Leadership within East Kent Neuro

Rehab Unit (EKNRU)

Melanie George

Principal Clinical Neuropsychologist

Outline of talk

• The context: the Francis report.

• Burnout and clinical care.

• Implications for leaders within the NHS.

The Francis report (2013)

• Poor care in the Mid Staffordshire Foundation NHS Trust, between 2005-2009, reportedly contributed to the avoidable deaths of many (possibly hundreds) of patients.

The Francis report (2013)

• Robert Francis QC, highlighted the role of government targets which focussed upon “financial issues”.

• He concluded that these had contributed to

an “ingrained culture” marked by “an appalling lack of care, compassion and leadership”.

Public shock, anger and blame

‘Disbelief as nurses

have to be told to

put patients first:

staff reminded to

treat sick with love

and compassion’.

‘Targets are crowding out compassion in the NHS. Medicine has become more efficient but less humane, a major report into the NHS warns.’

Mid staffs scandal shows compassion is the quality that should inform all healthcare’.

‘Damning report finds many NHS staff lack the ability and compassion to do their job’.

What is happening? Have NHS staff become cruel?

Or are they just burnt out?

Burnout and work engagement

Burnout is characterised by three elements:

1. Exhaustion

2. Cynicism

3. Reduced professional efficacy

(Maslach & Leiter, 1997)

Burnout and patient care:

the role of psychological defences

• “Dehumanizing patients can reduce healthcare workers’ feelings of burnout….

and let them cope better with the constant

pain and illness they see” (Waytz, 2012).

Burnout and patient care

• A longitudinal study of medical students, indicated that levels of empathy dropped in the third year of study and remained at a low level (Hojat et al, 2009).

• ….the suggestion being that as they became more experienced, they unconsciously protected themselves by reducing empathy.

What factors are contributing to this?

Three main sources of stress in healthcare

• Hospitals are consistently rated as one of the most stressful places to work (Cox, Griffiths, & Cox, 1996; Gibb et al., 2002; Firth-Cozens, 2003).

1) Targets:

National targets for services, irrespective of resources at a local level (Song et al., 1997; Kapur, 2013).

Main sources of stress in healthcare

2) Leadership:

• Sir Francis identified a culture of blame and bullying within the NHS.

• He related this directly to task orientated leadership styles.

Main sources of stress in healthcare

3) Emotional labour (Sawbridge, HSJ, 2014). Defined as, “Supressing emotions and managing those of others”.

In 2003, the Department of Health commissioned research exploring the emotional experience of patients. It captured how people feel when they come into contact with the NHS.

Emotional labour

• Patients and the public said that they tend to come into contact with the NHS when they are at their most vulnerable and emotional, which makes their emotions, and particularly their negative feelings, stronger.

NHS institute for innovation and improvement, 2003.

Twelve years on: added complexity

• Hospital stays have reduced in length dramatically; patients are now more seriously ill on average and staff have less time to get to know them (Beck, 2013).

• Up to 60% of patients have a “mental disorder” (depression, dementia) (Goodrich, 2013).

Emotional labour within EKNRU:

an example

Our patients

• Many of our patients experience personality changes and some exhibit challenging behaviour, secondary to disinhibition.

• We know that this is highly stressful for staff (Bersani and Heifetz, 1985; Quine and Pahl, 1985).

Adding to this, our patients often can’t say sorry… or thank you

• Our patients may experience communication impairments.

• Furthermore, following frontal lobe damage, it is common for patients to have problems with ‘mentalization’ (thinking about another person’s point of view).

“It is all stick and no carrot”

• “Some of our patients can be really challenging as a result of their brain injury….

• …we might face a barrage of abuse from a patient but have to remain polite and friendly. We could be called upon by the same patient later in the day to wipe their bottom…only to face another barrage”.

Staff nurse on EKNRU

Compassion at what cost?

The impact upon staff

The ‘Compassion Gap’ (Fitzgerald, 2014)

• In the past few years, patient satisfaction data has been improving.

• However, in contrast, NHS staff surveys reveal worsening levels of morale and engagement.

• Mental health problems, such as anxiety and depression, are common amongst nurses (Borrill et al., 1996) and doctors (Schwenk, 2010).

Accounts from ‘All nurses’ blog

• “I am having a hard time feeling any

emotion, either at work or at home.

I never used to be like this...”

• “I am far more emotionally detached

now..”

Implications for the organisation

• “Mental ill health is a major source of absence in the NHS and an issue that many managers are not comfortable with” (Boorman, 2009, NHS Health and Wellbeing report).

• NHS healthcare workers take an average of 10 days sick leave a year, compared with 6.4 days in the private sector.

The government’s plans:

Preventative and holistic models of care

• The new models of care that are promoted within NHS England’s (2014) ‘Five Year Forward’ view, calls for frontline staff to redouble their efforts to provide person-centred, relational care.

• Staff will also be required to collaborate more closely with other services.

• The aim of this is to address biopsychosocial factors and social inequality; major contributory factors in LTC and multimorbidity (70% of costs).

What is the way forward?

What is the way forward? • The Francis report provides the single greatest

leadership challenge the NHS has ever faced (Aidan Halligan, 2013).

What is leadership?

• “Leadership is establishing the conditions for others to succeed”.

Jocelyn Cornwell (2011)

The Point of Care Foundation and The Kings Fund

The challenge

• And yet, the overwhelming culture in the NHS described by Sir Robert Francis QC (2013) was disempowerment.

The impetus for change..

• The prime cause of stress in the workplace is the line manager (Hogan, Raskin and Fazzini 1990).

• We now recognise that if senior managers impose a command and control culture that demoralises staff and robs them of authority to make decisions, poor care will follow (The Commission on Dignity in care for Older People, 2012).

Leadership and patient care

• We know that the way healthcare teams rate the quality of team leadership, can account for up to 40% of the total variance in patient satisfaction (Corrigan, 2000).

• Clear implication: “If we want patients to experience kindness and compassionate care during their treatment, then the staff who deliver that care must experience the same kindness and compassion in the way that they are managed and led” (Belinder Weir, 2013).

Implications for the organisation

• Inclusive and engaging leadership is associated with improved efficiency and productivity (Bradley and Alimo-Metcalfe, 2008).

How has the government responded?

• The NHS Leadership Academy was launched in April 2012 following an announcement by the Secretary of State in May 2011.

• £46 million invested over three years on three core programmes.

• Aim is to train 10,000 staff each year.

Leadership style • A principal aim of the NHS leadership academy is to

enable leaders to move away from a “Command and Control” type leadership style (often called ‘Great man’ theory)…..

Leadership style

• ….to more distributed, facilitative and emotionally intelligent styles.

Emotionally intelligent leadership

• Modern leaders should focus upon managing the emotional climate and fostering a positive culture in the ward, team or directorate. (National Institute for Health Research, 2013).

• In order to do this effectively, leaders need to have good levels of self-awareness; “What is it like to be on the receiving end of me?”

What are we doing well on EKNRU?

• Supportive ‘no blame’ case reviews to ensure that we learn from our mistakes.

• Regular ‘working party’ meetings which enable staff to contribute to service development.

• Well staffed nursing team (no vacant posts).

What are we doing well on EKNRU?

• A culture of 360 reviews by staff in leadership positions.

• A focus upon MEANINGFUL patient outcomes, rather than just quantitative activity data (as recommended by Dawson and Burke, PWC, 2014 and the Point of Care Foundation, 2013).

What are we missing?

Preventative and holistic models of care

• The government is beginning to introduce policies and incentives, (organisational and commissioning level) to support person-centred and coordinated models of care.

• One criticism of the ‘Five Year Forward View’ is that it fails to champion the role of leaders or frontline staff (West, 2014).

The implementation of new models of care

• As highlighted by the Council of Deans for Health (2015, p.1), transformational change will largely depend ‘not on new structures but on the people who work in health and social care, who will need to adapt to new roles and services and learn new skills in order to make these changes a reality’.

The need for ‘un-learning’

• Frontline staff require support to address the legacy of firstly, the medical model; emphasis upon physical care, secondary to a focus upon organic causes and manifestations of ill health.

• The rise of long term conditions (linked to biopsychosocial and lifestyle factors), combined with the reducing threat from acute conditions (Moore, 2015), undermines its value.

The Medical model of health

• And yet, the training of doctors and many clinicians continues to be shaped by a ‘bio-physical paradigm of medicine’ (Rasmussen et al., 2014, p.122).

Managerialism

• Secondly: Managerialism/New Public management.

• Private sector practices were introduced into the NHS by Thatcher in the early 1980s. This ultimately paved the way for the introduction of the internal market in healthcare.

Managerialism

• NPM practices and the market orientation in the NHS have been blamed for fuelling a preoccupation with the reputation of the organisation (instead of patients), national targets and financial balance (Lewis, 2014; Department of Health, 2015a).

• Beck, (2013, p.12) believes that this has given frontline staff a sense that these are the ‘only things that matter’ in the NHS.

Implications for leaders

A ‘corrective’ to managerialism?

Leadership behaviours have to align with the

business that we are in- health and social care.

Professor Tierney-Moore (2014)

Lancashire Care Foundation Trust

A focus upon practical, caring skills

• Recognising and encouraging natural compassion via appraisals/ organisational awards.

• Supporting staff to develop new relational skills and tools:

• The Health Foundation

• The Point of Care Foundation

• National Voices

• Kings Fund (EBCD toolkit)

Implications for leaders

• We also need to be mindful of the fact that the NHS is draining those working within it.

• We need to address the “Psychological resource gap” (Fitzgerald, 2014).

• This means paying greater attention to the emotional needs of staff; providing psychological supervision via Schwartz rounds (The Schwartz Center, 2014).

Implications for leaders

• Individual ‘Restorative supervision’ (Wallbank, 2013http://www.restorativesupervision.org.uk/1.html) where needed.

• Routine and regular use of ‘The Professional Quality of Life Scale’ (Stamm, 2008); rather than waiting for annual NHS survey results.

• Use of the ‘double loop approach’(Fitzgerald, 2014).

Final point

Dissonance • Staff don’t need more blame and condemnation; they

need active, sustained supervision and support. In the high-volume, high-pressure, complex environment of modern healthcare it is very difficult to remain sensitive and caring towards every single patient all of the time. We ask ourselves how it is possible that anyone, let alone a nurse, could ignore a dying man’s request for water? What we should also ask is whether it is humanly possible for anyone to look after very sick, very frail, possibly incontinent, possibly confused patients without excellent induction, training, supervision and support.“

Joceyln Cornwell 2011 http://www.health.org.uk/blog/care-and-compassion-nhs

Does our leader understand?

Jeremy Hunt: message to NHS staff about changing culture in NHS

• “The lessons learned from the process include the importance of first-class leadership, proper staff engagement and the value of encouraging organisations to openly acknowledge and address failings. The fundamental change in culture, to one where the NHS listens to and acts quickly on what staff and patients say, is making a real difference.”

(18 July 2014).

A prevailing culture of blame? • “When the emotional stress arose from nurses having

made a mistake, they were usually reprimanded, instead of being helped” (Menzies Lyth, 1960).

• “The government plans to make nurses criminally liable for failings in patient care” (‘The Independent’ 2013).

• "Doctors who make mistakes in the care of their patients could face tougher sanctions, under plans being considered by the General Medical Council“ (Roy Lilley, NHS Managers 2014).

• Vs: Virginia Mason Hospital in Seattle.

The end

IF YOU READ ONE THING, READ THIS:

• Sawbridge, Y. and Hewison, A (2011). Time to care? Responding to concerns about poor nursing care. http://www.birmingham.ac.uk/Documents/news/Time-to-Care-Final-Report.pdf

• (NB: Additional slides for those who are interested).

What helps? Tips for leaders

• Our immediate line managers are the biggest source of influence on our wellbeing and performance at work.

• Evidence suggests that simply showing authentic personal concern for someone you are managing probably has more impact that anything else you might do.

What helps

• Give front line staff power to resolve problems and take action.

• Give them access to relevant resources.

• Appreciation, recognition and reward.

• Confidence in own capability.

The Point of Care Foundation How to engage staff in the NHS and why it matters (2014)

What helps

• In 2007 Saijo Mauno and colleagues from the University of Jyväskylä in Finland undertook a study of Finnish healthcare staff.

• They found that people having control over how they did their jobs was the best predictor of engagement, even more than management quality.

Cont…

What helps

• This and other studies (for example, Jari Hakanen and colleagues from Finland) suggest that leaders in healthcare wishing to engage staff need to think carefully about how jobs are designed to ensure:

• a manageable workload

• a sense of autonomy

• staff are involved in understanding resource availability

• self-esteem is promoted

• a positive climate is created.

Further information

• The Kings Fund website has a wealth of information on Swartz rounds. http://www.kingsfund.org.uk/

• The Point of Care Foundation. http://www.pointofcarefoundation.org.uk/Home/

• NHS Managers.net

• Sawbridge, Y. and Hewison, A (2011). Time to care? Responding to concerns about poor nursing care. http://www.birmingham.ac.uk/Documents/news/Time-to-Care-Final-Report.pdf

Suggested reading

• Beck, A. (2013) Compassionate care post Francis: How relevant is staff experience? Clinical Psychology Forum, 249: 10-12

• Cole-King, A and Gilbert, P. (2011). Compassionate care: the theory and the reality. Journal of holistic healthcare, 8 (3):29-36

• Hinshelwood, R.D. and Skogstad, W. (2000) “The dynamics of health care institutions”. In Hinshelwood, R.D. and Skogstad, W. (eds.) Observing Organisations, Anxiety, defence and culture in health care. East Sussex: Brunner-Routledge, pp 3-15

Suggested reading

• Menzies Lyth, I. (1960) Social systems as a defence against anxiety: An empirical study of the nursing service of a general hospital. Human Relations. 13: (2) 95-121

• Nolan, P, and Smojkis, M. (2003) The mental health of nurses in the UK. Advances in Psychiatric Treatment, 9, 374-379

• Onyett, S. (2014) Guest post: What will help prevent tragedies like Mid Staffs happening again? Time for a shift in attention [online]. Available from: http://discursiveoftunbridgewells.blogspot.co.uk/2014/02/guest-post-what-will-help-prevent.html

Suggested reading

• Razzaque, R. (2013) NHS: Marrying compassion with competition [online]. Available from: http://www.independent.co.uk/voices/comment/nhs-marrying-compassion-with-competition-8485705.html

• The Schwartz Center for Compassionate Healthcare. (2014) Schwartz Center Rounds® [online]. Available from: http://www.theschwartzcenter.org/improving-teamwork/schwartz-center-rounds.aspx

• Zagier Roberts, V. (1994) “Till death us do part caring and uncaring in work with the elderly”. In Obholzer, A and Zagier Roberts, V. (eds.) The Unconscious at work. East Sussex: Routledge, pp 75-83