Undertaking risk and relational work to manage vulnerability: Acute medical patients’ involvement in patient safety in the NHS

Why it matters

Patient safety has been a persistent concern in healthcare for over 20 years. Many studies over the last decade have explored the ways that patients are involved in their own safety, and most begin with the premise that patients can and should take on the role of identifying and reporting safety concerns. However, the ability of patients to be involved depends in part on their health condition and may vary across healthcare settings. Little attention has been paid to the health status of patients and how their sense of vulnerability might impact on their ability to participate in their safety.

In this article, we argue that patient involvement in an acute care context is influenced by vulnerability, which shapes the way in which patients work to minimise risks to their safety, using the NHS in England as our setting.

Approach

We conducted qualitative interviews with 28 acute medical patients in NHS hospitals in England over two periods: 2016 –17 and 2017–18. They were given an information leaflet and offered a choice of being interviewed in hospital, at home, or over the telephone.

Participants were recruited from short-stay assessment units and gastroenterology, respiratory and diabetic wards; all had been in hospital at some point over the weekend.

What we found

Most of the patients interviewed were acutely unwell at the time of their hospital admission and anxious about what would happen to them. Hospitals were often seen, at least at the start of their admission, as places of safety at a time when their ability to remain safe in their own home environment may have reached its limits.

Once admitted, acute medical patients were expected to hand over responsibility for their safety to the people who look after them by displaying trust in professional expertise and complying with treatment to get better. They sought reassurance that they could trust those caring for them and looked for evidence that they were safe. Participants demonstrated that they were ‘good patients’ by minimising their needs. They described being vigilant and raising concerns about their treatment and care which were not always successful.

Patients found it difficult to balance the need to show they were good patients who were keen to work with clinicians and help themselves get better with the need to be vigilant and raise concerns when necessary. Failing to get the balance right could increase their vulnerability, by  damaging their relationships with staff.

These findings contribute to our understanding of the contribution of patient behaviour in patient safety and highlight the roles of risk and vulnerability in influencing patients’ involvement in their own safety. They show that patients aren’t always able to be reflexive, autonomous consumers of healthcare, especially in acute care, because speaking up about concerns may itself bring risks.