ‘Just Culture’ and the need to be a learning organisation but this requires action and a shared vision.

How do we make a difference?

I am a fan of the rule of marginal gains and believe we have to remember no change is an overnight transformation but often a series of small positive steps over time.

Click to access ABriefGuidetoProcessImprovement-2.pdf

How can we make a difference every day?

Interestingly the ‘meaning research’ being undertaken by Dr Steve Suckling gives us a clue.

https://maslowfoundation.wordpress.com

We feel overwhelmed and driven by processes and directives which lead us to believe we need to be right and that the world is logical and rule bound.

We have not developed the skill of being actively open-minded or being able to feel confident with decision making related to uncertainty or how to fail without punishment.

We feel unsafe and this causes us to experience anxiety.

Understanding the principles of wisdom is a strong foundation.

With distributed wisdom, shared risk and psychological safety as our new core knowledge and skills, we will be able to create change in our organisational culture.

Just a reminder about how our bodies are geared to scan for danger!

As humans, we are evolved to be able to feel safe and connected to others.

An understanding of our nervous system gives us insight into why we we often feel danger, overwhelmed and anxious and have poor habits of defensiveness and conformity.

When you see a danger, our nervous system leaps into action.

If any of you have the opportunity to see Zoe Lodrick, please take the time as she will present the trauma response in a way that you will never forget.

https://www.zoelodrick.co.uk/resources

This has been called the “fight, flight, freeze or flop response,” and is managed by the sympathetic and the parasympathetic nervous system.

We may fight back (verbally or physically), or we may retreat. When we feel as though we are in danger, we may shut down and “freeze up.” Reactions can also include dissociation and behaviours such as ‘befriending compliance’ are all strategies to keep us safe.

All these responses have evolved to maximize our chances of surviving life-threatening situations but we are still using the same strategies and patterns whenever we are confronted by our modern day challenges.

Being connected to people creates a feeling of safety which is part of our evolution and a critical element to be present for our own wellbeing.

Our workplaces have become complicated systems which often create fear and therefore anxiety. We become defensive, withdrawn or compliant.

Before we can do anything different, we must create psychological safe spaces in which to thrive and this forms the basis of a ‘trauma informed culture’.

Psychological Safety First

https://www.leaderfactor.com/4-stages-of-psychological-safety

Stage 1: Inclusion Safety

Inclusion safety satisfies the basic human need to connect and belong. Inclusion safety allows us to gain membership within a social unit and interact with its members without fear of rejection, embarrassment, or punishment, boosting confidence, resilience, and independence.

Stage 2: Learner Safety

Learner safety satisfies the basic human need to learn and grow. It allows us to feel safe as we engage in all aspects of the learning process—asking questions, giving and receiving feedback, experimenting, and even making mistakes, not if but when we make them.

Stage 3: Contributor Safety

Contributor safety satisfies the basic human need to contribute and make a difference. When contributor safety is present, we feel safe to contribute as a full member of the team, using our skills and abilities to participate in the value-creation process.

Stage 4: Challenger Safety

Challenger safety satisfies the basic human need to make things better. It’s the support and confidence we need to ask questions such as, “Why do we do it this way?” “What if we tried this?” or “May I suggest a better way?” It allows us to feel safe to challenge the status quo without retaliation or the risk of damaging our personal standing or reputation.

Then when you feel safe – we can move forward with doing something better every day through the principles of wisdom.

Wisdom builds on our factual knowledge and procedural compliance.

We manage uncertainty through being open minded and having humility and taking the time to understand others perspectives.

This enables us to craft a collective narrative which is adaptive and flexible. It takes into account the context of the situation and welcomes risk and uncertainty.

However even where we have wise people, with collective discussions, in safe spaces – we still need the aspiration to change!