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“There's no such thing as the unknown—only things temporarily hidden, temporarily not understood.” James T. Kirk, Captain, Starship Enterprise. Star Trek, Season 1: The Corbomite Maneuver. Leading a large enterprise isn’t easy. Vision, compassion, humility, curiosity and adaptability are required attributes for those in charge to keep moving forward during times of relative calm or uncertainty. The stress and tragedy that accompanies catastrophic events can reduce the resolve and effectiveness of even the most accomplished leaders. Unprecedented large-scale situations, such as the Hurricane Katrina landfall or the September 11th terrorist attacks, reveal gaps in understanding that may not have been apparent before the disaster. These blind spots can dismantle the reserve of a leader and their team to culminate in poor decisions, inaction and organisational dysfunction. The COVID-19 pandemic is such an event. Rules are being mindfully adjusted to respond to the litany of process, clinical, financial and political disruptions healthcare workers must grapple with as they face the uncertain conditions of their patients, communities and themselves. It is incumbent on leaders to create stability by addressing these unknowns. Leaders within hospitals, social care organisations and within the public health spectra need to make immediate process adjustments to optimise effort, realise opportunities for improvement and learn to be resilient. They need to arrive at understanding while simultaneously managing challenges that emerge from the strained system to keep their enterprise on track. They need to do this by paying attention to safety culture, transformation and innovation, and will need tools and resources to do so. Leadership must build a culture to keep patients and workers safe. Leader’s communications and actions are core to the implementation of safe working conditions to provide the best care possible during a crisis. Yet, a Gallup poll of US healthcare workers found a lack of understanding of their organisation’s COVID-19 plan and lack of belief that safety policies in place will support their safe return to work. To address this gap, experts recommend leaders three steps to a better safety culture: use formal and informal mechanisms to explicitly communicate what the organisation is doing to keep staff informed and safe during the pandemic enlist their managers to implement policies, create opportunities to align the work of management and hold managers accountable to implement and sustain current practice and procedure talk to their people. Keeping an open dialogue through the use of established mechanisms such as ‘rounding’ can solicit insights and raise concerns to enhance the safety of teams and patients. Leadership must see opportunities to transform systems: COVID-19 has presented leaders with immense responsibility to act, adjust quickly as required and use those process changes to improve the overall system of care post-pandemic in preparation for the next unprecedented challenge. Geisinger Health System leaders in their article, 'How one health system is transforming in response to Covid-19' share the experience of designing their emerging COVID response to reliably innovate rather than only react. Leaders examined core system business concerns such as pharmacy and information technology by bringing together multidisciplinary groups that dismantled silos. Teams worked together using scenario planning to fully consider how restoring care processes, entering new work phases, preparing for the second wave and restoring financial viability would affect patients and employees. Leadership must use evidence and collective knowledge to adapt: The Journal of Public Health and Management Practice shares recommendations for leaders to meet COVID-19 stressors successfully. The article suggests leaders communicate well, be decisive, lead without hierarchy, remain proactive and take care of themselves to protect others. For example, to lead across a system seek expertise from a variety of organisational and environmental elements. Working with government officials, staff and peers can form collaborations, solidify shared purpose and distribute responsibility to serve a community well in crisis. Public health is a core partner in understanding how to guide, motivate and inspire change to enhance a collective response to COVID-19 and upcoming health threats. Clinicians in patient-facing leadership roles also exhibit these behaviours as their roles shift to manage crisis. The perspective of a New York cardiologist leading a COVID-19 infections disease service illustrates how the transfer of tacit knowledge around deliberate leadership observed daily while coordinating the service shaped his views on leadership and his ability to lead. Being emotionally available was a core characteristic that helped to express grief, exhibit vulnerability and openly share concerns, giving the experience the humanness it needed. This was important not only in his ability to mature as a leader but to demonstrate the empathy needed to get his team through the challenges at hand. James T Kirk knew how to lead. He sought consensus, learned from mistakes, yet acted as necessary to keep his crew safe, engaged and aligned with the organisational mission. He sought partners across the federation as needed. Kirk could be firm, decisive, yet empathetic. Have health leaders done similarly to protect staff, patients and the community, while gaining experience during COVID-19 to apply over time to enrich the care system at large and boldly go to a better, safer future?

Myths of pain: Myth 1: Pain meds compromise the abdominal exam. Myth 2: Treatment of pain will compromise a patient’s decision making capacity. Myth 3: Opiophobia: The fear of addiction Myth 4: She's not in pain! I just saw her sleeping! How can we improve? First: Stop saying that it’s not you. It is you! You suck at managing pain. Perhaps not in everyone, but you’re definitely mistreating someone. Once we accept this fact, we may become cognizant and then able to improve our practices. Second: Educate thyself. Tintinalli’s actually has a whole chapter on acute pain management. Studies show that short training sessions led providers to give more analgesia with improvement in patient satisfaction (5). Third: Simply ask. Ask your patients if they have pain and ask them if they want pain medication. Fourth: Don’t get caught up by stupid myths. Your patient is in pain, treat him! Last: Do not give in to the Great Opiophobia! We are emergency physicians and we aren’t afraid of anything!

Prerana Issar is the Chief People Officer of NHS England and NHS Improvement. She was appointed in February 2019 to this post, which was created after senior leaders in the NHS and Department of Health and Social Care realised that a new approach was needed to a number of serious workforce issues which had become apparent. Among these is the complex, and hugely important, issue of speaking up (sometimes referred to as whistleblowing or raising concerns). Prerana recently retweeted a message from NHS England and NHS Improvement that "It's so important (for NHS staff) to feel able to speak up about anything which gets in the way of patient care and their own wellbeing".[1],[2] She is absolutely right... in principle. She is right to point out that NHS staff have both the right and the duty to speak up about problems like this, as is spelt out in the NHS Constitution[3] and professional codes of conduct for healthcare professionals.[4],[5],[6] The problem is that in practice, as an unknown but substantial number of NHS staff have discovered to their cost, their careers may be at risk if they do speak up as is evident from almost all the replies to both tweets.[1],[2] There is a sad pattern of disciplinary action being taken against staff who have, in good faith, raised concerns in the public interest. Even though their motivation in speaking up in the first place is to improve patient care, they discover to their astonishment that they are considered to be troublemakers for having done so. A depressing cycle of suspension, isolation, unfair dismissal, denigration and blacklisting of the person who has spoken up is often played out, whilst the original concerns and their validity are covered up. What a waste of valuable resources. The existence of such hostility to staff who have spoken up is evidenced in the 2015 report of the Freedom To Speak Up (FTSU) Review: "an independent review into creating an honest and open reporting culture in the NHS".[7] The press release which accompanied its publication announced that the review "identifies an ongoing problem in the NHS, where staff are deterred from speaking up when they have concerns and can face shocking consequences when they do. The review heard stories of staff that have faced isolation, bullying and counter-allegations when they’ve raised concerns. In some extreme cases when staff have been brave enough to speak up, their lives have been ruined".[8] The FTSU report calls for "an overhaul of NHS policies so that they don’t stand in the way of people raising concerns with those who can take action about them" and sets out "20 Principles and Actions which aim to create the right conditions for NHS staff to speak up". The principles are divided into five categories: the need for culture change; improved handling of cases; measures to support good practice; particular measures for vulnerable groups; and extending the legal protection.[7] In theory the law protects whistleblowers, but in practice, as a procession of disillusioned NHS staff who have experienced reprisals from their employers after speaking up have discovered the hard way, it does not. Employment tribunals are an alien environment for most healthcare staff. Case after case has shown that they are woefully ill-equipped to deal with precipitating patient care issues, in which tribunals appear to have little interest. Even when NHS staff are, against massive odds, found to have been unfairly dismissed after raising concerns in the public interest, the so-called remedy they receive almost invariably amounts merely to paltry financial 'compensation'. These are monetary awards that generally come nowhere near compensating for the full financial consequences. The adverse impact of this lack of protection for whistleblowers is not only on the individual but also includes the chilling effect of deterring other staff from raising concerns and the consequences of cover ups. True overall costs to the NHS, patients, whistleblowers and taxpayers of retaliation against staff who speak up are very much greater than financial costs alone. Staff surveys show that nearly 30% of NHS staff would not feel secure raising concerns about unsafe clinical practice.[9] Over 40% would not be confident that their organisation would address their concern if they do speak up.[10] There is still a lot to do in this area, as has been brought to the fore by recent reports of hostile responses by some NHS organisations to staff who have raised serious personal protective equipment (PPE) concerns affecting patient safety and health of themselves and their families. To be fair, serial staff surveys show a marginal improvement in the percentage of NHS staff who agreed they would feel secure raising concerns about unsafe clinical practice, up from a disturbingly low 68.3% in 2015 to 71.6% in 2019.[9] And a further tiny improvement in the percentage confident that their organisation would address their concern, up from an even lower 56.2% in 2015 to 59.8% in 2019. Viewed from the perspective of NHS whistleblowers whose careers have been wrecked after speaking up these are painfully slow rates of improvement. Bearing in mind widespread reports of PPE shortages, and warnings to NHS staff not to make a fuss about this, it will be interesting to see whether this glacial pace of change in speaking up culture is maintained when the results of the 2020 survey are available. Based on experience in the last two years, we can expect another prolonged FTSU publicity campaign in the month preceding the annual autumn NHS staff survey. The NHS Interim People Plan, published in June 2019, refers to development of a focus on whistleblowing and speaking up. It highlights the need for inclusive and compassionate leadership so that all staff are listened to, understood and supported, and the need to do more to nurture leadership and management skills of middle managers.[11] The original aim was to publish a full, costed NHS People Plan by Christmas 2019,[12] building on the interim plan, but this was delayed by unforeseen events, including a change of government, general election, Brexit ramifications and now the coronavirus pandemic. The interim plan makes clear the need to embed culture changes and leadership capability in order to achieve the aim of making the NHS "the best place to work". There is much to do, and I wish well to those who want to make it safe for staff to speak up, but they must be under no illusion – there is a long way to go – and this will take more than an overhaul of NHS policies. I hope to develop these themes in future postings to the hub. Comments welcome. References NHS England and NHS Improvement tweet, @NHSEngland, 15 May 2020, 6:35pm. Prerana Issar tweet, @Prerana_Issar, 15 May 2020, 6:47pm. The NHS Constitution for England. Updated 14 October 2015. Nursing and Midwifery Council (NMC). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2015, updated 2018. General Medical Council (GMC). Good medical practice: The duties of a doctor registered with the GMC. 2013, last update 2019. Health and Care Professions (HCPC). Standards of conduct, performance and ethics: The ethical framework within which our registrants must work, 2016. Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS. Report by Sir Robert Francis QC, 11 February 2015. Press release: Sir Robert Francis publishes his report on whistleblowing in the NHS, 11 February 2015. NHS Staff Survey 2019. q18b: % of staff agreeing or strongly agreeing with the statement that: 'I would feel secure raising concerns about unsafe clinical practice'. NHS Staff Survey 2019 q18c: % of staff agreeing or strongly agreeing with the statement that: 'I am confident that my organisation would address my concern'. Interim NHS People Plan, June 2019. https://www.longtermplan.nhs.uk/publication/interim-nhs-people-plan/ NHS People Plan overview, 2019.

The SPSP website has many tools, resources and useful links, including: Patient Safety Climate Tool Patient Safety Climate Tool Guidance SPSP-Mental Health Measurement Plan

This web page includes: Films The framework Community Breaking bad news Ceilings of treatment Resources Evidence-based advice for difficult conversations, by Professor Ruth Parry, Loughborough University Poster and sketch note Telephone call checklist

This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review: 1. What is a work procedure? 2. Ensure a procedure is needed 3. Involve the whole team 4. Identify the hazards 5. Capture work-as-done 6. Make it easy to follow 7. Test it out 8. Train people 9. Put it into practice 10. Keep it under review. An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.

The free version of Hospify is available right now and is in daily use at over 150 clinical sites around the country including London North West University Healthcare Trust, County Durham and Darlington, University Hospitals North Midlands, Frimley Park and Lincolnshire Community NHS Trust. Hospify is also backed by Innovate UK, Wayra Velocity Health (in partnership with Telefonica and MSD Pharmaceutical), Kent Surrey Sussex AHSN and the UNISON and Managers in Partnership Unions. A premium version of Hospify specifically designed for healthcare teams is also now available. Called the Hospify Hub, it features an online admin portal for onboarding staff, a web app that syncs with users’ phones, broadcast messaging/paging with document attachments and a survey and data collection tool. Please email info@hospify.com for more details or visit hub.hospify.com to set up a Hub and give it a try for yourself.