Going for a listen when it’s time to talk

 After a few days off I returned to the team at my workplace today. There had been some happenings so I knew I would need to spend time catching up with other team members. In addition today has been called time to talk day, encouraging us to think about the power of small and act at a local level having conversations that concern our mental health. As usual today I issued invites to have an informal chat. These might have lasted a few minutes or as long as it takes.

I found myself wondering if I needed a different approach to the invites for these chats. Starting with the name ‘chat’, which to me involves joint talking. In a position of leadership and management of team members should I invite folk to a listen? I use listening with my colleagues as a way of checking how they are while trying to minimise using my voice. Asking questions comes into this process then letting the listening start. 

If appropriate I might offer an opinion or a story from my experience to illustrate a point. Such sharing does have its uses. The best bits come from listening, using all one has heard, and noting what’s been left out, to help the team member if help is what they want. 

So is having a listen what I should call it in my head, or out loud? Maybe just saying let’s have tea or coffee, or go for a walk is open enough, and the expected listening is the unspoken action? On reflection a good listen can make a positive difference, as I was reminded today when colleagues listened to me. For that benefit I’m very grateful. 

Doing things badly can be a good thing?

I have had an interesting week; work has been busy with the team doing good things for patients and each other. All very supportive and a joy that they can be trusted to get on with things.

I’ve had two task this week that needed delivering. One was a business case and the other an opportunity to deliver a 6 minute talk as part of a conference day on human rights in end of Life Care.

The business case would seem straightforward however getting the style right for the (NHS) organisation can be a challenge. Fortunately my boss has plenty of experience in our place of work and whilst I started it not very well I’ve submitted what’s been agreed is a much better version. Anxiety about how it might look and be received is lessened; taking the first step is the worst bit for me.

And that, I’ve just realised, is why blog writing regularly hasn’t been easy either.

So I was interested in reading the article by Olivia Remes that points to the science behind beating anxiety, and why doing something badly is a good idea.

This struck a chord with me; getting started is an act that I can successfully sabotage by myself. So reaching a finishing point (sending the business case for consultation, or posting a blog piece) becomes a cause for internal celebration.

The second task has been longer in development as I’d been invited to contribute to a quick fire afternoon session at the Sue Ryder hosted “Human Rights in End of Life Care” on 27th June. A 6 minute slot was mine, along with three others who are trainers like me. The slides were easy, the content came pretty easily too. It was the prospect of delivery that became a matter of anxiety. There was some rehearsal and having the slides safely loaded in advance were helpful strategies.

The night before was not good in terms of sleep and all that could have gone wrong in terms of travel added an extra layer of worry.

On the day the trip was fine and the venue was easy to find and had a nice auditorium. Even so there were nerves; I’m conscious that a poor presentation does no one any favours. As it happened my little contribution was kindly recorded on my iPad by another speaker. I can see I “immediately” a lot to begin with, and then had some trouble with the slides. I did get a hoped for laugh or two, as well as some serious points made. I could have done better (I believe) though I was told I’d done well.

Olivia is helpful in that she points out that doing something badly (or at least not very well) is a way to combat anxiety. So I’m reminded to be kind to myself; to trust the praise of others and to ignore the internal doubts that will lead to further anxiety.

And maybe there’ll be an increase in the frequency of my blogging?

Being a person-centred pin-up! Using my one page profile or #1PP

Going back to November 2014 I wrote about work, cancer and the power of support from friends who know me. It's about time I said more about recent events, including becoming a pin-up!
Before that, what about the cancer business? Well, further recent extensive biopsies are still negative; the relative trauma of the MRI felt easier. We watch and wait, keep taking the tablets.

What about work? I've had a fantastic time in the Quality team at Sue Ryder learning more, and being part of a diverse team whose complimentary skills and friendships have been invaluable. I was keen however to get back to a hospice based post, as that has always felt my true professional home. In the meantime I have kept up my interest in being person-centred, including updating my one page profile. You can find out more about the 1PP here via Helen Sanderson Associates.

Having been recently appointed Director of Patient Care at St Clare Hospice, Essex, I took copies of my #1PP on a pre-start visit and handed them out. The 1PP was greeted warmly and a volunteer happily demonstrated having read it by referencing my love of dark chocolate when we finally met. Towards the end of that visit a new colleague brought me a handwritten version of their 1PP that they had put together during the day. They were keen for me to know how best to support them and to know what is important to them. Of course I had to say they needed to find out what people appreciate about them too. Nonetheless I was pleased at the impact being so open was having.

As I write I have finished week one in the new role; checking with those I've met for the first time, they tell me they have all seen and read my 1PP. Being in a new workplace brings its own challenges such as finding your way about and who is in which office. One place I quickly found was the upstairs kitchen/copier room, where I can make drinks and pick up printing. It's been a good place to greet people too. It was only yesterday, day 5, that as I looked about the room in more detail that I realised a copy of my 1PP was pinned to the notice board! I was thrilled that a new colleague had taken the initiative; getting more 1PPs into place is the next task. Continuing the theme I have made sure I have made and delivered hand written thank you notes to those who have given me their time this week; on Monday morning I'll be taking the opportunity to use a person-centred approach to an important meeting.
Being a person-centred pin-up though was not quite what I expected, though I think it says much for the warmth of my welcome, and the energetic spirit of St Clare Hospice that it's become a reality.

The funeral of a friend who was a nurse

Working in palliative care, the end of life is a daily event, but today it touched me personally. I, and many others, attended a gathering and well attended reunion at the local Crematorium. We were there to remember our friend, boss, peer and co-worker. Of course there many family there too. Her husband had also worked with us. Jenni took the development of Willen Hospice, and its clinical services to a point where a 20 bed inpatient unit was complimented by all the community services with back up from incredible fund raising and retail support.
I know too that Jenni would play down her part, understandably pointing to the team effort involved.

Jenni had trained as a nurse, and went on later to manage a variety of services after leaving the hospice. Whilst care of the patients was at the forefront of her mind Jenni also had the care and development of her staff alongside this too. I think this is why so many turned up today, from all sections of the hospice, current staff and those who have moved on or been wise enough to retire. Many of the people there today came from Willen. I was lucky enough to have two bites of the cherry working there, both times Jenni took me on under her wing. In many ways these two appointments were critical to me in the development of my career, particularly in palliative and end of life care, and in taking me forward as a service manager. 

Whatever the role, Jenni had touched all these lives as well as all the lives of all those whom the Hospice has cared for. As such then the turnout today was a reflection of the esteem and affection we had for her. That a malignant disease should be the cause of her death at so young an age is another part of the story. 

Alongside that is her reputation for enjoying a night out. In the company of friends and co-workers the loudest laugh was hers. A love of gin, as well as other drinks if required, fueled many an evening. Of course Jenni loved her job and her family; she will be much missed.
Jenni leaves a significant legacy; people who continue to clean, cook and care for those who are frail and nearing the ends of their lives; those who have been encouraged to take chances, develop as people and as servants of those who need the care.
At a time when healthcare and nursing particularly are being frowned upon, and the NHS seems to be falling apart, I am proud to say Jenni was someone who taught us all how to do it right; how to enjoy work; and how to make a difference.  I am very happy to have known Jenni, though very sad now that she has left our presence. She was a light in our lives, and I look forward to carrying her legacy into the future.

Rethinking Implementation

This morning I had the opportunity to hear Dr Brian Smith http://www.pragmedic.com/ speak about the difficulties we face when implementing strategies, the big ideas organisations go for to take the business forward. The research Brian has been doing is leading to new thinking about why  implementation of strategies can fail.
The view is that a number of influences pay there part, not least the individual, group, organisational allegiances and alliances that exist.
It has made me rethink my approach to implementing our business ideas, as we strive to move forward in the challenging UK healthcare market.
I will be seeking to increase our skills at decision making and exercising discretion in planning.
We  be clear about who/what it is we are going after and what we are going to do to/for them.
There are some antecedents to over come, and individual commitment to test.
So long as our strategy is clear we are more likely to get there using a different approach than the usual one organisations use.
Time for implementing the re-think. Time for effective strategic achievement.

Time to Care, Dignity and Nutrition - a mixed result for nursing and management

This morning in the UK we awoke to the news announcing the publication of the CQC report Dignity and Nutrition inspection programme, see it at http://www.cqc.org.uk/_db/_documents/20111007_Dignity_and_nutrition_inspection_report_FINAL.pdf


The media focused on the poor practice and dubious standards the inspection team found, see  http://www.bbc.co.uk/news/health-15279796. The inspection teams were formed including CQC Inspectors, practising nurses and 'experts by experience' such as members of Age UK. I like that approach, the latter parts of the report explain how beneficial it was to the process and getting a relatively open response in areas under inspection. My own experience in the first Cancer services review conducted by the the original generation of the CQC line, the Commission for Healthcare Improvement (CHI) used nurses and Audit Commission staff. We didn't use patients to conduct interviews though there was work done with seeking their views. We are at last engaging those who are cared for in the process of inspection and evaluation of services. 
There were good practices in place though the consistency varied; it must be acknowledged too that some poorly resourced areas managed to meet the standards whilst others with more resources did not meet them. The report draws attention to the suggestion that mangers are not consistently addressing issues of poor performance (p13).


Alongside this are variations in the application of practice where some managers did not seem to have an accurate knowledge of what was happening, “When we asked about the red tray system there was a mixed response. Some senior nursing staff told us that the red tray system was in use but the junior nursing staff on the ward did not know what the red tray system was. They told us that they had never used it.” (p15).


Another quote was  “All the ward staff we spoke to on the stroke unit said they felt the unit was understaffed and the current levels were not appropriate to meet the needs of the patients.” (p13). 
What concerns me about these three examples is the theme of management competence. Inconsistency of performance should not be a problem if the managers understand how to address the issues and are supported in doing so. It is time to reclaim best practice - and encourage fellow nurses to speak up when poor performance is seen so it can be dealt with promptly.
Management by walkabout has been talked about in the past; it is one way to observe what goes on in your area of responsibility. It makes one visible to the staff, so they can speak to you as well as the people in your care. That would help improve reduce the dissonance between the presumption that those one manages are doing the right thing, and positively making sure they are doing the right thing. You stop looking quite so foolish as a manager that way. And the final quote about "all the staff we spoke to... " - there were presumably more than two (though this should apply even if only one) left me wondering about the support managers gave to staff to raise concerns and take them seriously. And why were the staff letting this go on without taking it further?
Somewhere managers have to be able to strike the balance that encompasses in the phrase 'the people in our care' not only the people who we are striving to help as nurses, but those in our employ for whom we also have a duty of care. Then we might have a better chance to get things right.

Reflecting reality - further learning from the Help the Hospice's conference

The previous two entries in this blog were made during the conference; then I got to the last day and it's time for the train and home, back to work, and all the reality one comes to expect.
What was the learning from the last day; what has been my learning overall?
The last Wednesday, 28th Sept 2011 started with reflections on experiences of commissioning from a hospice manager and a speaker from the London office of CAB, Helen Paris. The experiences shared were valuable and chimed with what I have witnessed. The experience of CAB as an organisation has been varied; not without pain at times was my impression. They are willing to share their experience and are already working with HtH to aid development of support that HtH can give to hospices.
I moved from that session to one about motivating people; David Smith ex ASDA spoke of his principles for getting high performance from those working for you. He reminded us that though our products are very different from a worldwide business, we all employ people and they are similar whatever the business we're in.  I found myself marking our place against the ideas he spoke of - it was useful reminder that though we're getting better there is still some way to go. 
The other part of the session was the CEO of ST Peter' Hospice Bristol, Sandie, talking about the challenges she faced when starting and finding the business needing reshaping in terms of relocation and closing one site. Her reflection was unflinching and at times so candid I was aware some found it too much. None-the-less with a certainty of purpose and perseverance the changes came about and progress has been made, including making savings along the way. For me it was the way that Sandie had to face unexpected demons (even in the local Waitrose) that left me thinking about how well should be prepared for change.
The last plenary featured Jessica Corner speaking about the challenges of cancer survivor-ship, and what that might mean for hospices in the futue, caring for those with cancer that becomes a chronic condition. Finally Jo Hockley led a for me a profound session around visuising the invisible in end of life care for those in care homes. Her experiences in her work led her to challenge us to look for the subtext of what was going on when someone was dying; listening for the 'spill words' as Terry Prachett calls them. 
And my final impressions? Well my reality is shared by others, and they seem to cope OK! The commonality and common sense well applied can make all the difference to the way we work and the results we create for those in our care, be they patients or members of the team delivering the care. There will be more; it will come from experimenting with ideas and suggestions that flow from the conference. Better still, it will come from sharing the learning and experience as we go along. 

Transformation for the future through trust

Another day has gone by at the Help the Hospices conference giving me more to think about. Faith Mwangi-Powell gave us a personal insight into strategic alliances and all the pitfalls and positives along the way. A key theme was trust in each other at personal and organisational levels. In the end the partners will share the risks and rewards of joint ventures; this links to Tim Harford's words of yesterday about taking risks - the small bet. Tim reminded us it was ok to make mistakes so long as we made good mistakes from which learning can take place. Faith echoed this saying we can make mistakes but we must learn not to repeat mistakes; either way we will benefit as organisations as well individuals.
Cooperation was a theme from Tom Hughes-Hallett (Marie Curie) and Julia Palca (Macmillan) - I was not so convinced that Macmillan get the importance of seeing other's viewpoint; Tom was honest and open inviting us to question and involve others in order that we can go on doing good things for our patients.

Inbetween these sessions was an absorbing workshop on personal mastery in leadership by Sally Watson and Jeff Jackson. It focused on the notion that our past is the most important resource in terms of recognising our leadership style and practice. We were encouraged to look back and share in confidence then consider how important it is to let go, and listen to what we can discover by removing the blocks we may have. (This is my simplified version of their slimmed down version of what they use so may not be completely accurate). Once we have done that we can discover new solutions that we can act on.
I felt it left us in place where we would have to trust ourselves; they argued by trusting ourselves and being ourselves we will be aware of the impact we have on others and lead to transforming the situations we face as leaders. 
Then the senior nurse managers met over lunchtime to look at ways to support and network amongst our peers; it is essential for the future, and there were encouraging signs of willingness to participate.

So a day of transformation - in reality and with potential to transform the future.

Different names, Same reality

Call it what we like work is work and the same behaviours cross our path; those with ideas and a willingness to experiment; those who fail to see that they are struggling; the sit and back see folk who contribute only silence and odd looks; those in a hurry and those who get by through asking the right question or raising a pertinent point, and saying no more.

I think anyone in UK health care will recognise a meeting I've been to today. All the above was there. This one happened to be at a PCT - while trying to adapt to the changes in the NHS swirling about them they are making an effort to find cost savings and improve the quality of service on offer to the people they're responsible for.

It's a quarterly meeting with a project overview role; there was an agenda set and sent out in good time; the reporting was long winded and difficult to follow as we had to ask for clarification of points. Only one reporter had made an effort to prepare - even then it was done by picking through a pile of papers others had sent in.
Progress is difficult to measure and actions hard to pin down.

Will this deliver the proposed changes and cost savings? I remain sceptical. Until the reality of performance in meetings, and the general performance of people in key posts is challenged I fear for the future. The reality is likely to end unsatisfactorily for all involved and only lead to calls for more change. Lets give time and energy to investment in people and their performance - get everyone speaking; get people competent to Chair meetings in place; have people understand the responsibility of preparing for meetings, and making an effort to participate.
No matter what the organisation commissioning health care in the future may be called, be it a senate, consortia, cluster or cynical (sorry - clinical) commissioning group, the reality is more of the same.
And that is a worrying thought.

Failing nurse leadership puts jobs at risk, or how nursing needs to do better

Three Nursing Times headlines today led to me creating the title for this blog; see https://mail.google.com/mail/?shva=1#inbox/12e7ad7e48c73a94

The United Lincolnshire Trust is taken to task for its poor record keeping, associated with poor standards of care. Where were the managers? What kind of compaints does this Trust get? It would be easy to pick on the front line staff - and they must be responsible for either actions or inaction that led to this situation. However someone should have been checking the quality of the care on offer, and looking for the evidence it was being deliverred. Nurse leadership would help with this; providing a framework for staff to learn and develop. It'll be the spring before the CQC reports - I'd put money on this saying nurse leadership is lacking, and the United Lincolnshire Trust have been tasked with making immediate improvements. I hope the managers are up to it. The staff will need support and opportunities to develop - I don't hold out much hope for that in the current financial situation.
Meanwhile NHS Trusts are still in a state of flux over nurse leadership and its importance - a survey has found areas where development of leaders takes place - but plenty of evidence leadership and management are being held back by financial pressures. The survey was following up after the Francis inquiry into Mid Staffs last year. 
My esteemed colleague Dave Dawes head of the Foundation of Nursing Leadership was quoted a saying: "It’s sad that nursing leadership has been identified as an issue in almost every [NHS] inquiry in the last 20 years.

“The same issues seem to come up again and again, and don’t seem to get any better.”

The Foundation is at http://www.nursingleadership.org.uk/index.php

With financial pressures building to squeeze education and development spending we are surely storing up trouble that will result in further failure at some future point. United Lincs Trust may have been spotted before it's too late and so avoid becoming a disaster - but can we be sure the CQC will always be there to catch the next oranisation in time?

And on the financial pressure theme - at the Pennine Acute Trust they are warning about 1,000 posts being under threat. Amongst other ideas they want to stop using temporary staff and redeploy permanent staff into new roles. I feel pressure coming on for those who may manage or have specialist skills; perhaps really good leaders who help mainitain good standards of care and maintain the delivery of a safe effective and appropriate environment in which the people of the Pennines can have their care.

At risk are not just jobs but standards of care and the reputation of nursing - all because we keep doing the same thing; not investing sufficiently in leaders and managers.

Care and compassion? Time to think and act.

Care and compassion?
I must start by saying  the Ombudsman's website itself deserves praise for its layout, clarity and ease of use.
This report from the Health Ombudsman's office is difficult reading for a nurse; however I feel it should be compulsory reading for all in the health care business; particularly those in training. Not only have the patients and families been let down; the behaviour of 'front line ' clinical staff and management alike have led to this situation. They have let their professions and colleagues down too.
I must acknowledge the good work that goes on within the NHS day by day; but the numbers of complaints the Ombudsman has to deal with leaves me wondering about the frequency with which health care professionals are getting it wrong.
Yes, nurse and doctors are getting it wrong too often - leading to standards of care that fall far short of best practice that are rightly exposed in the report.

The reasons may be varied - but unless staff speak up about pressures on them (e.g. staffing levels, poor practice of colleagues), using written reports copied to unions, there will be no evidence that they noticed the pressures and acted to bring them to the attention of managers and others who are responsible.
Whatever the reasons staff may have for poor standards - it would seem individual clinical staff are not applying the principle of putting the patient first; allowing themselves to be distracted from that tenet is where it begins to go wrong.
It can be forgotten that each of us may have others to whom we are important; the story of Mr & Mrs J shows that so well.
Even within areas of care (cancer and Palliative care) where so much has been written about good practice; education offered and expertise is available, that Mrs N and family went through what they did only serves to reinforce negative messages about the way people die - and support the argument for the need to introduce legislation allowing the opportunity to help those who wish to end their lives by assisted suicide, for example.

Such examples play right into the hands of those who will sensationalise all that is worst about health care; and management is no exception. When reading the Case studies http://www.ombudsman.org.uk/care-and-compassion/case-studies it is the poor response to the original complaint that leads to the Ombudsman being involved. Why is the NHS taking so long to get investigation, communication, and restoration through action right? An apology early on can go a long way to making people feel heard. Subsequent action is important too; making sure those involved know how serious the situation is; reinforcing the need to think at work - to work on your thinking too - so that we all remember who to put first as we go about our work.