The circumstances of the incident
The incident took place on Ward X during an early shift. During this shift, there were 30 patients on the ward, in four six bedded bays and six side rooms. During the early shift, Mrs J was seen on the ward round and was discharged by the medical team. Mrs J had had a laparascopic cholecystectomy five days previously, but had developed pneumonia in the postoperative period and therefore had been on the ward much longer than had been anticipated. Mrs J was a 58 year old semi-retired librarian with a history of hypertension treated with antihypertensive medication.
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During this morning shift, the staff nurse, Nurse M, looking after all the patients in Mrs J’s bay, was asked to discharge Mrs J by the medical team, and Mrs J was very relieved, and called her daughter and son in law to pick her up ‘after lunch’. Mrs J needed medications to take away (TTAs), and needed her discharge paperwork completing, and her community nurse needed to be informed to attend her at home the following day. Nurse M had two other patients to discharge that day, and had to provide care for three other patients, two of whom had had surgery the previous day. Nurse M carried out the medication round in her bay at 8 am and at 2pm.
At four pm Mrs J’s daughter approached me to ask why her mother had not been discharged yet. She was considerably distressed, as her mother’s stay in hospital had been much longer than anticipated. The perceived delay in her discharge had upset the patient and her family.
Nurse M stated that she had started the discharge but been too busy to complete it during her shift. She therefore handed over the discharge to the afternoon shift nurse, Nurse F. Mrs J was discharged at 6pm. The next day, her daughter telephoned the ward to complain that Mrs J was discharged without her anti-hypertensive medication.
The actions taken
As the ward manager, I spoke to the patient’s daughter and apologised for the discharge taking so long, and for the failure to provide essential medication to take home. I spoke to Mrs J and to the community nurse, Nurse P, in order to ascertain whether there had been any adverse effects on the patient’s condition. Mrs J’s daughter had visited the GP the following morning and obtained a replacement prescription, and so Mrs J missed only one dose, and one delayed dose of her antihypertensive medication. No adverse impact had been identified.
Following this incident, I reviewed the case notes of Mrs J, and all the patients in B Bay on Ward X, to ensure that there had been no other oversights or omissions. I reviewed the discharge documentation for the second patient discharged that day, Miss T, and found that all was in order. A review of the discharge notes for Mrs J showed that the TTA prescription had not included the antihypertensive medication.
The staff involved
Nurse M, a Band 5 nurse with 3 years experience. Nurse F, a Band 5 nurse who joined the ward 3 months previously. The ward manager, a Band 7 nurse. Nursing Assistant L, a trained HCA with eight years experience on this ward.
The patients involved
Mrs J, a patient recovery from healthcare associated pneumonia after a laparascopic cholecystecomy.
Five other patients in B Bay on Ward X: Mrs T, Miss S, Mrs L, and Ms K.
Other important aspects and considerations that you consider necessary
The ward was full that day, and there was one member of staff missing for part of the morning shift, due to sickness. The omission in the medication order can be localised to the Senior House Officer who signed the TTA request, but Nurse M should also have identified that the medication was missing, either at the time of completing the form. Nurse F should have identified the omission when she checked the medication with the patient at the time of discharge. Both nurses were questioned and given a verbal reprimand.
As a ward manager, observing the behaviours of staff working together within a ward team, I have often noticed that the discharges which are ordered at the time of the ward round early in the morning are often not completed until the evening, even when the discharge is relatively uncomplicated. I have also noticed that this reflects other aspects of care, where staff do not seem to be working particularly quickly or efficiently. In this situation, the behaviours of staff seemed to indicate on first analysis that staff were overworked and that this omission occurred because of pressure on staff. However, this author also identified other issues which were contributing to the situation. The first was that I noticed how staff had fallen into particular behavioural patterns during the early shift, which meant that they often left discharges to be completed by the afternoon staff. It seemed that certain staff tended to fall into this pattern, and to fall into particular routines in which they slowed down at certain times during the shift. I noted as well that there were a particular sub group of nursing staff that behaved like this, and that there was a divide between some staff and those who supported them, such as the HCAs. For example, Nurse M and HCA L did not seem to work well together, and I noted that Nurse M had addressed this by simply not delegating too much to the HCA.
This situation seems to indicate that not only is good management and leadership needed in order to address what seems to be an issue of staff behaviours, but also good leadership in relation to team working, warranting an analysis and examination of team working. It became apparent that as the ward manager I would need to use the position of team leader to destabilise the ingrained patterns of work behaviour and break up old alliances which might be impeding effective teamworking. The conclusion reached was that this was not simply a case of finding fault with Nurse M and Nurse F, but deconstructing the circumstances that had led to this mistake. The fault in this situation is diffused amongst all of those involved. This included a potential that it was my own leadership at fault in this situation, requiring me to bear some of the responsibility for this occurrence.
Leadership within nursing requires a complex set of skills and attributes, and the ability to manifest a strong nursing leadership role. However, it is challenging because of the nature of the work, which can change rapidly at any point in time, and the nature of staff relationships and behaviours, which can involve complex interactions and inter-dependencies. Fostering effective teamworking in this situation, and leading a team towards better ways of working, is likely to be very challenging even when circumstances are good, but in a position where the team is one staff member short, it could be argued that this makes it all the more challenging. A manager needs to understand the whole theory and practice of teamworking within organisational contexts, and also understand how they can, in their own leadership role, support effective team working and improve care standards, whilst at the same time supporting staff dealing with a heavy and complex workload.
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All nurses must manage themselves and their own workloads, and must develop self-awareness of their own traits, strengths and developmental needs. This author has spent some time reflecting on their own capabilities, and has identified their own strengths, such as the ability to carry out routine tasks swiftly, and to prioritise care and workloads for better patient care and more efficient management of tasks and demands. Another personal strength is the ability to take a wider view and to consider a range of factors affecting workload, and team working, including skill mix and different personalities and how well staff work together.
The academic field of organisational studies has long been concerned with leadership, theoretically and practically. It is a multifaceted concept and has been considered from a variety of perspectives, including an applied perspective with specific reference to nursing. There tends to be a polarisation of theoretical perspectives, in which some believe that some people are destined to be leaders because of pre-existing or innate abilities or proclivities, traits which make them ‘natural leaders’; and some theorists posit that leadership is comprised of a set of skills and applied knowledge that can be acquired and used by anyone trained in them (Day, 2000, p 5810.) Thus some would argue that the people possessing ‘natural’ leadership skills and abilities would be the best leaders, while others continue to assert that there is no difference and that a person given the right training and development could be a good leader (Green, 2003, p 27). There is merit in both perspectives, in that a natural leader who has had training could be argued to be potentially better than one who has no predisposition to leadership, and that there may be some people who are not suited to leadership roles who should not aspire to be leaders. However, suggesting that leadership is something which can be learned is a much more egalitarian viewpoint, which could be positive, but could result in people being placed in positions of ‘official’ leadership against their own preference, when their true strengths lie elsewhere.
In relation to the situation described in the report in part A, this author would argue that not only did the team require more directive leadership at this time, but that such leadership should be visible, tangible, and strong enough to ‘lead’ the team towards more collaborative and supportive working practice (Bishop, 2009). The literature shows that clear lines of command are important, but clear, strong leadership is more than simply exercising control over people, it is a more bilateral approach which engages leader and team in managing work in such a way that it improves patient care (Clegg, 2000, p 31). However, Grint (2005, p 1467) also shows that in order for leaders to be effective, they must be able to motivate others to follow them and to go in the direction they have indicated. Thus leadership is more than simply guiding people, it is about engaging with them and making them ‘want’ to follow the lead. Thus it is possible to see that authority does not locate an individual as a leader on its own; the ‘followers’ must accept and support that leader as well (Grint, 2005 p 1467).
In this case, however, the leadership activities must be very much directed at leading a diverse team of disparate individuals with a range of personalities, skills, and experience, as well as differing roles and responsibilities. Breakdowns in interprofessional working and communication are common within healthcare settings (Sutcliffe et al, 2004, p 196). However, organisational theories argue that there are typical types of roles that individuals assume within teams, and the seminal theory here is Belbin’s (1993 p 57) team roles theory. This theory is useful because it allows the leader to ‘manage’ individual team members and motivate the team more effectively through understanding their team roles (Belbin, 1993 p 57; Johansen, 2003, online). Anything which enhances team working is likely to improve communication, enhance team and individual worker efficiency and effectiveness, and improve nurses’ satisfaction with their working lives, contributing to better practice standards (Amos et al, 2005 p 10; Clegg, 2000 p 31; Dimeglio, 2005 p 110), and this author would also argue that exploring how to manage a team more effectively would help them to contribute to their own professional development (Bandura, 1994 p 71). Thus, an effective leader could look at the eight defined roles which are said to occur within organisational or workplace teams, some of which may be fulfilled or enacted by more than one person at a time, just as one person may enact more than one role at once (Belbin, 1993 p 57-59). Effective teams ideally demonstrate that members enact all the roles defined (Johansen, 2003, 0nline). Belbin (1993 p 57-59) describes these as: the calm, confident chairman, objective but unemotional, generally infallible; the impatient shaper, coercive, unafraid of confrontation, directive and apt to destabilise the status quo; the problem-solving plant, an imaginative highly intellectual and creative individualist who may not be a good team player; the informative and enthusiastic resource investigator, good at communicating, who can find their motivation flagging; the analytical and evaluative monitor evaluator, who can be perceptive but cynical; the reliable company worker, who plods along and reaches goals but can display a degree of rigidity and inflexibility; the mediating team worker who tends to be both a communication hub and coordinator, using effective social skills to propel the team along; and the conscientious and deadline-conscious completer-finisher (Johansen, 2003, online). This author would argue, however, that the team leader could occupy one or more of these roles, but if they have a manager, may not be viewed by others to be a member of the team, per se, and so not included in the ‘inventory’ of team members. Thus there may be a flaw in this theory, because there is no specification of how a manager would necessarily fit in to this team.
Team leadership in this context, however, is complicated by the nature of healthcare practice in which teams are comprised of multiple professionals and occupational groups (Cockburn, 2004 p 66), and thus a nurse manager of a ward has to be able to be a leader across different professions and disciplines and may need to display different leadership behaviours in order to achieve this (Murphy, 2005, p 128).
One way in which a ward manager might lead in this manner is through quality management activities (Sale, 2005), and the use and promotion of evidence for practice, a process which requires multiprofessional input (McLaren et al, 2002 p 444). But in this case, the issues which have proved most challenging relate to the ways in which team members manage their workloads, and perhaps also the ways in which different professionals within the team communicate with each other. The manager must lead the team towards a new way of functioning effectively, by ensuring all members are functioning appropriately and fulfilling their different roles (Amos et al, 2005 p 10). This author would argue that within the greater quality agenda, the common goals of quality assurance should act as a common driving force for better teamworking (Martin, 2003).
In this instance, the ward manager will be working to encourage better multidisciplinary team (McFadzean, 1998), but this does not mean that they have the authority to discipline some members of the team, such as the medical staff, and here, historical divides between the professions may impede the process of team building (Hartley, 2002, p 178). In this situation, Nurse M and Nurse F should both have felt able to ask for assistance if they were busy, and should have checked the TTA prescription, but the ultimate responsibility lies with the SHO who wrote the prescription. Legally, however, all are accountable. But the ward manager, as team leader, would lead by example by accepting the shared accountability of this omission (Sheldon and Parker, 1997, p 8). Thus the nurses should be supported to accept this shared responsibility, but at the same time should be supported to examine their practice and see where it could be improved, such as looking at how they could improve delegation skills so that basic tasks are more effectively delegated and advanced nursing responsibilities are better met (Curtis and Nichol, 2004, p 26), and how they can improve interprofessional communication (Kenny, 2002). This author would argue that nurses in the ward setting are all required to develop leadership skills, as an extension of their professional role, and this equates to the concept of distributed leadership (Harris and Spillane, 2008, p 31), and within this model, leaders are developed, supported and empowered, at every point on the scale of organisational hierarchy. Therefore, in this situation, the ward manager would need to understand who acts as what within the team roles inventory (Belbin, 1993), and also support leadership skills to emerge amongst staff at every level. The HCA described in this scenario, for example, exerts significant influence, and these leadership attributes could be harnessed to improve team working, rather than destabilise the hierarchy.
The role of the manager as team leader in this scenario is clearly also to provide feedback and evaluation to the team, and to explore the consequences of these circumstances in a way that should prevent it from occurring again (London et al, 1999, p 5). Providing feedback in an empowering manner can improve performance within the team (London et al, 1999, p 5), and therefore, evidence from available research would suggest that effective leadership would achieve this through multiple approaches.
Research suggests that optimal team performance and quality of care requires good leadership (Beech, 2002 p 35; Green, 2003 p 27). This seems to require what Murphy (2005 p 128), describes as charismatic, transformational leadership, in which “charismatic transformational leaders espouse intellectual stimulation and individual consideration to empower staff and enhance patient care. Nurse managers that develop and foster transformational leadership can surmount oppressive traditions and confidently navigate a complex and rapidly changing health care environment.” However, leaders such as this will continue to struggle with the hierarchies and inherited culture and traditions of the professions (Murphy 2005 p 128). But it is through such activities that proactive nurse leaders mould the future of nursing itself, and contribute significantly to the quality agenda (Shirey, 2006, p 256). Thus the leader in this scenario needs to re-educate the team, and act as a role model for the team to develop their own leadership capabilities (Cummings et al, 2008, p 240).
It would appear that in this situation, the risk involved was avoided by luck rather than judgement, and it is imperative that the ward manager addresses the behaviours and habits which have led to the omission concerned. However, it would not be enough to simply discipline those concerned, because multiple factors have affected this occurrence, and the staff involved will have to continue to deal with these factors in the daily working lives. Therefore, leadership will lead, guide and empower staff to be able to better address their work roles whilst managing the competing demands on their time and attention, through better self management, better communication, better team working, and with clear, motivational guidance from a true leader.
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