Assumptions that underpin Act Wisely

1. A wise action is one whose intention is to benefit a patient, which is why many people choose to become clinicians
2. Widespread demotivation and poor psychological health among clinicians is a signal that we should be more concerned about how they, too, can benefit from practising (See Safety for All, below)
3. Caring for patients is not a solitary act: in addition to clinician and patient, more than one other clinician is often directly or indirectly involved
4. Practice is complex. It does not follow the rule: “I treat, you get better”. Rather, it follows the rule: “We work together to understand what is going on, what could be done about it, and how that could best be achieved.” It is because practice is complex that wisdom is required
5. Education must be action-orientated. It would be simple if practitioners simply had to regurgitate what they had been taught. That, though, would not benefit patients. Only by acting can clinicians benefit patients
6. Benefiting patients cannot be a wholly risk-free practice. Any action that affects something so complex as health can have unintended consequences. That is why patients need clinicians to be wise, not just competent
7. Something as complex as Acting Wisely to benefit patients must be learned by taking increasingly complex wise actions under supervision
8. Clinicians do not become wise solely by acting and gaining experience; they learn by reflecting on actions they have taken, and the outcomes of these actions, and ways of acting even more wisely

“Rather than making calculated choices between alternatives, organizational actors often make decisions based on fulfilling their identities and on following rules and routines that they themselves may not be aware of” Engeström 2018

Safety for all

Analysis of Mutual Safety

It has long been known that patients can be unintentionally harmed by even the seemingly wisest actions. That is an inevitable feature of any complex problem. People who believe it is possible to make practice 100% safe tend to blame clinicians when patients are harmed. That is unwise because a culture of blame makes practice psychologically unsafe for clinicians. This results in burnout, career breaks, reliance on agency staff and …. harm to patients. Safety is, therefore, something that clinicians as well as patients have a right to expect. Practice will truly be safer when the rule is to optimise benefit and minimise harm for everyone, whilst acknowledging that harm can never be completely eliminated. Wise actions are actions that make safe all stakeholders safer.

Learning to Act Wisely

One way of learning is by working alongside wise actors. Another is reflection on experience in psychologically safe settings. Supportive colleagues and friends play a vital role in helping clinicians learn reflectively from experience. Act Wisely puts Donald Schön’s theory of reflective learning into practice. Complex practice throws surprises at us, which require us to act wisely in the heat of the moment. The pursuit of wisdom has two important components. One is to be reflect back on surprising situations after the event, being conscious of what they meant to us and how we responded. Schön used the term ‘reflection on action’ to describe the purposeful act of thinking back on such experiences. We learn best when someone listens non-judgementally and helps us derive greater wisdom. Since ‘the road to hell is paved with good intentions’, reflection should result in commitments to specific wise acts when similar situations arise in future.