Accountability, clinical education, Clinical Governance, dutyofcandour, Ethics, health, healthcare, nhs, patients

Identifying bullying – ‘Secret squirrels’

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

Last updated: 07.010.2025

clinical education, Clinical Governance, Ethics, health, healthcare, medicines, nhs, patients, prescribing

Evidence Based Medicine. Myths, truths and things in between – a blog for everyone

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).

  1. NICE guideline [NG56] Multi Morbidity and Clinical Assessment
  2. NICE Guideline [CG 76] on Medicines Adherence
  3. NICE Guideline on Shared Decision Making (2021)

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.


Alternatives to medicines – Choosing wisely

‘Choosing wisely’ from James McCormack

Key learning point:

‘Top-down medicine is dead’

We are best experts in our own care.

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.

Click here for more on our patient led clinical education work.


Steve Turner is a retired nurse prescriber and clinical educator.

Comments welcome: carerightnow@gmail.com

Click here for more links to Steve’s work

Page last updated: 21.05.2025

Accountability, clinical education, Clinical Governance, Community Care, Ethics, health, healthcare, Law, medicines, nhs, prescribing

Psychotropic medicines for people with learning disability / autism

Prescribing psychotropic medicines for people with learning disabilities / autism who show symptoms of distress*

( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour. Often referred to as anti-psychotic medicines).

Summary:

People with learning disabilities and / or autism can be prescribed antipsychotic medicines for reasons other than to treat psychosis. This is a complex area that involves detailed knowledge off the patient and inclusion of everybody concerned with their care. This includes parents relatives and carers and must involve anyone with power of attorney [LPA] or a Court of Protection Deputyship. This piece sets are some of the key areas to consider when prescribing in the form of an aide memoire. It is important to note that the art and science of prescribing is not simply about writing a prescription. It is also prescribing decision if a medicine is stopped, changed or the dose altered, or if a non-medical option is chosen. Avoiding unnecessary prescribing should be an absolute priority and all guidelines refer to this. On the other hand, some patients require unusual medicines regimes. If this is the case, then the reasons for this must be fully documented as part of a multidisciplinary process including best interest decision-making. This must then be regularly monitored and reviewed.


Key points:

Facts:

  • Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine, or is over/under the recommended dose).
  • This prescribing can include multiple anti-psychotic medicines, often medicines in the same class. There is a limited evidence base for this type of prescribing. Concurrent prescribing of this nature renders the medicines off-label.
  • Psychotropic medicines in people with learning disabilities / autism who show symptoms of distress* should be initiated by an appropriate specialist, after which they are not always prescribed by a specialist in this area.
  • Diagnostic overshadowing may lead to inappropriate prescribing.

Diagnostic overshadowing is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition.

Actions to take for each person:

  • A Holistic assessment including taking all measures possible to understand why the person may be distressed, and taking actions to alleviate this, based around the person.*
  • Ensure that the prescribing takes into account the tests and  monitoring required for safe prescribing, and takes into account the latest national and local guidelines.
  • Before prescribing it’s important to understand all triggers and environmental factors. Plus the reasons for behaviour now and what has happened in the past, including what works well and what acts as triggers*.

There are ongoing concerns that psychotropic
drugs are used inappropriately in people with
intellectual disability. [2]

After exploring ALL options, if medicine is thought to be the answer:

  • Ask about allergies, sensitivities and adverse reactions to medication. Check the documentation on this and ensure it’s recorded accurately (e.g. if the person has reacted to a drug is the nature of the reaction recorded in full, and has it been shared with all involved in the person’s care).
  • Take into account views of family and carers.
  • Take into account any advance decisions and support plans.
  • Take care to avoid diagnostic overshadowing.
  • Ensure there is specialist initiation and review of the prescribing.
  • Ensure Multi-Disciplinary team involvement & inter-organisational involvement.
  • If the prescribing deviates from guidelines (for example around tests and monitoring required and dosage) this must be documented, with a reason.
  • Act in accordance with the Mental Capacity Act [MCA] , where capacity to make a specific decision is lacking. (NB: Mental Capacity assessments must be time and decision specific).
  • Best interests decisions must involve all parties, be fully documented & regularly reviewed. This includes involving people who have Lasting Power of Attorney [LPA] or are Court of Protection Deputies.
  • Where appropriate, use a tiered approach to prescribing – ‘start low, go slow’.
  • Ensure involvement of Second Opinion Appointed Doctors (SOADs#) to provide a statutory safeguard where consent is an issue.

Follow up and monitoring:

  • Confirm the monitoring required and ensure a process is in place for this.
  • Set a review date.
slide13

Link to above page (section 4 of the MCA on best interests)

#‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

  • Clear documentation is vital:

    • Of the holistic assessment
    • Of the condition that’s being treated by the medicine(s)
    • Of the indication for each medicine (i.e. what it is being prescribed for) is explicitly documented, and this information is available to everyone involved in their care.
    • Of possible precipitating factors and measures that help the person*
    • Of patient involvement
    • Of carer and family involvement
    • Of multi-disciplinary team involvement
    • Of the decision making process and rationale for any best interests decision(s).
    • Of the rationale for prescribing / not prescribing
    • Including review dates and evidence of reviews
    • Real time monitoring of the effect of the medicine(s), including any as required ‘prn’ medicines.
    • Documenting evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.

Information sources and links:

  1. Royal Pharmaceutical Society [RPS] (2021) A Competency Framework for All Prescribers  https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/competency-framework 
  2. Royal College of Psychiatrists – Faculty of Psychiatry of Intellectual Disability (2016) Psychotropic drug prescribing for people with intellectual disability, mental health problems and/or behaviours that challenge: practice guidelines. Document Ref: FR/IXD/09 http://www.rcpsych.ac.uk/docs/default-source/members/faculties/intellectual-disability/id-faculty-report-id-09.pdf?sfvrsn=55b66f2c_6

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed Feedback and views welcome, send them to carerightnow@gmail.com 

Steve is a retired nurse prescriber, former Head of Medicines and Prescribing for @MedicineGov , former Associate Lecturer at Plymouth University  and a former NICE Medicines and Prescribing Programme Associate.




Version 7   Dated 25.11.2024

Revision history:

25/11/2024

Out of date links removed, information sources updated, some text & links removed. Extra explanatory text added.

03/05/18

*Following feedback from parents & carers I’ve changed some wording and added some additional wording which puts the patient first. Thank you for the feedback.

12/12/2018

Updated with link to the RPS Competency Framework for all Prescribers, following feedback from readers.

09/01/2019

Updated to include reference to diagnostic overshadowing.

14/01/2019

Updated to include allergies, sensitivities adverse reactions and feedback from teaching sessions.

15/01/2018

Updated to include specific mention the Mental Capacity Act.

20/04/2019

Notes that medicines related option should only be considered if non-medical options have not worked. Minor amendments to text.

21/08/2019

Updated following feedback re: evidence base on prescribing combined antipsychotics. Point revised, new sentence and link added, ‘There is a limited evidence base for this type of prescribing.’

18/10/2021

Updated to include reference to the updated RPS Prescribing Competency Framework for All Prescribers.