The newly published interim report on the Irish Safety Culture and After Acton Review Experience study (iCAARE) (Finn et al 2024) describes the many enablers and barriers to the successful integration of After Action Review. It should be read by all those working in patient safety in the NHS in England specifically, as well as for those responsible for any new behaviour change initiative. Of particular value is the weighting of the domains which support implementation as well as those which hinder it.
Ireland’s Health and Safety Executive (HSE) was the first country in the world to incorporate AAR into its Incident Management Framework (IMF) and since 2018 over 500 staff in the country have been trained as AAR Facilitators.
This rigorous and meticulous research uses the Theoretical Domains Framework (TDF) as a lens through which to identify the concepts emerging in the focus groups held with the AAR Conductors 6 months after they completed their training. In essence the paper is a gap analysis between the expectations held by the newly trained AAR Conductors and the reality of implementing AAR with the identification of a number of barriers and enablers that will inform future action. This element of the iCAARE study involved one in 12 staff at a tertiary hospital participating in 1.5 days simulation based training as AAR Facilitators. Six months after this was completed, 14 of them participated in focus groups to reflect on their experiences since then.
Key insights from the research.
- Enablers versus barriers
It is interesting that 7 enablers, 12 barriers and 8 enablers/barriers were identified by the participants in the focus groups across all 14 TDF domains. In other words, more barriers to implementation were identified and when enablers were articulated, these were also seen as possible barriers. Perceiving more barriers than enablers 6 months after training may be because only 4 of the members of the focus groups had led informal AARs, as responding to the pandemic and an IT cyber attack had been dominating the work context. Yet it is something we regularly see in the weeks following the AAR Conductor Development courses we run for healthcare providers in England. However motivated and skilled staff are when they complete the training, the shift in behaviour required to take the first steps forward can be perceived as too big, and this needs to be recognised in how staff are supported after training.
2. Domain focus
The study focused on the three theoretical domains that contained the richest data on processes acting as enablers and barriers and these are highly reflective of the healthcare context.
2a. Reinforcement. To achieve any behaviour, change at a small or large scale, we know that active reinforcement for the new activity is vital. In large organisations such as hospitals, where there is a huge amount of information “noise”, being able to reinforce new behaviours can be challenging. This study highlighted that activities to increase the probability of a response to training, had not been widespread and the lack of reinforcement had acted as a barrier to implementation. Whilst knowledge about AAR did diffuse through the hospital, there was a lack of visibility of AAR, with no launch events or promotion. No protocol stipulating a pathway to use AAR, and a lack of leadership driving the regular use of AAR, meant that those who were trained were not yet leading formal AARs.
2b. Professional role and identity. This domain relates to who has responsibility for arranging and facilitating AARs as well as who is best placed to organise AARs and was seen as a barrier as well as an enabler. Traditional thinking about professional roles and their position in the hierarchy has become increasingly problematic within healthcare as inter disciplinary and cross functional collaboration becomes so essential to the effective delivery of care. What came across was a lack of ownership for arranging AARs to enable one’s colleagues to learn. There was also tension between recognising the value of middle grade management roles leading AARs in other areas, and with cross functional teams, with the potential reactions to doing so. Straying outside of one’s own role and professional identity carries some risk.
2c. Emotion. This domain acted as both a barrier and an enabler, as participants described mixed feelings around AAR practice. Fear of the pressure and responsibility associated with being a facilitator featured along with a lack of confidence in managing peoples’ feelings and achieving a resolution. However, the simplicity and quality of the AAR questions felt positive, and understanding of its value in supporting hospital staff to regulate their emotions and enabling staff to connect to the end point of care felt valuable and was an enabler.
3. Unintended benefit of the focus groups?
This interim report will be followed by a further publication of the iCAARE study results that were gathered six months after the focus groups. By this time over 30 AARs had taken place. Is it possible that the conduct of the focus group discussions could have raised awareness of AAR in the hospital again? It is certainly my experience that when running Action Learning Sets for acute hospital AAR Conductors, the energy and motivation to overcome the barriers to practice is definitely raised as well as the skills being refreshed.
Implications for implementation
Here are some of the actions which the paper recommends, which will help guide implementation in the NHS.
- Reduce the time lag between equipping staff with the skills to lead AARs and the immediate reinforcement and promotion of AAR following training.
- Invest in structures and processes to make access to AAR easy and widely understood.
- Ensure there is a pipeline of AAR work to be done for those newly trained.
- Provide active and visible leadership for the AAR approach.
- Recognise the emotional reaction pattern that participants may have as they start to use AAR, building confidence in individuals and providing support as they move from novice to expert.
Judy Walker Associates Ltd specialises in providing high quality training for AAR Conductors and in delivering long terms support to ensure staff move smoothly from novice to expert AAR Conductors. Please get in touch if you would like to have a chat info@jw-associates.co.uk
