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Social Science & Medicine 69 (2009) 1777–1779

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Social scientists and patient safety: Critics or contributors?q

Charles VincentImperial Centre for Patient Safety & Service Quality, Department of Biosurgery & Technology, Imperial College London, United Kingdom

a r t i c l e i n f o

Article history:Available online 21 October 2009

Keywords:Patient safetyBiomedicineCliniciansSocial scienceSocial scientists

q I thank Jonathan Benn for his helpful comments oand the Health Foundation for funding this programmResearch Unit is affiliated with the Centre for PatientImperial College Healthcare NHS Trust which is fundeHealth Research.

E-mail address: c.vincent@imperial.ac.uk

0277-9536/$ – see front matter � 2009 Elsevier Ltd.doi:10.1016/j.socscimed.2009.09.046

a b s t r a c t

Patient safety has been high on the national and international agenda in healthcare for almost a decade.It is proving to be a tough problem; tough in cultural, technical, clinical, and psychological terms andbecause of its massive scale and heterogeneity. While many of the challenges and problems of patientsafety are social and organisational, few social scientists are involved in patient safety. Clinicians andclinical researchers are for the most part open to other perspectives, but that they may not fullyappreciate the potential contribution of the social sciences. Social scientists can, for instance, assist indrawing attention to the need to take an account of the social and cultural context of patient safetyinterventions, by drawing on narratives and stories to illuminate organisational processes and byencouraging greater use of ethnographic and observational research. However, if social scientists are tohave a real impact they need to do more than simply offer critiques of patient safety and move to activeengagement with clinicians and patient safety researchers.

� 2009 Elsevier Ltd. All rights reserved.

Patient safety has been high on the national and internationalagenda in healthcare for almost a decade. It is proving to be a toughproblem; tough in cultural, technical, clinical, and psychological termsand because of its massive scale and heterogeneity (Vincent, 2006).Major campaigns have been launched in the United States anda number of other countries, usually centred on a core of definedevidence based clinical processes. Bold claims have been made for thesuccess of some of these initiatives, but the extent and nature of thesegains has been questioned. The Safer Patients Initiative in the UnitedKingdom – discussed in this Special Issue by Benn (special issue) –represents one of the most ambitious programmes, bringing togethercultural change, leadership initiatives, measurement and a variety ofimplementation strategies at clinical level. Considerable efforts havebeen made to improve safety, but progress has been slower thanhoped and evidence of definitive improvements is restricted to rela-tively few units and systems. One reason for this is that, for all theenergy and activity, measurement and evaluation have not been highon the agenda (Vincent et al., 2008). However, bringing about changeon the ground has also been harder than many realised when patientsafety first became a priority (Leape & Berwick, 2005; Wachter, 2004)

The papers in this issue cover a wide variety of themes and arewritten from somewhat different perspectives, in terms of

n a earlier draft of this papere of work. The Clinical SafetySafety and Service Quality atd by the National Institute of

All rights reserved.

methodology, underlying philosophy of social science and approachto patient safety. They agree however in arguing that patient safetyhas not given sufficient attention to the potential contribution of thesocial sciences and that this has impoverished the field in researchterms. The lack of attention to wider social and inter-personal issuesmay also go some way to explain the slow progress and theextremely variable impact of interventions. As a number of thepapers illustrate, the intended impact of an intervention is an ide-alised perspective; in practice different groups may interpret theprogramme in different ways and the whole process evolves and ismediated by a variety of cultural and inter-personal factors.

The purpose of this invited commentary is to reflect on thesefindings, the methodological issues raised and on the role of both thesocial sciences and of social scientists which do, I believe, need to bedistinguished. Avariety of viewpoints are expressed and I do not wishto single out any one author; rather I consider a number of differentarguments and critiques which run as common threads througha good proportion of the papers in the Special Issue. Before turning tothis however, I address a basic issue which I believe is an importantbackdrop to the more methodological discussions and which, to mymind, is an absolutely critical question for anyone who wishes to workin the clinical world. What is the purpose of patient safety research?

The purpose of patient safety research

The various authors, it seems to me, approach patient safetywith very different motivations and varying views of their ownpersonal engagement and responsibilities. In part this relates to the

C. Vincent / Social Science & Medicine 69 (2009) 1777–17791778

longstanding debate within the social sciences on the relativemerits and disadvantages of being an insider or an outsider, dis-cussed in some of the papers. This issue emerges in a parallel waywithin patient safety, in the sense that a sociological or psycho-logical perspective brings breadth and scope, but may lack a fullappreciation of the work process and clinical milieu; conversely theclinical perspective does not easily lend itself to a wider apprecia-tion of systems and social forces.

There is however another critical dimension which must beaddressed if one wishes to work effectively with clinicians,managers and others facing the daily challenges of healthcare. Asa colleague of mine, a Professor of Anaesthetics put it, ‘they [socialscientists] come and observe us, do their research and go awayagain’ (this is a polite paraphrase of his remarks). The same manhowever has worked closely over decades with social scientists andis deeply appreciative of the varying perspectives on his work andhis world. But he is acutely sensitive to the motivations of those ofus from the world of social science and of the moral purpose behindour work. Whether a researcher is welcomed and accepted in hisworld depends not on methodology or philosophy of science but ona much simpler but sometimes more challenging question: are youhere just to study us for your own purposes or to work with us onimproving the care of patients? The acceptance and indeed utilityof the research stems in part from this basic premise and moralpurpose.

Social science and patient safety: some strong criticisms

All the authors in the special issue rightly regret the lack ofinvolvement of social scientists in patient safety. However, some offermuch stronger and more trenchant critiques of patient safety practiceand research. Three particular themes stand out. No one authorexpresses all these viewpoints, and in some cases these views areimplicit, rather than clearly stated, but they are all recurring themes.

Dominated by a narrow view of measurement and evaluation

Several authors suggest that the narrow scientism that domi-nates biomedicine is dangerously misleading when applied topatient safety. Measurement is distrusted, and disavowed in favourof an interpretive framework. In fact we have recently argued thatnot nearly enough attention has been paid to measurement andevaluation (Vincent et al., 2008) but this is tangential to the maincriticism. It is true that the clinical world, particularly the medicalworld, is dominated by measurement and that data are trusted overopinion. In practice, of course, this is set within a complex discoursein which data is only one feature of a broader discussion. However,reading some of these papers, I detected a lack of understanding ofwhy measurement is so valued in the clinical world. Measurementis important there because it reflects matters of real deep concernto patients. Counting surgical site infections of course does notcapture the complexity of clinical life, but the monitoring ofinfection levels is no small achievement and critical to infectioncontrol. This would be hardly worth stating, save that suchmundane activity appears to have been undervalued by some.

Hostility to qualitative research

A number of papers presume that medicine in general, andpatient safety in particular, is not receptive to qualitative orethnographic research. It is true that research of this nature is lessfamiliar to clinicians, but to my mind the assumption that theseapproaches will automatically be rejected is outdated. In 2000 theBritish Medical Research Council, a bastion of bio medicine, pub-lished guidelines on the evaluation of complex interventions

explicitly recommending a qualitative element. True, the overallframework was quantitative, but there was a clear understanding ofthe importance of understanding the wider context and evolutionof such interventions. In the British Medical Journal, for instance,there are many instances of qualitative research including articlesintroducing or recommending qualitative methods; Quality andSafety in Healthcare, part of the BMJ stable, has still more qualita-tive papers (see, for example, Brown & Lilford, 2008; Crawford et al.,2002; Elwyn, Buetow, Hibbard, & Wensing, 2007; Greenhalgh et al.,2008; Lambert & McKevitt, 2002).

Clinicians are unaware of the wider issues

The conversation of clinicians and the interviews and narrativescontained in these papers in this Special Issue, are certainly revealingof clinical life and it is a tribute to the researchers involved that theywere able to obtain such frank descriptions of, in some cases, veryprivate and indeed painful events. Some of the commentary on thenarratives however, and the accompanying weighty theoreticaldiscourse, appears to suggest that the themes described would beunfamiliar to clinicians and those working in patient safety. I wouldsuggest that this assumption is unwarranted and that most of theseissues are all too familiar to anyone trying to improve the safety ofcare. Matters such as inter-group conflict, tribalism, negotiation overthe care of critically ill patients, the conflicting agendas of manage-ment and clinicians are the stuff of everyday conversation and alsoquite well represented in the medical literature (Campbell et al., 2007;Ham, 2003; Sexton, Thomas, & Helmreich, 2000; Shipton, Armstrong,West, & Dawson, 2008; Thomas, Sexton, & Helmreich, 2003). This isnot to say that these matters are not important, or that the analysesmay not be fruitful. However, clinicians, managers and patient safetyresearchers are people who are well aware of them; the questionuppermost in most people’s minds is how to work effectively withthese social and psychological forces in the interests of both personalsurvival and patient welfare.

Social science and patient safety: towards a positivecontribution

Some of the stronger criticisms I have described are reallyattacking a straw man, a caricature of the clinical world. I believethat these views are partly based on a misunderstanding of patientsafety together with a lack of familiarity with clinical work and theeveryday conversation of clinicians. There is however a morenuanced version of the issues raised above, which I believe hasmuch more force. We could express this roughly as follows:

� Patient safety must of course address issues of measurementand evaluation, but more attention needs to be paid to thesocial and cultural context,� Formal safety interventions are strongly influenced in their

impact and evolution by wider organisational and culturalfactors which are insufficiently studied and appreciated,� Narratives and the exchange and discussion of stories are

a crucial medium of exchange in healthcare organisationswhose influence is seriously underestimated,� The role of ethnographic and qualitative research has been

insufficiently developed in the patient safety context,� Social scientists have a more important role to play in the drive

to improve safety than is currently appreciated.

Achieving greater long term involvement of social scientists andother relevant disciplines in patient safety is certainly a challenge.The issue of the engagement of the necessary range of disciplineshas been thoughtfully addressed by Robert Wears and Shawma

C. Vincent / Social Science & Medicine 69 (2009) 1777–1779 1779

Perry, both academic emergency physicians, and Kathleen Sutcliffe,a social scientist, in their discussion of the medicalisation of patientsafety (Wears, Perry, & Sutcliffe, 2005). They point out, followingJens Rasmussen (1997), that ‘requisite variety’ is critical to complexmultidisciplinary problems such as safety. Requisite variety meansthat a research team has ‘a sufficiently diverse set of backgrounds,viewpoints, skills, and interests, such that hidden assumptions areexposed, a broader repertoire of options, tactics, and tools madeavailable, tacit knowledge made more explicit, and more inter-pretations and preferences expressed. If a team enlarges what it cando, it also enlarges what it can see’ (Wears et al. 2005).

They go on to argue, on the basis of a review of speakers atprominent patient safety conferences over the years, that:

Although we do not believe that anyone involved in patientsafety or patient safety research openly disputes the idea thatthere is much to be learned by applying the ‘‘safety sciences’’ tothe problems of healthcare, we wish to point out a disquietingtrend. Experts in the safety sciences have been gradually dis-appearing from view in patient safety. At the first Annenbergmeeting in 1996, almost 20% of the speakers were scientists andscholars from non-healthcare fields, such as psychology, engi-neering, sociology, organisational behaviour, etc. An additional20% were also not directly associated with healthcare but rep-resented other important viewpoints, such as the law, orpatients and their families... the absolute number and therelative proportion of safety scientists speaking at these meet-ings have fallen sharply(Wears et al., 2005: 6)

Wears et al. go on to discuss a number of reasons why this hasoccurred, including loss of interest from social scientists, theculture of healthcare, funding strategies and the fact that health-care staff may now feel that they have absorbed the lessons ofpsychology, sociology, engineering and other non-clinical disci-plines. The paper needs to be read in its entirety to capture the fullargument, but they suggest a number of ways of opening uphealthcare to other disciplines and encouraging fruitful collabora-tions. In particular they argue that professional organisations andfunding bodies need to create long term relationships and collab-orations between clinical disciplines and social scientists anda career structure for young researchers that enables them to focuson patient safety without detriment to their career prospects oftheir standing in their core discipline.

In summary, it is undoubtedly true that social science and socialscientists have much to contribute to patient safety, whatever their

underlying perspectives. I have argued that clinicians and clinicalresearchers are for the most part open to other perspectives, butthat they may not fully appreciate the potential contribution of thesocial sciences. Patient safety, as Wears and colleagues (2005)show, has lost touch with the social sciences to some extent whichis regrettable but certainly remediable as the papers in this specialissue show. However, as I argued earlier, there is a more funda-mental question to consider as a social scientist approachingpatient safety which is much more important to those in healthcarethan questions of methodology and philosophy: Do we approachpatient safety simply as critics or do we aspire to be contributors?

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