Foundations of safety—Realistic Medicine, trust, and respect between professionals and patients

Introduction

Patient involvement has become a foundation of safe care. In earlier eras, patients were largely excluded from decisions affecting them. Now they play a crucial role in both proactive and reactive ways; such as patients having their own checklist, or in medication reconciliation (proactive) and/or involvement in investigations (reactive) [1, 2]. Many times, patients will contribute to safety in informal, mostly un-noticed, and oftentimes in unrecorded ways. However, patients’ abilities to participate in their safe care and the deeper understanding of what is required to enable them to do so requires more attention [3]. Additionally, how professionals conceptualize safe care and the ways they experience their relations with, trust of, and respect regarding, patients [4] is poorly understood.

We refer to these elements as ‘soft dimensions of safety’. They are not necessarily measurable, do not manifest in linear ways to produce definable outcomes, but are vital to safer care [4]. For example, enabling an atmosphere to speak up, and being transparent, are not hard metrics—and cannot be.

How can we acknowledge these soft dimensions as vital foundations of safer care [4]? These are as important as the most quantifiable key performance indicators. We need a greater focus on these soft skills, and to integrate them into practice. They are the cornerstone principles of Realistic Medicine [5, 6] (see Table 1). There are many benefits to this if we get it right—for example, applying soft skills and personalized approaches undoubtedly contributes to reduced risk.

Soft dimensions of safety

Our argument, then, is that healthcare systems are too often myopically data- and measurement-focused [7]. However, the complexity of services means important aspects of their functioning and delivery of safe care are simply not measurable. The soft dimensions of safety give new insights into why care needs to be realistic—ultimately, through better relationships [3, 4, 7]. There are, of course, multiple soft dimensions: for example, those that professionals use when they assess the quality of their own work. Professional pride and the dignity clinicians provide to care encounters are two of these.

Soft skills are developed through building trustful connections with patients and walking the extra mile for them [4]. The trust and relational dimensions between professionals and patients are further underscored in following up vulnerable patients [3], in privileging safe care over everything else [2], and in participating in restorative approaches after adverse events [8]. We all know this—that the very best professionals develop at every opportunity good relationships, communications skills, and trust. And healthcare leaders can support these soft dimensions through creating appropriate work conditions [2].

Listening to patients and good communication reduce risk

Take one compelling soft skills example: good communication. This is easy to advocate, and every University course training clinicians does so, but it is challenging to do in the hustle and bustle of clinical practice. One reason is that patients are increasingly empowered, playing an active role in their care. This acts to equalize the clinician–patient relationship. Ultimately, good relationships and respect in healthcare—as in other aspects of life—are built by showing consideration for the other person’s interests and wellbeing while recognizing their capacities and ambitions.

Communication is thereby key to good outcomes and is far more than just telling patients what to do—it is interactive, not a monologue. This is at the heart of Realistic Medicine. The Realistic Medicine principles in Table 1 are now increasingly being embedded in healthcare interactions [5, 6]. Indeed, a core aspect of good communication, effective listening, is often implicated in reduced risk. But there is a way to go, and listening needs to be further strengthened as a fundamental part of improving safety and growing a culture of understanding [5, 6].

Future direction in advancing safety

Of course, it is true that future improvements in healthcare safety need hard data and refined measurements, but they require the soft skills relying on talking and listening to patients, providing them with clear and sufficiently detailed information without jargon, and having them as active participants in their own care decisions and plans. Clinicians need to be transparent about what they do not know, as well as what they do. After all, this is the type of care we want for ourselves and our families. We frame it as ‘humanizing healthcare’ and ‘safety first’.

Respect, dignity, listening, and good relationships are all crucial for a wholistic and sustainable approach to care [4, 9]. These principles of Realistic Medicine can be applied to align soft ‘and’ structural dimensions of safety—reminding clinicians and patients that good care is co-designed care [6]. Communication, establishing trust and respect, and engendering good relationships are fundamental to the effectiveness of any system. They always were—but now we know this as Realistic Medicine, and need more of it every day, in every setting, in every country.

Funding

Siri Wiig and Hilda Bø Lyng are funded by the Research Council of Norway from the FRIPRO TOPPFORSK program, grant agreement no. 275367.

Conflict of interest

None declared.

References

Author notes