and informs Judy that her husband has been abusing Brad, both verbally and physically, over the past year; the beatings have escalated in frequency and intensity over the past month. Brad’s mother feels unable to protect her son and fears for her own safety. Judy alerts Child Protective Services and calls the women’s crisis center. She then makes a highly critical report of Belinda to the clinical director of In the language of human factors, Belinda and Brad’s encounter occurs at the sharp end, that place where weaknesses in the system of an organization come together to produce harm. As a mental health professional, Belinda is accountable for contacting Child Protective Services if she suspects or knows of child abuse. Her failure to do so is potentially an active failure (an operational error at the delivery level of the organization) and stems from inaction and faulty decision making (mistake). However, given her lack of experience and as a recent graduate of her master’s program, it is understandable that a considerable gray area exists in this clinical situation. Being unlicensed, Belinda necessarily must rely on supervision to manage cases and guide decision making. Numerous latent failures (hidden factors rooted in the work processes of the organization) facilitate this systemic error. These include an unmanageable caseload that most likely causes distraction and fatigue, inadequate supervision for an inexperienced worker, and a poorly communicated policy for reporting suspected abuse (if such policy exists at all). Decisions made at the blunt end, that is, by external forces and management, might include diminished state funding and resulting organizational budget cuts, which in turn produce an overworked staff. In a culture of blame, human error is accepted as the sole cause of a sentinel event. Clinicians are held accountable for mistakes, and all learning stops. Error-prone conditions remain hidden in the system, lying dormant in broken work processes, waiting to produce yet another disastrous event. In this case example, Belinda has been singled out as the lone culpable individual. In a culture of safety, she would still be accountable, but her mistake would be handled in a different, nonpunitive manner. In a culture of safety, this adverse event would be viewed as a learning opportunity, an opportunity to improve the system, adopting a perspective that includes the totality of the patient event. To understand how this adverse event and Belinda’s decision making would be managed in a culture of safety versus a culture of blame, the following section introduces selected cognitive and organizational concepts. the substance abuse clinic. Case Study 1: Discussion Judy, the social worker who met Brad and his mother in the emergency department, is a mandated reporter, which means that she is obligated to report child abuse to Child Protective Services. However, Judy’s overly critical response—without speaking to Belinda and without understanding the complexity of her work situation—is the observer’s unfortunate reaction to an adverse outcome in a culture of blame. It is a reaction that is governed by cognitive phenomena known as hindsight bias and fundamental attribution error (Flick & Schweitzer, 2021). Hindsight bias makes it likely that Judy will simplify the conditions surrounding the mistake, exaggerating what Belinda should have foreseen. At the same time, hindsight bias causes Judy to be unaware of the way her own perception is influenced by knowing the situation’s adverse outcome (Brad’s broken arm). Fundamental attribution error leads Judy to attribute the adverse outcome to Belinda’s personal inadequacies (incompetence and negligence), rather than attributing the negative outcome to situational factors beyond her control (inadequate supervision, an unmanageable caseload, incomplete information, and
inadequate training on how to manage suspicions of abuse). Although hindsight bias is always present when a mistake is evaluated in retrospect, and fundamental attribution error is a pervasive tendency, Belinda’s actions would be handled differently in a culture of safety. A culture of safety is also a just culture, which means that Judy, the social worker in the emergency department, would still alert Child Protective Services. However, as an experienced social worker who is fortunate to work in an organization committed to safety, Judy would recognize her unnecessary critical reaction as a knee-jerk human response to an adverse event. She might reflect differently on the impulse to blame a single individual for what is, in fact, a complex situation created within an equally complex system of care. Being more conscious of the totality of factors, ideally, she would contact Belinda to learn more about the situation. Normalization of deviance describes the phenomenon of accepting aberrations as a natural course of doing business (Wright et., al, 2020). In alcohol and drug abuse clinics, such as the one in which Belinda and Dr. Bledsoe work, high caseloads are accepted as a fact of life. Despite solid research that proves fatigue leads to a number of problems—lapses in attention, inability to stay focused, reduced motivation, compromised problem solving, confusion, impaired communication, slowed or faulty information processing and judgment, diminished reaction time, and a loss of empathy (Cash et., al, 2020)—probably none of the clinic’s employees would be aware of or question the distraction and fatigue they are experiencing; they would, most likely, accept their stressful work environment as the way things are. Diffusion of responsibility is a term from social psychology that refers to the phenomenon of not performing a task because a person assumes that someone else will take care of it (Liu et al., 2022). In this case, Belinda might assume that the clinic secretary was correct that reporting her concern to Dr. Bledsoe was sufficient or that, after checking with Dr. Bledsoe, the secretary would handle any necessary reporting requirements. In contrast, in a culture of safety, nothing is assumed. Reporting requirements are clear, and every employee is certain about their responsibility concerning what to report and where it is to be reported. Belinda’s uncertainty about her suspicion of abuse when faced with Dr. Bledsoe’s curt dismissal, and her inability to take corrective action when she believed her client to be at risk, are examples of the authority gradient. The authority gradient—the inability to speak truth to power—reflects power dynamics and the way that differences of opinion are handled in hierarchical cultures (Luva & Naweed, 2022). Workers who perceive themselves to be in lower-status positions with less power are reluctant to give negative information to individuals they perceive to have more authority and are hesitant to question the decisions of their superiors. The authority gradient has been identified as a dynamic that occurs between pilots and copilots, between doctors and nurses, and between students and attending physicians (Murray & Cope, 2021). The authority gradient is disempowered communication, which can have disastrous consequences in hazardous work environments, as members of the field of aviation discovered in the late 1970s. Following several air disasters, the examination of cockpit voice recordings revealed that copilots’ indirect and ineffective wording of critical information failed to capture the pilots’ attention in time to avert disaster. In response, the aviation industry developed a training program to improve situational awareness. Known as crew resource management (CRM), this program
EliteLearning.com/Counselor
Book Code: PCUS1525
Page 54
Powered by FlippingBook