**3. How social work leadership can help improve the quality and safety of care: Especially for vulnerable individuals and groups**

Social work leadership is important because if we accept the fact (and I used that phrase advisedly and carefully) that patient safety is about the social as well as the technical dimensions of care, then social workers can provide unique insights and leadership into the risks and responses to those dimensions. In this section I will look at five areas in which social workers can provide leadership in patient safety: clinical governance (and other safety frameworks); understanding the social dimension of risks; advocacy; interprofessional practice; and equity.

#### **3.1 Clinical governance**

Clinical governance emerged in the United Kingdom in the late 1990s as an approach to improving the quality and safety of care. It was developed at least in part as a response to major patient safety inquiries, especially the Bristol Royal Infirmary Inquiry into the higher than expected deaths in children who were undergoing operations for cardiac problems at that hospital. That inquiry found, as quoted by the British Medical Journal *"… poor teamwork between professionals, "too much power in too few hands," and surgeons who lacked the insight to see that they were failing and to stop operating"* ([35], p. 181).

Clinical governance was defined as *"a system through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"* ([36], p. 62). Many countries around the world, mostly but not entirely Commonwealth countries, have adopted all or some of the elements under a clinical governance approach. These elements include: *"accountability, vigilant governing boards and bodies, a focus on ethics and regulating qualified privilege. It also includes taking steps to institute measures such as continuous improvement, quality assurance, audit, applying standards and ensuring they are met, using clinical indicators, encouraging clinical effectiveness, promoting evidence-based practice, participating in accreditation processes, managing risk, reporting and managing incidents, focusing on patient safety, improving the sharing of information, supporting open disclosure, managing knowledge effectively, obtaining patient consent, providing feedback on performance, promoting continuous education, dealing with complaints effectively, encouraging consumers to participate in decisions affecting their care and credentialing of medical [and other] practitioners"* ([37], pp. 12-13).

While not all countries' safety systems may include all of these elements, most have adopted at least some of them. Social workers can and should be involved both in ensuring that such systems are in place, and in participating in the review processes to ensure a wider lens is included in activities such a root cause analysis processes [38].

#### **3.2 The social epidemiology of patient safety**

One specific role for social workers to contribute to clinical governance (and related activities) is in explaining and exploring the way in which individual's and group's social characteristics make increase their risk of adverse events and harm. There are multiple examples of this, but I would like to discuss two in particular: the way in which risks do not just start and end with the clinical encounter and what is known as diagnostic overshadowing.

As I discussed earlier in this chapter, relatively little work has been undertaken by patient safety researchers about the way in which a person's social characteristics may increase their risk of harm. This increased risk can occur prior, during or after the medical intervention. Research has shown, for example, that malnutrition increases a person's risk of hospital acquired infection. Yet it is well known both that geriatric patients are more likely to enter hospital with malnutrition and that some patients, including children and older adults, are at risk of developing malnutrition while in hospital [39, 40]. Malnutrition is a pre-operative risk factor [41], but understanding and responding to this risk requires both general clinical knowledge and an understanding of the vulnerability of particular individuals and groups.

*Social Work Leadership for Patient Safety DOI: http://dx.doi.org/10.5772/intechopen.105535*

Another example of increased risk is patients discharging themselves against medical advice (DAMA), and therefore missing out on the care they require. It is easy to think 'it's their decision' but the reality is that for many vulnerable groups, the reasons are due to factors such as the affordability of care [42] or in the case of First Nations people, a lack of cultural safety [43].

Another specific risk which social work leadership can address is the effect of diagnostic overshadowing. Molloy, Munro ([44], p. 1363) define diagnostic overshadowing in relation to people with mental illnesses in the following way *"One form of discrimination is diagnostic overshadowing, which is a judgment bias where health care professionals mistakenly attribute clinical manifestations of physical illness (eg, pain, tachycardia, hypertension) to manifestations associated with a pre-existing mental illness … This leads to physical illnesses being underdiagnosed and undertreated … Common causes of diagnostic overshadowing related to health care professionals who care for mental health consumers include fear, avoidance, lack of education, lack of confidence, and lack of clinical assessment, including symptom recognition … and negative unconscious bias".* Cho ([45], p. 1) adds that *"Systematic biases that disproportionately affect historically marginalized groups underlie some of these misdiagnoses."*

It is not only people with mental illnesses who experience diagnostic overshadowing. Evidence of the negative impact of diagnostic overshadowing has been identified, for example, in patients with schizophrenia [46], people with intellectual disabilities [47], people with learning disabilities [48], with physical disabilities [49], children and young people including children with Down's Syndrome [50, 51] and with autism [52].

Cho ([45], p. 1) argues that physicians (and I would add all clinicians) *"… must pay special attention to the ways in which they or their field may be unconsciously biased towards or lack information about certain identity groups."* This is a difficult topic and one which most decidedly requires leadership, including the ability to able to influence and negotiate with all the parties involved [53].

#### **3.3 Equity**

One of the underpinning factors in the social epidemiology of patient safety is the equity of care. *"Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided*" ([54], p. 433). This requires that *"… equal access to available care for equal need, equal utilization for equal need, equal quality of care for* all" ([54], p. 434). I would add and equal quality and safety for all.

As noted earlier in this chapter, the Institute for Health Innovation in the USA has included equity as the quintuple aim of healthcare. This, it has been argued, requires that *"… all improvement and innovation efforts a focus on individuals and communities who need them most"* ([10], p. 521). Social work leadership can and should be involved in both identifying those individuals and communities who most need interventions and working to ensure that conscious discrimination or active bias does not occur.

The decisions around medical rationing during the COVID 19 pandemic are a case in point. Chen and McNamara ([55], p. 511) argue that *"The current public health crisis has exposed deep cracks in social equality and justice for marginalised and vulnerable communities around the world."* Lee ([56], p. 1) notes that the pandemic trigged "inequity amplifiers" including *"(1) expansion of riskscape, (2) reduction of social ties, (3) uncertainty of future, (4) losing trust in institutions, (5) coping with new knowledge,* 

*and (6) straining on public spending".* One way the 'straining on public spending' was addressed was through the issuing of treatment guidelines.

One way this played out was through the issuing of guidelines and decision tools around the world which were ageist and or ableist [57–59]. These clinical decisions tools compounded governments' often slow responses to provide the additional care required by these groups [60], even though it was clear from the start of the pandemic that they were at higher risk (as were people from certain ethnic backgrounds – both patients and staff). Discriminatory decisions ranged from the distribution of vaccines [61] to the provision of treatment and care, including *"… reported rise in the number of 'do not resuscitate' orders being imposed on people with disabilities … Vulnerable members of society, including older persons and people with disabilities, were seen as being most at risk, and healthcare professionals were advised to prioritise those who had the best chance of recovery in the event of a mass outbreak*" ([55], p. 1).

From an ethical and human rights perspective these clinical decisions, which would adversely effect some groups in the community and not others, were forms of iatrogenic harm [62]. The fact that these discriminatory guidelines emerged during a pandemic, or crisis, can provide a part explanation, but not an excuse, and they mirrored at a macro level, the decisions made at Memorial Hospital in the US during Hurricane Katrina, where patients were euthanised without their or their family's knowledge or consent [63, 64].

As Marks ([62], p. 104) argues, history *"… calls into question the very idea of the pandemic/non-pandemic distinction. Given the countless failures to heed warnings prior to COVID-19, and the inevitability of future pandemics, we must consider a pandemic as something that is either happening or about to happen. That argument becomes all the more compelling when we recognize that—as COVID-19, Hurricane Katrina, and many other crises periodically remind us—the burden of systemic failures to prepare for public health emergencies falls disproportionately on communities suffering from systemic inequalities."* In short what COVID has done is to show how deeply social attitudes towards the vulnerable can affect clinical decisions. The role of social work leadership? McGuire, Aulisio ([65], p. 23) (as part of the Association of Bioethics Program Directors (ABPD) Task Force) concluded their review of the ethical challenges arising in the COVID-19 Pandemic that *"Even in the face of the terrible burdens of an overstressed healthcare system, disability communities need special consideration to avoid inequities"*.

### **4. Attributes of social work leaders addressing patient safety**

I must begin this penultimate section of this chapter with the provisio that this list of attributes is neither comprehensive nor evidence based. Rather it draws on my experience and research over 30 years as an academic interested in the quality and safety of care for vulnerable groups and individuals. Competencies are often dived up into three categories: knowledge; skill and attitudes [66]. In this section I will address two key attributes for social work leaders under each of these categories.

#### **4.1 Knowledge**

Although there is a wide range of knowledge associated both with health leadership and with patient safety, in this section I would like to address what I believe are two key concepts we can use as social workers engaged in improving the quality and safety of care (including all the various elements of clinical governance and similar frameworks. These are intersectionality and epistemic injustice.

#### *4.1.1 Intersectionality*

As we have seen in the section on the impact of diagnostic overshadowing, it can be the multiple vulnerabilities of individuals and groups that contributed to heightened risk rather than any one single characteristic. One way of understanding that factor is through the lens of a theory called intersectionality. Intersectionality has been used to examine *"… the multiple interacting influences of social location, identity and historical oppression"* ([67], p. 288) and the way that *"… the a priori centralization of one system of inequality, social status, or identity, obscures the ways in which systems of inequality co-constitute and mutually reinforce one another"* ([68], p. 210).

This situation can be seen in the death of Mr. Brian Sinclair (although there are similar cases around the world). Mr. Sinclair *"… died in the Emergency Room [in a Canadian hospital] in 2008 … His physician had referred him to the emergency room as he had a blocked catheter. Health care workers assumed that Sinclair was a drunk, poor, and homeless Indigenous man seeking shelter, and therefore, he was never triaged into the system. He waited 34 h[ours] in the waiting room and was pronounced dead when a physician finally decided to see him*" ([69], p. 37). In other words the assumptions made about his social status resulted in his not receiving the medical care he required.

An awareness of the intersectionality might assist in mitigating the risks faced by people such as Mr. Sinclair. Wilson, White ([70], p. 9) argue that *"Rather than pretending that differences do not exist, or minimizing their potential impact on the patient–clinician relationship, intersectionality acknowledges how multifaceted differences shape the patient–clinician interaction and forces a reframing that can lead to improved outcomes. An intersectional conceptual framework also requires an exploration of how institutional practices within the clinical environment, even those that seem neutral, unfairly advantage some and disadvantage others."*

They conclude that *"(1) An intersectional lens requires the clinician to confront his or her own biases, whether the presumptions are of commonality or of difference between the clinician and the patient. (2) Understanding clinician–patient interaction through an intersectional lens complicates the picture, challenges assumptions (sometimes yielding surprising information), and potentially clarifies issues that arise between the patient and the clinician"* ([70], p. 13). Once again, I would argue, social workers are in a unique position to both educate other health professionals about these risk, and support the patients at risk through advocacy (which will be discussed in following sections).

#### *4.1.2 Epistemic injustice*

Another source of knowledge for unpacking the social epidemiology of patient safety is through the lens of epistemic injustice [71]. *"Epistemic injustice is a kind of injustice that arises when one's capacity as an epistemic subject (eg, a knower, a reasoner) is wrongfully denied"* ([72], p. 1). There is evidence that this occurs in several ways in healthcare, including the dismissal of complaints from vulnerable groups and individuals, including people with low levels of formal education [73], people with mental illnesses [74, 75], and most recently people experiencing long COVID [76], to name just a few groups.

Understanding and addressing the risk of epistemic injustice is profoundly important for patient safety. *"Evidence provided through patient safety inquiries and a number of high profile cases includes testimonials of both patients/families and staff who have raised concerns only to have them dismissed [23]. For patients, families, carers and communities, that dismissal amounts to an epistemic injustice, where patient testimonies are "… are often dismissed as irrelevant, confused, too emotional, unhelpful, or time-consuming' ([77], p. 530). Denial of patients' (families' and communities') concerns do the people involved a significant symbolic violence as well as actual harm [78].* As Carel and Kidd (2014, 530) note *"… ill people are more vulnerable to testimonial injustice, because they are often regarded as cognitively unreliable, emotionally compromised, or existentially unstable in ways that render their testimonies and interpretations suspect"* ([27], p. 15).

In their study of patients' access to their own case notes, Blease, Salmi [79] argue that epistemic injustice disproportionately affects what they call 'marginalised patient populations' (ie the same groups I have identified as vulnerable), *who "… may suffer a 'double injury' when it comes to information blocking. Perhaps because they are vulnerable to nonconscious forms of epistemic discrediting, and communication breakdowns, such patients may accrue greater benefits from accessing their notes away from the pressures and limitations of the face-to-face encounter"*, yet such access is less likely to occur for those groups ([79], p. 5). In other words vulnerable groups are more likely to be dis-believed (within the healthcare context) and at the same time, less likely to have access to the tools which might improve their care (such as access to their case notes). This area of knowledge ties in closely with the advocacy role for social workers, discussed under the skills section.

## **4.2 Skills**

The two skills I would like to consider in relation to the role of social work leadership for patient safety are interprofessional practice and advocacy.

#### *Interprofessional practice*

Much has been written about interprofessional practice over the last two decades, and the links between poor interprofessional practice and or teamwork and unsafe care have been a recurrent theme in both large scale patient safety inquiries [23] and the research literature. As Blacker, Head ([80], p. 316) note, *"In recent years, attention to the importance of interprofessional collaboration in achieving high quality health care outcomes has been growing significantly. Such collaboration has been linked with greater provider and patient satisfaction, enhanced recruitment and retention of staff, improved patient safety and outcomes, and lower health care costs."*

Reeves, Clark ([81], p. 145) in their review of the interprofessional patient safety literature, support this argument and add that *"A common underlying reason for failures in patient safety has been ineffective teamwork and communication, which has spawned an increased emphasis on improvement … Effective interprofessional collaboration and teamwork is understood to rely on continuous and open communication, an understanding of different professional roles and responsibilities as well as respect for colleagues from different professional groups." Blacker, Head ([80], p. 319) also note that the IHI's Triple Aim framework, which I discussed earlier in this chapter calls for "… skills in team-based care, collaboration, and interprofessional service delivery".*

Despite the evidence supporting the importance of inter-professional collaboration, barriers continue to hamper the practice, including professional hierarchies and leaders who are unfamiliar either with interprofessional practice per se or with the benefits thereof [80]. As Pullen-Sansfaçon and Ward ([82], p. 1284) note social *Social Work Leadership for Patient Safety DOI: http://dx.doi.org/10.5772/intechopen.105535*

workers have a unique contribution to interprofessional practice. *"Social workers, with their values, knowledge and training in groupwork, have potentially a special role to play in facilitating interprofessional teamwork."* This is especially true if we consider Nancarrow, Booth [83] 10 principles for effective interprofessional teamwork, the first of which was for the team to identify *"… a leader who establishes a clear direction and vision for the team, while listening and providing support and supervision to the team members"* ([83], p. 5).

#### *4.2.1 Advocacy*

Addressing risk factors is not just matter of knowledge about the clinical evidence, but also about being understanding and address the social conditions which may contribute to people's or groups' risk, and the ability to able to advocate for those groups. As Swinford, Galucia ([84], p. 513) argued in relation to the COVID pandemic *"… social work has much to offer in our roles as researchers, educators, practitioners, and advocates during this crisis, and our foundational principles serve us well."*

Social work training is unique among health professions in preparing professionals specifically for advocacy roles. This includes providing a vision and gaining support for strategies which address health and healthcare issues through the lens of social justice [85]. As our research showed, clinicians identified patients without an advocate as being at higher risk within the health system [26], and that was before COVID shone an even brighter light on the risk of not having an advocate in healthcare [86, 87].

#### **4.3 Attitudes**

The final component of competency standards is that of attitudes. I have chosen two specific one to consider in relation to patient safety: compassion, which has recently emerged as focus in patient safety and humility, which is closely aligned with compassion and which ties back to questions of epistemic injustice.

#### *4.3.1 Compassion*

The interest in the role of compassion (as well as empathy) in organizations in general [88] and more recently in healthcare in particular [89] has gained momentum over the last decade - both in relation to healthcare staff and to patients (and their families). Dewar and Nolan ([90], p. 1249), adapted the work of Lown, Rosen [91] articulated the four essential characteristics of compassionate care: *"1) a relationship based on empathy, emotional support and efforts to understand and relieve a person's distress, suffering or concerns; 2) effective interactions between participants, over time and across settings; 3) staff, patients and families being active participants in decision making; and 4) contextualized knowledge of the patient and family both individually and as members of a network of relationships."*

Mannion [92] notes that one of the factors which might undermine compassion by healthcare providers towards patients is the compassion fatigue which is associated with caring roles associated both with high levels of stress and the high demands of emotional labour.

de Zulueta ([93], p. 1) undertook a review of the literature relating to compassionate leadership in healthcare. She argues that *"Compassionate health care is universally valued as a social and moral good to be upheld and sustained. Leadership is considered* 

#### *pivotal for enabling the development and preservation of compassionate health care organizations."*

She goes on to describe how compassionate leadership contributes to healthcare organizations and links most of the elements identified as supporting the type of just culture required for a safe healthcare environment [94]. *"Developing leadership for compassionate care requires acknowledging and making provision for the difficulties and challenges of working in an anxiety-laden context … This means … sustaining high levels of trust and mutually supportive interpersonal connections, and fostering the sharing of knowledge, skills, and workload across silos. It requires enabling people to experiment without fear of reprisal, to reflect on their work, and to view errors as opportunities for learning and improvement. Tasks and relational care need to be integrated into a coherent unity, creating space for real dialog between patients, clinicians, and managers, so that together they can cocreate ways to flourish in the context of illness and dying"* ([93], p. 1).

West, Eckert ([89], p. 17) further explains this process by making explicit links between compassionate leadership and organizational cultures which provide the psychological safety for employees required to foster innovation and high-quality care. Such cultures are marked by compassionate leadership which is displayed via four key elements: "inspiring vision and strategy (i.e. unwavering focus on high-quality continually improving compassionate care; inspiring and meaningful vision; shared understanding; clear, aligned, manageable challenges and tasks; and alignment between workload and resources); positive inclusion and participation (ensuring all voices are heard; creating psychological safety and encouraging teams to be compassionate to one another; valuing diversity including patient groups, positive attitude to differences; and fair resolution of conflict); enthusiastic team and cross-boundary working (i.e. working compassionately with other teams (inter-team compassion); being supportive and collaborative; and having a 'how can we help?' attitude); and support and autonomy (i.e. creation of a positive climate – high levels of engagement, positivity and creativity; freedom to be autonomous, but with support; and treating staff with compassion).

#### *4.3.2 Humility*

West ([95], p. 73) also makes the link between compassion, humility and the quality of care in the following way *"Compassionate team members demonstrate a commitment to mutual support, building cohesion, modelling trust and demonstrating humility (rather than arrogance or directiveness)."* In other words, humility is strongly associated with psychological safety in teams, which in turn is associated with higher levels of patient safety [96, 97], including engagement in quality improvement work [98].

The importance of leaders' humility plays out in several ways. Firstly, as a characteristic of leaders (including of course social work leaders), humility means that the person in charge is able and willing to listen and consider the opinions of others. Humility as a leadership trait associated with effective leadership [99].

Secondly, as West ([95], p. 75) goes on to describe, humility is also a characteristic of organizations with compassionate cultures. In these organizations, *"Leadership strives to be authentic, open and honest, showing humility (a commitment to learning to improve their leadership, for example), optimism, appreciativeness and compassion."*

Thirdly, the idea of humble leadership is a *"… shift to go away from the person, hero, leader to seeing it as a process … to get away from looking at what does the individual need to be a leader, and examining the many, many ways that leadership occurs"* ([100], n.p.) including abandoning the *"… image of the self-reliant, heroic leader in favor of a shared* 

*Social Work Leadership for Patient Safety DOI: http://dx.doi.org/10.5772/intechopen.105535*

*leadership model characterized by humility and partnership"* ([101], n.p.), which in turns creates a positive organizational culture and a joint commitment to organizational goals (including patient safety and quality improvement) [102].

Finally, there is also a significant body of research which addresses the idea of cultural humility. Cultural humility as a way of addressing the needs of people from diverse backgrounds (both patients and staff) has overtaken the earlier concept of cultural competence. This is because, as Fisher-Borne, Cain ([103], p. 165) argue, *"Within social work and beyond, cultural competency has been challenged for its failure to account for the structural forces that shape individuals' experiences and opportunities. In contrast, the concept of cultural humility takes into account the fluidity of culture and challenges both individuals and institutions to address inequalities".* For social workers and all other health professionals, cultural humility *"… incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations*" ([104], p. 117).

Robinson, Masters ([105], p. 162) created what they call a conceptual model for healthcare leaders of the five 'Rs' of cultural humility, which are equal useful as a summary of the behaviors associated with leadership humility in general. The five Rs and their associated questions (which leaders ask themselves) are:

*Reflection Aim: One will approach every encounter with humility and understanding that there is always something to learn from everyone.*

*Ask: What did I learn from each person in that encounter?*

*Respect Aim: One will treat every person with the utmost respect and strive to preserve dignity and respect.*

*Ask: Did I treat everyone involved in that encounter respectfully?*

*Regard Aim: One will hold every person in their highest regard while being aware of and not allowing unconscious biases to interfere in any interactions.*

*Ask: Did unconscious biases drive this interaction?*

*Relevance Aim: One will expect cultural humility to be relevant and apply this practice to every encounter.*

*Ask: How was cultural humility relevant in this interaction?*

*Resiliency Aim: One will embody the practice of cultural humility to enhance personal resilience and global compassion.*

*Ask: How was my personal resiliency affected by this interaction?*
