Choices (part 2)
So what can I do for to improve my decisions and judgements in my home?
In my last blog I argued that to reduce variation and improve quality in care homes we need to understand the decisions and judgements of the (flawed) humans that live and work in this most complex of social systems.
In this blog I want to pivot and look at 10 things we can do in almost any complex social system to improve our choices. But first a caveat. These 10 tips are not magic bullets and come with no guarantees. Some of the evidence for these comes from settings other than care homes. They are however techniques that have helped others and whilst each home is unique, they are not unique as complex social systems. Schools, hospitals, prisons, and other human workplaces all share common features – not least the need to make choices and exercise judgement in resource constrained, often time and socially pressured, conditions.
Speak up – but constructively: why? Because when people feel psychologically safe it makes raising concerns (even the small ones) easier and speaking up improves safety in care. Staff are more likely to report mistakes or highlight good quality. Lots of the evidence comes from healthcare, but it is hard to argue that it wouldn’t apply to long-term care.
Reflective debriefing (those end-of-shift conversations that make a difference): deep learning (ie. really learning from mistakes) and emotional processing helps if people talk. Whilst the evidence is patchy, the potential is clearly there if we reflect on real shift events and focus conversations.
Model your thinking (‘think aloud’) When we are forced to articulate the reasons for what we do we build shared understanding and foster a collective situational awareness. But making the invisible (reasoning for decisions and judgements) visible also acts as a window into why we do what we do. If we can’t justify it (even if the justification is “gut instinct”) then we can’t be accountable for it. It’s a good litmus test for the quality of our choices.
Share the positive: reinforcing good care boosts morale and aligns team norms around desirable behaviours. Plus, heck… its good to be nice!
Spot - and name – patterns: One definition of insanity is doing the same thing over and over and hoping for different outcomes. If a care home team shifts from reactive “fixes” to systemic improvements based on underlying assumptions, values and policies (double-loop learning) they are more likely to come up with “deeper” more effective solutions. An example, a resident falls overnight. In single loop learning the care team increases night time checks (but medication errors increase and residents don’t get to the toilet, as staff are tied up checking on falls risks). A double loop approach might involve the staff asking, “are we dismissing night-time anxiety as confusion?
Encourage learning (not blame): A just culture that focuses on learning versus blame increases reporting and reduces harm.
Shared handovers with reflection: Debrief-laden handovers prompt deeper attention to resident changes and decision-making clarity. Studies on communication safety suggest structured dialogue is a key part of noticing nuances and supporting decisions. Tools such as SBAR might help for choices to be made and leaving room for reflection can help learn from choices already made.
Support psychological safety in social care: Teams where staff feel safe to speak up care more effectively. higher psychological safety among care staff correlates strongly with knowledge sharing and patient-centred care outcomes.
Reflect informally post-stress (‘micro-debriefs’) Brief peer reflection fosters emotional resilience and better future decision-making. Social work debriefing interventions mitigate moral distress and enhance staff wellbeing.
Ask better handover questions Curiosity-focused queries (“what concerns you today?”) shift handovers from data transfer to judgment sharing (and feeling more comfortable doing this)
By Professor Carl Thompson