Reflection on Leadership for Person-Centred Care

Introduction

Arguably leadership is very essential for the implementation of person-centred care in nursing practice. It is essential suggests the NMC (2015) code that all nurses must act as change agents and through service development and quality improvement provide leadership that will enhance the experience of care and well being of clients.  Amanchukwu, Stanley and Ololube (2015) posits that leadership consists of a kind of responsibility aimed at reaching some specific ends through the application of human and material resources as well as making sure the process is cohesively and coherently organized. Similarly, Northouse (2017: p143) defined leadership as a “process whereby an individual influence a group of individuals to achieve a common goal.”  There are different approaches employed by leaders to motivate people which are called leadership styles. Scholars such as (ref) argues that the leadership style of any leader is his or her characteristics behaviours used in guiding, managing, directing, and motivating a set of people. Great political movements and social changes are often inspired by great leaders who can lead or persuade followers to create, innovate or perform well.

Traditionally, leadership in nursing has been closely associated with transactional leadership incompatible with core values of the profession [7]. Scholars such as 8 and 9 recommended transformational leadership for bedside registered nurses and others suggested authentic leadership [11], as well as emotionally intelligent leadership [12, 13]. While traditional leaders like head nurses or nurse managers gets authority through formal appointment [14], registered nurses at the bedside aiming to enter the leadership group attain authority from the support, perception and acceptance of others who works with and trust in them [15]. The band 6 clinical nurse leader is at the start of such a leadership ladder.

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Stanley [17] posits that clinical nurse leaders or band 6 nurses’ leaders are usually positive clinical role models that can demonstrate a high-level of clinical capability and knowledge. These group of nurses exhibit good communication skills, are approachable and open minded, with high visibility and accessibility in practice, are excellent decision-makers who tends to display the core values and beliefs of nursing via their actions (17).

This essay aims to reflect on and critically evaluate the role of the clinical band 6 leader in adult nursing. Borton’s development framework (1970) will be the reflective tool used to structure the essay. According to Donald Schon, reflection is twofold: reflection-in-action and reflection-on-action. Reflection carried out when the event is taking place is called Reflection-in-action while reflection that looked back after the event has taken place is reflection -on-action. Reflection in action happens when the practitioner upon encountering something puzzling or encountered a surprise stimulus is made to think or redesign what he/she is doing while it is still in progress (Greenwood, 1993). Reflection-on-action on the other hand is action taken to turn information into knowledge through embarking on a cognitive post-mortem. In the words of (Fitzgerald, 1994), when a practitioner retrospectively contemplates on practice to uncover through the analysis and interpretation of information remembered the knowledge used past events, a reflection on action has taken place.

Borton’s 1970 reflective framework is an easy straightforward model of reflection which has 3 easy questions on an experience to be reflected on which is: what, so what, and now what. The frame work allows the practitioner to reflect without the structure being placed in front of him or her which accounts for why many health care professionals recommended its application.

It is imperative that ethical issues such as confidentiality, informed consent and anonymity are considered in any study that concerns people. As such and in agreement with Nursing and Midwifery Council (NMC, 2015) this reflective essay based on a case study will aim to maintain the confidentiality and privacy of the patient used by adopting a pseudonym throughout. 

Patient presentation

Mrs A is a 38-year-old lady who is five weeks pregnant, presenting with severe abdominal pain she and has been was referred by her General practitioner to the unit for a scan. After the scan Mrs A was diagnosed with life ectopic which is a serious case of when a pregnancy is outside the womb: a life threating situation as there is a risk that it can rupture and cause further health damage. The doctors admitted to the ward as she required an emergency operation to remove the ectopic pregnancy from the fallopian tube. It was the doctor who performed the scan that had to break the uncomfortable news to the patient. Understandably, Mrs A was very upset and tearful as this was her first pregnancy and she was not expecting to be told she needed to go to the theatre for an emergency operation to remove the ectopic pregnancy from the fallopian tube. Mrs A came to me immediately after her discussion with the doctor.

What?

Person centred care that is holistic requires the collaboration of all members of a care team (ref). Looking back one can appreciate that the situation was life threatening and required immediate and coordinated response from our team of care practitioners. The main reason for revisiting this event is to review and reflect upon what I experienced during about this incident, and possibly learn from what was a challenging and complicated situation. The question I need to answer is whether the decision I made on that day to prepare her in a make shift ward was appropriate or could be improved.

My initial role was to carefully and accurately analyse the situation -in line with my Belbin’s team role of a completer finisher, and realised Mrs A will need to have a bed urgently with which she can be prepared for her surgery (Bronson, 2018). The team met briefly and agreed some action plans. The response of the staff nurse was very appropriate as she counselled the patient and made sure she rang her next of kin and cannulate her and take bloods for full blood count and group. Contrary to my preferred team role I delegated some tasks to the HCA including checking her vital signs, giving the results to the staff as well as taking Mrs A’s blood to the lab so it can be processed urgently as she was going to the theatre. While the staff nurse was with Mrs A, I bleeped the bed manager about a patient needing a bed urgently on the ward in preparation for an emergency surgery. The bed manager rang back and informed me that there were no beds available in the hospital.  I found this response unacceptable. I felt as if the bed manager was uncooperative and she could have done more to arrange for a bed in such a life-threatening situation. I was angry and frustrated that there is no contingency plan to deal with a situation like this at the unit.

The team met once again, and I informed them of the new development and suggested preparing the patient for theatre in the treatment room as the bed manager said there are no beds available on the ward. As a team, I believe our response was appropriate and well-coordinated. My role now was to turn the treatment room where staff normally take patients bloods to the room to prepare Mrs A for theatre. I had to create a temporary room for taking the bloods of the patents who needed to have bloods taken and make sure staff are aware of what I was planning, and they all agreed with my plan. I moved the blood trolley to the temporary blood room and the patents that needed blood taken all had the bloods taken and privacy and dignity and confidentiality was maintained.at all times. The clinic ran smoothly. On reflection I realised that I had taken up the leadership role of the team. Next, I informed the gynaecology senior house officer and the gynaecology registrar on call that there is a patient in the unit that needs emergency theatre and there are no beds on the ward and that we are already preparing her for theatre. And, that she needs to be consented and reviewed by the anaesthetist (Bronson, 2018).

Unfortunately, by the time Mrs A was fully prepared and meet the anaesthetist it was 5 pm and time the clinic supposed to be closed. Yet there was still no bed for the patient, so I had no choice but to send the rest of my team members home and wait with the patient until she was collected for the theatre at 6;00pm. a

The reflective process is not complete until the patient’s feelings are considered. Mrs A was not only apprehensive but also confused. She was unable to understand the delay in getting her a bed and needed reassuring constantly that everything will be alright. 

So what

Not too long after the incident I went through an agonising period of self-examination. I was worried in case I had inadvertently introduced the possibility of blood contamination when I moved the blood trolley to another room thereby causing more harm. But on reflection, I concluded that my decision was appropriate both because I have a duty of care to Mrs A (Larsson, and Sahlsten, 2016) as her medical team leader and because there are stringent safeguards in place to ensure bloods taken are not contaminated (Moak et al., 2015).

Retrospectively, I realised that as the team leader I had prioritised Mrs A’s needs above all else by first ensuring that a room was created for her ensuring her privacy, dignity and confidentiality are maintained as well as deliver care to other patients on the unit, making sure the clinic always run smoothly and ensuring the safety of all patents. Ectopic pregnancy, according to experts (ref) is an incidence when a fertilized ovum is implanted outside endometrium. Medical experts believe that the complications that arises from this situation remains the one of the most significant causes of death and morbidity during the first trimester. Treatment typically consist of either surgery or with methotrexate. Doctors will usually prescribe surgery as in the case of Mrs A when there is an immediate cause for complications arising.

Consequently, it was this knowledge that prompted my action to create a bed for Mrs A as quickly as possible. Ethical considerations also suggest that health practitioners must always invoke the Principle of Non-Maleficence, meaning “first do no harm”. The decision to prioritise Mrs A’s need was also guided by this principle that puts the onus on nurses to ensure that their clients are not harmed or come to any harm (van Uffelen J G Z et al. 2008).

Theoretical analysis of the event would suggest that it was an opportunity for me to discover that I had the ability to use the transactional leadership style in addition to my usual leadership style which is transformational (Bass, 1985; Burns, 1978). Although in the unit under normal day to day activities I use the transformational style due to it having a positive effect on communication and teambuilding to achieve a common goal, the event with Mrs A was a short-term episode that needed to be directed, so requiring a transactional style of leadership (Govier and Nash, 2009). The event also highlights how effective the unit’s medical team are as a team. According to Lord Darzi (2008; p 201) ‘Leadership is not just about individuals, but teams.’ Our ability to work well as a team gave the event a successful outcome for the patient.

This level of analysis gave me a deeper insight into the situation and reinforced my initial conclusions relating to the proper and appropriate course of action.

Now what

As soon as I was informed by the bed manager that there were no beds available on the ward and Mrs A had to go to the theatre for an emergency operation. I instinctively knew I had to find a solution to her problem. So, I had to prepare Mrs A for the theatre in the clinic informed the gynaecology senor house officer o call and gynaecology registrar on call that Mrs A will be prepared for theatre in the unit for her procedure. I put plans in place to make sure it was possible for her to be prepared in the unit for theatre.

The incident showed that the unit is not prepared for this sort of emergency. An emergency pack for theatre with all the items needed on a trolley in the treatment room for if a patient needs an emergency procedure and there is no bed on the ward should have been the minimum in place for this sort of situation. According to (ref) Ectopic pregnancy happens in ……………………………, so a unit like ours should have developed a contingency plan.

Next will be for us to create a pathway for patients that need admission to the ward when there are no beds available on the ward and the clinic is closed. I was so much in favour of such a pathway that I started to explore the possibility to avoid the repeat of Mrs A’s episode. The team met together to reflect on the episode and agreed to put together an emergency pack in the first instance to deal more efficiently next time.

According to Lawal et al. (2016), a multi-disciplinary evidenced-based practice care management tool designed to cater for the need of patients presented with a predictable clinical course is known as a clinical pathway. This pathway or care plan must include the definition of the different tasks of care professional involved, sequenced and optimized by day, hour or visit with outcomes intervention specific.

The episode highlights how important it is that an Emergency Gynaecology Unit (EGU) pathway for is created for those patients at risk of being admitted to the ward, when available beds are in short supply and the day clinic is closed: something currently missing from my unit. As stated previously, there is no pathway in place for this situation in our unit.

My research into the use of pathways in other units showed that there are EGUs under Barts Health Trust, Royal London and Whipps Cross Hospitals. The pathways in these trust als appears to be the same, which is once the patient needs to be admitted on the EGU, the registered nurse informs the bed manager about these patients.  If there are no beds available when the clinic is closed, the registered nurse informs the bed manager and the patients are sent to the Accident and Emergency (A&E) department. Our unit is under Newham University which with Royal London and Whipps Cross Hospitals, are all part of Barts Health Trust; I therefore feel that the trust should implement the same pathway for all their Hospitals. Currently a registered nurse must stay with the patient until a bed becomes available. Sometimes the patient does not get a bed until 8pm, even though the clinic closes at 5pm. It is not safe for any patient to be left in the clinic on their own particularly patients presenting with an ectopic pregnancy, or miscarriage in transit, as there is no resuscitation trolley available on the unit. Such a situation could be avoided with the creation of a pathway, that detailed how patients should be transferred to a named A&E department when the clinic is closed. A diary will be created for recording the details of such patient, making sure the pathway is monitored constantly and members are aware of patient’s movements. The pathway should be audited every month, safeguarding that the pathway is being followed. A DATIX report should be completed when there is a delay of thirty or more minutes in transferring the patient from the EGU to the ward, or to the A&E department.

The implication for practice is that staff stress level will be reduced, and the safety of both the patient and staff will come first. There will be less complaining from the staff for working late and having to complete a DATIX report each time they must leave the clinic late. In monetary terms, money paid to nursing staff and others working late to wait with the patients to get treatment will be saved by the NHS.

However, like all projects involving professional collaborations, getting all the stakeholders together for a meeting, as well as persuading the named A&E stakeholders to accept the proposal for patients to go to their department when the clinic is closed will be a challenge.

References.

• Amanchukwu, R.N., Stanley, G.J. and Ololube, N.P., 2015. A review of leadership theories, principles and styles and their relevance to educational management. Management, 5(1), pp.6-14.
• Bronson, R., 2018. Ectopic pregnancy—still a challenge. Fertility and sterility, 110(7), pp.1265-1266.
• Cable, S. and Graham, E., 2018. “Leading Better Care”: An evaluation of an accelerated coaching intervention for clinical nursing leadership development. Journal of nursing management.
• Darzi, A., 2008. High Quality Care For All: NHS Next Stage Review Final Report. London: DH. tinyurl.com/darzi-finalreport
• Govier, I., Nash, S., 2009. Examining transformational approaches to effective leadership in healthcare settings.Nursing Times; 105: 18, 24–27.
• Larsson, I.E. and Sahlsten, M.J., 2016. The staff nurse clinical leader at the bedside: Swedish registered nurses’ perceptions. Nursing research and practice, 2016.
• Lawal, A.K., Rotter, T., Kinsman, L., Machotta, A., Ronellenfitsch, U., Scott, S.D., Goodridge, D., Plishka, C. and Groot, G., 2016. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC medicine, 14(1), p.35.
• Mok, W., Wang, W., Cooper, S., Ang, E.N.K. and Liaw, S.Y., 2015. Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses. International Journal for Quality in Health Care, 27(3), pp.207-213.
• Northouse, P.G., 2017. Introduction to leadership: Concepts and practice. Sage Publications.