**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* 
