Background: Clinical governance requires having a process for adverse incident review and management to ensure the organisation ‘learns from its mistakes’ to prevent repetition. How leadership implements this system may enhance learning and patient safety, or have the unintended consequence of raising alarm, possible demotivation, and staff becoming risk-averse. The impact of the existing Ambulance Service incident management process was assessed from an organizational culture aspect.

Methods: Action research uses iterative and collaborative cycles of study, action, and reflection to not only understand a complex situation by holding an attitude of inquiry but also to bring about positive change. Dialogue and narrative enquiry were used to collect data using a grounded theory approach for data interpretation. Dialogue was used both for reflection and for initiating change at various levels within the Service.

Results: Initial data indicated a moderate fear culture in the Service, with staff becoming risk averse in the clinical environment due to concerns of being called for investigation. Dialogue sessions were held with key role players highlighting the experiences of staff. The impact of these conversations were reflected on and the outcomes of this reflection was used to frame further dialogue. Narrative (stories) of staff experiences were collected and used in the dialogue to highlight the impact of the adverse incident review system on staff morale. Based on these conversations, leadership made changes, including developing new incident review process with peer involvement, changing leaders of the process and an increased focus on communicating feedback to staff. As one staff member noted the mood in the corridors is much lighter.

Conclusion: Action research provides an effective method for leaders, working in the real world environment, in dealing with the complex issues to bring about positive change, both in quality and patient safety, and staff satisfaction point of view.