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.

Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.

Managing neuropenic sepsis My role as an acute oncology CNS is to improve cancer services. Part of my role is the treatment and management of neutropenic sepsis. Neutropenic sepsis is an oncological emergency following chemotherapy, whereby the patient’s immune system has been depleted by the treatment for their cancer. The body’s natural defense system has been wiped out from the cytotoxic drug, making the patient more susceptible to infections and, therefore, sepsis. The national standards for treatment of neutropenic sepsis are: Early warning symptoms: call the chemotherapy 24-hour hotline, manned during the day by the chemotherapy nurses and out of hours by the oncology ward nurses who are trained in giving advice to patients on chemotherapy. A high or low temperature is normally the worrying symptom. The UKONS 24 Hour Triage Tool: an algorithm used to support the nurses' advice. The patient is then advised to attend A&E or, if acutely unwell, call an ambulance. Once the patient arrives in the emergency department, the national standard 'door-to-needle time' is to receive antibiotics for suspected infection within 1 hour. How we improved cancer patient safety Monthly audits showed that for 65% of all patient's suspected to have neutropenic sepsis, none received appropriate treatment. This was usually because of contra-indicating admission i.e., came in with left flank pain, or poor triage. An alert card is given to every patient receiving cancer treatment for them to present to the emergency department, alerting everyone that the patient is receiving cytotoxic drugs and advice on how to manage this. The audits I performed highlighted that the patients who presented to the emergency department out of hours did not receive appropriate antibiotics in time. This correlated to no acute oncology nurse present. These findings led to us changing our practice to a nurse-led service. We asked the chemotherapy hotline to alert us to anyone they had advised to attend the emergency department. This allowed us to meet the patient at the front door, and to support and arrange for doctors and nursing staff to give the correct management in time, expediting and eliminating error. The errors I speak of were never incompetence; they were human error. One nurse to 20 unwell patients in the emergency department is unsafe. The emergency department is the frontline in all acute trusts. In the trenches, fantastically skilled but overworked and under-valued. This was noticed by the acute oncology team. I derived that we as a team needed to change our working hours. 10 hours days, 4 days a week. Excluding weekends, where the oncology registration would stand in for the acute oncology service. This worked on days where neutropenic sepsis admissions were many, but still did not support the out of hours admissions. Teaching and training were my next focus. I set up a trust-wide acute oncology conference where I invited all trust staff to attend, inviting guest speakers, experts in their field, to teach and train nurses, doctors, the receptionist, anyone who would meet a patient on cancer treatment. We trained emergency department nurses to be able to prescribe and administer the first dose of antibiotics to ensure the door-to-needle time less than 1 hour was adhered to. Training empowered the emergency staff. Training is investing not scolding. Following these changes, our monthly audit numbers went from 65% to 80–90% over the course of 3 months, which showed a huge success. However, then January came, ambulances queuing down the hill from the emergency department. 345 admissions with only two beds within the trust. 25 staff shortage. Door-to-needle times became 3 hour rather than 1 hour. Our team consisted of three CNS to cover the acute hospitals with emergency departments. 50 referrals a day predominately for new diagnosis of cancer. Door-to-needle times on audit were at an all-time low of 25%. The worst I had seen it. Look at the contributing factors: 25 staff nurses down, huge demand on admissions and beds, limited capacity to review patients. During this month, acute oncology CNS predominantly lived in the emergency department, prescribing and administering the antibiotics ourselves to ensure safe practice. This did not come at a cost to the rest of our service and ensured patient safety. It dramatically improved our door-to-needle times. Acute oncology CNS are a necessity and, I personally think, the unsung heroes of an acute trust. We can prevent hospital admissions and avoid delayed discharges, freeing up beds and supporting and advising doctors to investigate patients appropriately and safely. Why I love my role I enjoy my role. It is a rewarding role. I have had the privilege to meet and work with the most beautiful people in the most harrowing of times. The worst times. But it is worth it. Meeting someone who has been in pain and suffering for 3 months at home who has come into hospital because the pain had got to much. They are aware something is wrong but isn’t sure what. Breaking the bad news that this is a cancer and having the time and resources to support that patient and their family. Knowing I am making a difference. Even when the outcome is that this person is not fit enough for further investigations or would not be safe enough to have chemotherapy, but advising them that the main focus of care should be symptom management and palliative care to ensure quality of life. To feel that I have made a difference and, more importantly, to hear that I have. Ensuring patient safety through diagnosis to treatment and to the end of life care. Something we must not overlook the importance of. Although acute oncology CNS is not as well-known as critical outreach nurses or heart failure nurse specialists, it is equally important and necessary. A case study I would like to end this blog with a case study of a patient named Brendan*. Brendan was a 24-year-old man who presented with a 3-day history of right upper quadrant pain. Clinically jaundice. 10/10 pain. Unable to move. He had an ultrasound in the emergency department on Wednesday pm. He was referred to acute oncology in light of suspicious radiological diagnosis of cancer. Within 48 hours, acute oncology had reviewed him and broken the bad news to him that he had cancer. Cancer of unknown primary. The young man was discharged from hospital. We ensured a support service in system (given him our CNS number), managed his pain, arranged further investigations and discussed in a multidisciplinary meeting the best site for biopsy. We booked the biopsy and arranged a clinical appointment 1 week later with our acute oncology consultants. We called this young man every day for symptom reviews and holistic support for him and his family. He received chemotherapy within 3 weeks of diagnosis and is alive to this day, with a cancer that is rare and difficult to treat. Having only had six hospital admissions. This is why acute oncology are a necessity to any hospital and community service. *Name has been change to ensure confidentiality.