Martin Hogan

Systemic transparency: ‘A fish rots from the head down’ The saying ‘a fish rots from the head down’ describes how ineffective management and leadership can have a huge, detrimental impact on our systems and teams. It can be the root cause of an organisation’s failure and demise. Applied in this case, the government would be the head of the fish and the NHS the body. From the beginning of this pandemic it has been clear to us in the NHS that we haven’t been informed of truths regarding personal protective equipment (PPE), testing and expectations of the health service. Transparency around this would have led to a safer working environment for staff and patients and reduced the risk of harm. If, for example, we had been made aware that additional PPE wouldn’t be available for five days, plans could have been implemented. Clearer ideas could have been put in place with regards to social distancing at work. Clinical leads, chief exec and managers could have better supported the care of their staff, who in turn could have provided better care for their patients. Those poor, ill-informed decisions at the top make it very difficult for those of us further down the fish. This style of leadership leads to reduced levels of engagement by staff, deconditioning of resilience, increased sickness and poor and unsafe staffing levels. We need more transparent communication from the government for patients/the public too. Short and sharp facts. Posters. Avoidance of jargon and mixed messaging during briefings. For example, people were informed they must self-isolate for 14 days if they had recently travelled in a zone 2 at-risk country, however, shortly after the announcement the advice changed to seven days of isolation. This confusion has an impact on infection control and the spread of the virus. Which in turn, impacts our health service and those of us working on the front-line. Raising safety concerns We all knew the guidelines for PPE was substandard and putting us and our loved ones at great risk. Feedback on lack of appropriate PPE fell on deaf ears. There wasn’t clinical time to write Datix reports whilst looking after acutely unwell patients. There was of course the option to complete these outside of working hours but this was not done, due to staff burnout. Fear and loyalty to managers, clinical leads and colleagues also prevented people from escalating concerns. The PPE guidelines differed every shift I had. This of course was due to the shortage. I started off with a surgical mask, plastic apron and gloves and ended my time on this unit with a visor, FFP mask, gown, hair cover and specialist gloves. This alerted us all to the fact we hadn’t been looked after. We had been put at risk. I asked my manager in week four why, as we had been put at risk/exposed, were we not being offered a test. She quoted the policy - “only if you’re symptomatic”. Eventually government standards introduced testing of front-line staff. But there was a catch.... only intensive care and resuscitation staff. I politely challenged this, given I was treating patients with continuous positive airway pressure (C-PAP) prior to and post Intensive Care admissions. Again, this was met with disdain and I was reminded that, “we’re all in the same boat”. Colleagues and I discussed our anger and disappointment with the clinical lead. They agreed with us but felt their hands were tied, as did their lead. We felt that perhaps being interviewed by the news would help our cause. This was flatly rebuked…the communications team would strongly advise against it. Burnt out and gagged we carried on. PPE improved but to this day there has been no offer to test. We need to promote a working environment which allows staff to meet with leaders and to ask questions. For everyone to be given opportunity during work time to debrief and discuss concerns around things that aren’t working or aren’t safe. Staff mental health Early on, the tragic suicide of an Intensive Treatment Unit (ITU) nurse drew attention to the fact that staff mental health was at risk. I believe that nationally, this issue should have been spoken about more, and much sooner. Locally, our psychiatric and wellbeing teams put fantastic support systems in place for staff; virtual clinics, leaflets and regular one-to-one meetings. This had a huge impact. As a team, we utilised whatever we could find. I also instigated a ‘time to talk’ system during work, to debrief as a group. Maslow’s Hierarchy of Needs model could have been utilised brilliantly at the rise of the pandemic. It would have allowed us to be aware of the detrimental impact it could have on front-line staff and what to expect. It would have helped us to begin preparation of self-care. The term ‘corona coaster’ started as a funny meme but quickly became an important adjective to my team and patients. It is used to describe the emotional ups and downs during the pandemic. The shock of hearing 1000 people died in one day, mixed with the panic of ‘how will I fill my day off?’. Giving the shock, grief and stress a name allowed for myself and colleagues to relinquish self-blame from these feelings and to identify the cause. After action review We all know that one of the most effective developmental tools while working on the front-line is to learn from mistakes. What can we take from this? What went well/ not so well? After action review can give a team, trust and/or area time to analyse flaws. The ‘time to talk’ system enabled us to reflect on tasks or areas of concern. For example, “today when Mr X become quickly unwell, I went to help him and he coughed in my face. I didn’t feel I had the correct PPE…” Opportunity to do this with colleagues was hugely powerful and important prior to us going home to our loved ones, who understandably feared our contaminated return. Talking and listening to relatives Supporting patients’ families over the phone became a large part of my role as a nurse looking after people effected by COVID-19. Many of them benefited from having open discussions surrounding their fears and concerns. Mr Z for example, stated he was worried his wife may die, but didn’t want her home yet as he didn’t want to die. This was a very frank and realistic fear. Giving time to talk and listen has proved to be an incredibly important in understanding everyone’s safety concerns. Final thoughts I hope that by sharing our experiences and learning from this challenging time, we can continue to identify how to build a culture that promotes patient and staff safety. Collaboration between managers and front-line workers and capturing the insight of both patients and staff and will be key to this process. Stay safe. Be kind.

Key recommendations Ask the patient if they would like to have the conversation and how much information they would want. All healthcare professionals reviewing patients with chronic conditions, patients with more than one serious medical problem or terminal illness, should initiate shared decision making including advance care planning in line with patient preferences. Conversations about the future can and should be initiated at any point. The conversation is a process not a tick-box, and does not have to reach a conclusion at one sitting. Be aware of the language you use with patients and those they have identified as being important to them, and try to involve all the relevant people in agreement with the patient.