Although I’m not an academic and haven’t studied bullying in depth, I’ve experienced it and I’ve also been in situations where, I now recognise, I took a bullying approach. This has led me to consider the difference between accountability and bullying:
Accountability The key thing for me is the difference between holding people to account (e.g., by openly discussing problematic beliefs and behaviours) and bullying.
Accountable actions are driven by the intention / motivation of helping all involved and building an interconnected community based on honesty and trust. (‘Tough love’ if you like).
‘Secret squirrels’ Contrast this to the scenario where bullies criticise people without being specific about what’s being questioned, act secretly and withhold information, blacklist people, create over complex rules which can’t be followed and hide behind bureaucracy and hierarchy.
Specific bullying behaviours include undermining, whispering campaigns, behind closed doors conversations etc.
Look out for cultures where the modus operandı is ‘kiss up – kick down’. If this is the case, the organisation has problems. It will not be able to deliver its aims effectively and may be creating an unsafe environment.
In my experience, around the time of my protected disclosure, I was involved in meetings and discussions where those who had set up the meeting had not stated the purpose of the meeting in advance (or on one occasion deliberately misled me). In these meetings they had clearly rehearsed their questions. Questions that were designed to belittle and discredit.
Sounds familiar?
In these cases, this seems to be motivated by a desire to cling on to power, deny failings, use ‘playground’ tactics and break connections which aren’t in line with the overall agenda (often not made public).
These behaviours are frequently the result of bullying from higher up the chain, and a culture where leaders are not comfortable with ambiguity. Bullying in this context is not always recognised as such, and victims are made to feel it may be their fault. This compromises patient safety.
Bullying is a problem which affects all areas of work, and all sectors. I remain optimistic that, because of the profile this issue now has, things are changing. There’s a long way to go yet, and many injustices to be rectified.
‘People deal far better with uncertainty and stress when they know what’s going on, even if the information is incomplete and only temporarily correct. Freely circulating information helps create trust, and it turns us into rapid and more effective learners’
Margaret J Wheatley (2007) ‘Finding our Way. Leadership For an Uncertain Time’. Berrett-Kohler Publishers Inc. San Francisco
Background: From 2008 to 2014 my company ran education sessions on managing medicines in a mental health trust. In common with some other mental health trusts the provider also looked after paediatric community services. This is not a mental health service. It covers children with complex health needs including enteral feeding tubes, ventilation, epilepsy and rapidly changing medicines.
Children under the care of this service may be taking in excess of 15 different medicines per day, have complex titration regimes, emergency drugs with associated care plans, plus numerous ‘as required’ (prn) medicines.
It is not unusual for children with complex conditions to be under the care of up to five different providers, and to move between three different providers in one day. For example, from a Home Care Service to the Special School, to a Short Break House, also being seen in an Outpatient Clinic on the same day too. As a result, parents frequently have to repeat the information on their child’s medicines every time they move to another service, or a new person is involved.
Where to start? The idea for change came about because of concerns that the staff in Children’s Short Break Houses were not learning what they needed about children’s medicines, as the learning was geared to the majority of staff who worked in mental health. So a new learning package for children’s staff was commissioned.
Part of the work to design the learning package included a baseline assessment which was conducted with parents and staff. This soon revealed that training alone was not the answer. It showed delays in medicines information reaching GPs, workarounds for obtaining information in order to administer medicines in the houses and a general lack of confidence in the whole process.
As a result, we looked at the whole system starting with the area where most concerns had been raised, which was having an up-to-date complete list of a child’s medicines available at all times (medicines reconciliation). The system in place for Short Break Houses involved paying a local GP (not usually from the child’s GP Practice) to write up a medicines chart for each child. The process was fraught with difficulties and delays and widely disliked by everyone directly involved.
So we set about looking for a new way to manage the lists of medicines with more training and more input for the staff in the services involved. We came up with a new (and much more robust) process for medicines reconciliation in the Short Break Houses. This was fully documented in a new policy and involved cross-checking by both the staff and the parents.
Just before this went live, we asked the parents to review and comment on it and they said: ‘If you’re producing an accurate and up-to-date list of my child’s medicines, why keep it the Short Break House, can’t it go with my child?’ So, the My Medicines chart, which travels with the child, was born.
What was involved? The My Medicines process led to the design and production of a new chart which has to be signed and checked by the parents. It resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go.
Benefits: The new process, which continues to evolve, means that the child’s GP is now directly involved in day-to-day medicines reconciliation (they weren’t before); the parents are always asked to check and sign the charts (they weren’t before); verbal messages about medicines are never taken, and incomplete (or missing) directions are rapidly rectified (never worked around).
Some specific benefits of the new process included: • It reduced the risks of error, by providing full and accurate information on children’s medicine across their entire pathway. • It cut out the need for parents to keep having to repeat what medicines their child is taking to different professionals and care agencies. • It freed up medical and clinical time which was previously spent chasing missing information. • It reduced the number of third-party handovers and transcribing of prescription information.
Looking back, it’s hard to believe that the old ways of working, which caused so many difficulties (especially for front line staff), were carried out for so long. These risky practices, or similar, are believed to still be commonplace in England.
Revealing hidden incidents and near misses:
In the first month of the project we raised 17 medicines incidents or near misses. Of these 11 related to problems with communication of information across the child’s pathway.
Resolving these has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further. Previously many of these incidents were not logged or tracked across organisations. In some cases, it was only due to the vigilance of the staff and parents that they were spotted, and errors avoided.
Accepting the changes:
The project was well received by parents and staff and resulted in improved communication and engagement between different clinical groups and providers. This included the Consultant Paediatricians (working for the secondary care provider), who were initially sceptical.
The project was less well received by the relevant medicines and prescribing committees, who were understandably concerned about who owned the My Medicines chart and had agreed to its content. Explaining this was made more difficult because it is hard to get across the complexity of the arrangements, due to the critical nature of the children’s illnesses, in a committee setting.
I make no apologies for ensuring from the outset that it was the parents who owned the charts, which were designed by the project team (not a committee) to meet all best practice standards. It always worries me that when it comes to cross- organisational working the formal committees and systems in place can inadvertently act as a barrier to safety rather than promoting it. There is no doubt we had designed a safer process and my company was happy to take accountability for any associated risks.
As a legacy of the project, a Community Paediatric Pharmacist was appointed specifically to work with this group of children. So whatever evolves will now be based on inter-disciplinary thinking and working and will have clear safety parameters. I am grateful for the enlightened thinking of the leaders who commissioned this work and supported this novel approach.
Steve Turner RGN, RMN, Ba (Hons), P.G. Dip. Ed.
This example was included as a NICE Shared Learning resource and was highly commended by NICE in 2015.
In producing a teaching session on evidence based medicine, it occurred to me that there are some important points everyone needs to know, and that they are summarised well in these videos from James McCormack. So, if you like learning through the medium of song and dance, these are for you 😃.
There are some links to important guidelines and academic references too. Some of the comments on learning points reflect my personal views.
Assessing the evidence
‘Viva La Evidence’ from James McCormack
Key learning points:
Look for absolute numbers.To assess clinical studies, you need to have sight of the ‘absolute numbers’ and the figure for Absolute Risk Reduction [ARR]. Sales and marketing people may just tell us about Relative Risk Reduction [RRR]. This figure stays constant with different populations, and always looks better. To be honest I find this concept easy to understand but hard to explain. Here’s a link to an article which goes into more detail.
POOs and DOOs. It’s helpful to look closely at the relevance of the research for patients. Is it focused on outcomes that are patient-oriented [POOs] or disease-oriented outcomes [DOOs]? Click here for a related article.
‘The End of Guidelines’ – how useful are they in real life
‘The end of Guidelines’ – from James McCormack
Key learning point:
Guidelines not tramlines
Most current guidelines are written for specific diseases and conditions when, in reality, many people often have more than one long-term condition. In fact, most people with chronic conditions, and most people over 65, have multiple health conditions. This together with other factors such as past experiences, health beliefs, ethnicity, poverty, lifestyle and cultural factors, will influence the choice of medicines.
To help with this there are some important NICE Guidelines, which should be cross-referenced in practice guidance (local and national).
All prescribers should be familiar with and use these guidelines in helping patients choose medicines & treatments. This includes the patient’s choice not to take a medicine, which is specifically noted in the NICE Guideline on Medicines Adherence.
Guidelines are just that – ‘guidelines’ – and not to be followed blindly without question or reference to the individual patient.
The clinician’s role has changed from being the ‘expert’ to that of a teacher, advisor, mentor and sometimes an advocate. At the end of the day, in everyday situations, what we do is our decision. The much-used phrase ‘shared decision making’ is inappropriate in my view, it stems from the old fashioned ‘doctor knows best’ attitude. I prefer to use the phrase patient led decision making.
Following on from my blog on making the most of remote consultations, I realised it would be helpful to talk about the outcome patients should expect from consultations (wherever they are conducted). This blog is based on my clinical experience, on feedback from patients, carers and relatives, and on my experience of helping look after my mother at the end of her life.
There are some simple things that everyone should come away with at the end of a consultation. Knowing the plan & what the next steps are. Where to find information on what has been discussed and what to do if things get worse. If this information isn’t made clear, ask ‘what’s the plan?’
Consultation information:
At the end of the consultation, you must:
Have agreed a plan (even if this is ‘watch and wait’, or a referral on)
Have written information on what has been discussed& where to find support
Know the signs of improvement or the signs of deterioration to look for
Know when & who to contact if things change
Know who to contact in an emergency
At the end of the consultation:
At the end of the consultation, you should know:
That your concerns have been listened to
That the agreed actions will be taken
That you can seek a second opinion if needed
That the consultation will be communicated to all involved in the patient’s care
You should also receive:
Written information on the consultation. This may be in the form of notes, a care plan or visit summary & copies of ALL communication between clinicians.
‘If you’re not provided your records (as you should be), you may wish to keep a record of your consultations yourself and / or record them. As a clinician I encourage this.’ – Steve Turner RGN; RMN; Ba(Hons); P.G. Dip. Ed
In a future blog I’ll look at communication and documentation. What form should this take? Covering all options including online access to records, patient-held notes, visit summaries, assessment letters, patient notebooks, body maps, recordings, images. How can we ensure patients & all involved have this information in real time?
Medicines errors in care homes are unacceptably high. A key study found that residents taking seven or more medicines had a 79% chance of being victim of a medicines error (Alldred et all 2009).This led to several follow-up studies and actions to improve medicines management in care homes, including a move to implement electronic medicines administration [eMAR] systems. A recent study explored medication-related incidents and their causes in UK care homes. This review emphasised the need for improved medication management processes to reduce errors and enhance patient safety (Irons et al 2022).
Best practice in medicines record keeping
The management of medicines in nursing and residential homes is part of a highly complex pathway. It involves multiple staff groups and organisations.
These include the G.P.; all who prescribe medicines and treatments; Care Staff of all grades; Support Workers; Consultants; Specialist Practitioners; and Pharmacists.
Benefits of electronic MAR charts
The benefits of implementing electronic MAR charts fall into three categories.
Improved legibility.
Improved access (e.g., if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging, or mislaying them).
eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing.
Systemitic reviews indicate that carefully planned and implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care (Gates et al 2021).
Challenges of implementing electronic MAR charts
There are three ‘bottom line’ challenges to manage when transitioning to electronic MAR charts.
1. Assessing potential eMAR systems. Thisis critical, as poorly designed systems will not deliver benefits, and eventually fail. The system must be easy to use and free of unnecessary jargon, using only approved acronyms or mnemonics. Electronic systems also offer the opportunity to introduce features which enhance safety, some of which, such as time ordered charts, are difficult to include in a paper-based syste
Here’s a some key features to look for:
Photo identification
Time ordered charts
Body maps
Drug images
Start and finish dates
Insulin charts
Warfarin charts
As required – prn- charts
Does the system record the reason prn medicines were given?
Medication history
Medication profiles
How the system records allergies and sensitivities
What alerts and warning messages are included?
How the system copes with medicines dispensed directly from hospitals
How does the system cater with titration of medicines and variable doses
How does the system cater with weekly medicines (e.g. alendronic acid)?
Use of monitoring information (e.g. INR for warfarin administration, lithium level recording, BMI, B/P, pulse etc.)
That the system uses up to date approved terminology
Does the system records medicines not given or partially administered, with a reason?
How the system can be used to order and control stocks of medicines
How easy is it to produce reports from the system?
2. Data Security and Protection. It is vital that the system handles patient consent; patient confidentiality, system access; ownership of patient identifiable data; storage and transfer of data in a way which is compliant with the laws and regulations of your part of the U.K.
All organisations and systems that access to NHS patient data must successfully complete the NHS data security and protection toolkit [DSPT]. This toolkit provides assurance that the system suppliers are handling data safely and that personal information is handled correctly. You can search the supplier’s NHS DSPT registration here: https://www.dsptoolkit.nhs.uk/OrganisationSearch
3. Process Reviews. It is important to look at your current processes and how the new system will work. For example, there have been problems where urgent acute prescriptions were supplied by a different pharmacy from the pharmacy linked to the home’s eMAR system. The eMAR system must be able to cope with all aspects of prescribing from multiple sources and prevent information having to be duplicated.
Training and support requirements
Quality training and support, both during the implementation and on an ongoing basis, underpin all successful healthcare I.T systems. There are four areas which are sometimes overlooked that deserve special mention:
1. Many of the users of eMAR systems will be Healthcare Assistants or other non-registered skilled staff. As a result, it will be important that the training they receive reinforces their duty to keep accurate records, that they know where to go for help and advice and their role and responsibilities are made clear.
2. A substantial number of staff may speak English as a second language. Therefore, it is important that eMAR systems do not use any unnecessary jargon, and that any help text is in plain language.
3. Appropriate knowledge of Data Protection (GDPR) and Information Governance rules and regulations is essential and should be built into any training programmes.
Overall, consideration needs to be given to the nature and content of the training needed to implement the system, including how this is linked to the policies and procedures and overall governance of the home.
Good suppliers will be able to give advice and support on this.
Conclusion
Record keeping in medicines management is a critical safety area for care homes. The current high level of medicines errors is in care homes affects half a million people in England.
The prospect of implementing electronic systems for recording medicines administration holds great potential but is not itself without risk. It needs to be approached carefully in the light of the complex arrangements and multiple organisations involved in prescribing, supplying, administering, dispensing and monitoring medicines for your residents.
Given the considerations over choice and implementation of systems, eMAR can overcome problems of legibility, transcribing, and access to records and information in a way which is not possible with paper systems.
In years to come it is likely that, just as most G.P.’s would not want to return to paper systems, care homes will come to see electronic systems in the same way. The main beneficiary of this will be the residents in terms of improved safety.
References:
Alldred P, Barber N, Buckle P et al (2009) Care home use of medicines study (CHUMS): Medication errors in nursing and residential care homes – prevalence, consequences, causes and solutions. Report to the Patient Safety Research Portfolio. Department of Health, London.
Peter J Gates, Rae-Anne Hardie, Magdalena Z Raban, Ling Li, Johanna I Westbrook, How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis, Journal of the American Medical Informatics Association, Volume 28, Issue 1, January 2021, Pages 167–176, https://doi.org/10.1093/jamia/ocaa230
Irons, M. W., Auta, A., Portlock, J. C., & Manfrin, A. (2022). Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review. Home Health Care Services Quarterly, 41(2), 91–123. https://doi.org/10.1080/01621424.2021.2007196
Author: Steve Turner RGN, RMN, Ba (Hons), PG Dip Ed – an experienced nurse educator, who has worked in strategic consultancy and on change projects across healthcare in the UK.
Steve Turner's blog site 