Lectures for THP

Medical Professionalism: “Values, behaviours and attitudes that promote professional

relationships, public trust and patient safety”

Royal College of Physicians (UK) Definition

Patients’ must trust their Doctors with their lives and wellbeing.
“A set of Values, Behaviours and Relationships that underpins the trust the public has in
doctors”

Irish Medical Council Definition

“set of intrinsic values expressed as extrinsic behaviours which justify the trust between
patients and doctors and between the public and the medical profession”
3 Pillars of Professionalism:
1. Partnership: Doctors working together with patients and colleagues toward shared
aims and with mutual respect. Patient-centred care • Working together, trust,
advocacy
2. Practice: Behaviour and values that support good care. It relies on putting the well-
being of patients first. Caring • Confidentiality • patient safety • Integrity • Self-care •
Practice management • resources
3. Performance: Behaviour that provide the foundation for good care. Competence •
Reflective Practice • Role models • Teaching medical students and doctors to practice.
Integrity: Patients must be able to trust their doctors to be honest, and to carry out work in
the interest of patients, in line with professional values. Colleagues must be able to rely on
you to be truthful and to act in patients’ best interests.

Honesty: treating patients fairly, acting in good faith, and making decisions about treatment
without discrimination. Honest communication.

Ethics: Building trust by role-modelling ethical behaviour

principles:
 Autonomy: Patient’s right to determine their own healthcare.
 Justice: Distributing the benefits and burdens of care.
 Beneficence: Doing good for patient.
 Non-maleficence: Making sure you are not harming the patient.

Working in Partnership:
 Working together with patients and colleagues toward shared aims and with mutual
respect.
 Trust; Patient-centred Care; Working Together; Good Communication;
Advocacy/support.
 Where disagreements arise, you should try to resolve them, with respect.
 The primacy of patient welfare: altruism, trust, and patient interest
 Autonomy: Be honest with patients and educate patients to make decisions. It is the
patient’s right to make their own decisions about their health.
 Social justice: addresses physicians’ societal contract and distributive justice.

Self-Care : You have an ethical responsibility to look after your own health.
Doctors are entitled to good support when they suffer. However, they should make sure that
the condition of their own health does not cause patient harm. If there is a risk to patient
safety, you must inform the relevant authority without delay.

Reflective Practice:
“the process whereby an individual thinks analytically about anything relating to their
practice with the intention of gaining insight and using the lessons learned to maintain good
practice or make improvements where possible”.
 Developing insight to improve standards of care.
 Focus on feedback and descriptions of what you have learnt/understood.
 Reflective practice includes formal and informal reviews.
 FORMAL: audit and outcome data
 INFORMAL: How personal values affect communication and care of patient.

Quality Improvement (QI)

Is the combined efforts of everyone to make changes that will lead to
• better patient outcomes
• better care
• continued development and supporting of staff in delivering quality care

Evidence Based Practice

 conscientious(wishing to do one’s work thoroughly), explicit, judicious and
reasonable use of best evidence in making decisions about care of patients.
  EBM integrates experience and patient values with the best available research
information.
 EBM is a process of life-long, self-directed learning in which caring for our own
patients creates the need for clinically important information about diagnosis,
prognosis, therapy, and other clinical and health care issues.

CULTURE OF PATIENT SAFETY

 Providing medical treatment involves some risk. However, you should make sure that
treatments you provide are safe.
 Adverse events may still arise. Adverse events are events that result in unintended
outcomes for patients as a result of interventions, or the systems used in managing
patient care.
 If an adverse event occurs, you should make sure its effects are minimised
 If you are involved in an adverse event, you should report it, learn from it and take
part in any review of the incident.

Bullying is defined as offensive, intimidating, insulting behaviour, a misuse of power

through means that humiliate/injure the person to whom it is directed.
Bullying is destructive whereas effective supervision is developmental and supportive.

Harassment is unwanted conduct related to sex, gender reassignment, race/ethnic origin,

disability, sexual orientation, religion, or age:
• Has the purpose of violating a person’s dignity creating a intimidating environment for
person

Disruptive Behaviour: any behaviour that shows disrespect for others, or slows the delivery
of patient care.
bullying, abusive language; • Arguments; • violence; • Comments that may be perceived as
harassment; • Mocking; • failure to respond to calls;• Failure to work with others.

High-stress specialties (surgery, obstetrics, cardiology) most prone to disruptive behaviour.

Overall 4% of health care professionals engage in disruptive behaviour.
Bad Behaviour can undermine a culture of safety.
Medical Error Third-Leading Cause of Death US.

Not all behaviour which seems inappropriate is disruptive, e.g. Healthy criticism •
Making a complaint to an outside agency • Testifying against a colleague • Good faith

PROFESSIONAL MISCONDUCT
Conduct which doctors consider disgraceful; and conduct connected with doctor’s profession
and concern that it has fallen short by omission/commission of the standards of conduct.

Poor Professional Performance: failure to meet the standards of competence (knowledge or

skills or both) that can reasonably be expected of medical practitioners practising medicine of
the kind practised by the practitioner

Complaints
• Stage 1: Investigation by PPC- Preliminary proceedings Committee
OUTCOMES:
 No further action
  The complaint needs to be referred to Council’s professional scheme
 Resolve by Mediation : Alternative Dispute Resolution (ADR), considered if:
complaint does not need referral to FTPC* Mediation can only be carried out if both
parties agree
 Refer to Fitness to Practise Committee(FTPC)
Stage 2: FTPC – fitness to practice committee (three people), held in public, a legal advisor
hears evidences and makes findings.
OUTCOMES:
No findings vs Finding—refer to sanction
• Stage 3: Sanction
 Admonish: which means to reprimand firmly
 Advise.
 Censure: criticise strongly
 Conditions: impose a sanction whereby conditions are attached to a doctor’s
registration, including restrictions on their practice
 Undertakings: request that a doctor undertake not to repeat the conduct
 Transfer: transferring a doctor’s registration to another division
 Fine: up to €5,000.
 Suspension: suspend a registration for a defined period
 Cancellation of a doctor's registration: erasing the doctor from the medical register
and withdrawing the doctor's right to practice medicine in Ireland

Learning Health Systems:

 Have leaders who are committed to continuous learning and improvement.
 Systematically gather evidence in real-time.
 Employ methods to improve decision-making.
 Promote the inclusion of patients as vital members.
 Capture data to improve care.

The Task of Medical Education: Definition

“To shape the novice into the effective practitioner of medicine, to give him the best available
knowledge and skills, and to provide him with a professional identity so that he comes to
think, act and feel like a physician.”

Professional Identity Formation: Definition

“A representation of self, achieved over time during which the characteristics of the medical
profession are internalised, resulting in an individual thinking, acting and feeling like a
physician.”
- Transformation
Socialisation: process by which a person learns to function within a particular group by
internalizing its values and norms.
- Role models, mentors and coaches • Experiential learning
- Peripheral Participation to Full Participation

Role Models “people we can identify with, who have qualities we would like to emulate and
are in positions we would like to reach”
ROLE MODELS- observational learning
 Learning by observation of behaviour.
 Attention
 Retention: we must take mental image and convert into actual behaviour
 Reproduction.
 Motivation: only effective if motivated to produce the behaviour themselves
Andragogy: helping adults learn- teaching adults

Situated Learning Theory

Knowledge is situated and influenced by activity, context and culture in which it is used.
Cognitive Apprenticeship (Modelling, Scaffolding, Fading, Coaching)
Collaborative Learning and Problem-Solving
Reflection
Practice
Personality Traits (Selection)
The Hidden Curriculum: the informal curriculum and part of our unconscious learning:
• How real doctors act in the real world
• Behaviour is infectious, adopted and perpetuated
• Cycle of cultural reproduction: students become doctors and teachers
• Role models are key
Functions in an unconscious manner, values are often invisible because they are taken for
granted
Remain unnoticed until something unexpected happens

Medical students are hypersensitive readers of the new environments, thus want to “make
sense of things” • students move deeper into the culture of the group they seek to join, they
accept and become desensitized to the inconsistencies that once grabbed their attention, they
“see less” as more and more of their surroundings become taken for granted.
- Important that what is taught in undergraduate is not “undone” by behaviour
witnessed on the clinical wards
- Positive role models for professionalism are important
- One does not want two sets of curricula: a formal ideal version and a pragmatic real-
life version

Curricula: Definition
 Formal curricula: What a school formally states its learning objectives
 Informal curricula: unscripted and ad hoc teaching that occur outside of the formal
curriculum (e.g., during ward rounds). Can be consistent/inconsistent with formal
curriculum. E.g. “the rules say this is how you do a procedure, but everyone knows
(around here) that the best way to carry out the procedure is this other way.” There is
nothing hidden here- Everyone is quite aware both of the formal and the “other” way.
 Hidden curricula: lessons, that are embedded in a school’s structure and culture but
not intended to be taught. May be consistent/inconsistent with curriculum.
 Null curricula taught through omission—for example, when something that is not
mentioned in class -students conclude that it must not be important

Community of Practice: Definition

“a social network of individuals who share an overlapping knowledge base, focused on a
common practice”.
Transitions: Definition
“Limited time in which a major change occurs, that results in transformation”
intense learning periods
Transition is the process of change from one form, state, style or place to another.

Unprofessional Behaviour Medical Students

Failure to engage • Dishonest behaviour • Disrespectful behaviour • Poor self-awareness.
“When students do not demonstrate professionalism, they should not be allowed to graduate
with a medical degree even if they demonstrate satisfactory academic outcomes”
Medical Schools must ensure students have: • Knowledge of professionalism • Attributes of
professionalism • Have policies to define and address Unprofessionalism

Passive Aggressive Behaviour:

Give Backhanded Compliments • Play the Victim • Procrastinate • Exclude People • Keep
Score • Sabotage • Stubborn • Say Yes, When they mean no • Push Your Buttons • Silent
Treatment • Sarcastic

Clinical Learning Environment: Definition

social interactions, organizational cultures, and physical and virtual spaces that shape
participants’ experiences and learning.

CLE: Tomorrow’s Doctors (GMC)

The report highlighted problems such as bullying, discrimination, harassment, the presence of
poor role models, bringing the enterprise of clinical learning environments to attention.

Caring when treating patients: showing compassion, kindness and consideration to patients
and family, and making sure to meet patients’ needs
Compassion is the feeling, when a person is moved by the distress of another, and desire to
relieve it; pity that inclines one to spare.

Dignity-You must always treat patients with respect.

Equality-You should not discriminate.
Personal relationships -maintain professional relationships with patients, respecting privacy.
Relationships with colleagues- behave respectfully towards all staff in the workplace.
Teaching medical students is vital to the continued provision of safe healthcare.

Guideline for Medical Schools Ethical Standards • Appropriate Behaviour

Irish Medical Students are subject to the disciplinary procedures of their Medical School.

Duties of a Medical Student

General Medical Council (GMC) and Medical Schools Council (MSC) have published
guidance for medical students to outline: “The standards expected of them - both inside and
outside of medical school”

Life Long Learning Definition

“all Learning Activity undertaken through life, with the aim of improving knowledge, skills
and competences within personal, civic, social and/or employment-related perspective”
Learning throughout all stages of life • Formal system of education and informal activities

Irish Medical Council Professional Competence

As of May 2011, doctors are legally obliged to maintain their professional competence by
enrolling in professional competence scheme operated by postgraduate training bodies. They
must:
 Enrol postgraduate training body scheme most relevant to your practice.
 Engage in 50 hours of CPD and 1 clinical audit per year.
 Retain documentation relating to your maintenance of CPD.
 Ensure you receive a statement of participation from the professional competence
scheme.
 Declare to Medical Council maintaining your professional competence .

Domains of Appraisal and Revalidation

Patients must be able to Trust doctors with their lives and health.
 Knowledge, skills and performance: Patient-Centred
 Safety and quality
 Communication, partnership and teamwork

Patient safety is the prevention of errors and adverse effects to patients associated with health
care.
Why Patient Safety? • Patient Harm 14th Leading Disease • Adverse Event 1 in 8
Admissions • 30-70% Harm Preventable • 4.2% Adverse Events cause Death

The prevalence of adverse events in admissions was 12%.

70% of events were considered preventable.
Two-thirds were rated as having a mild impact on the patient, 9.9% causing permanent
impairment and 6.7% contributing to death.

Clinical risk management

Risk is the effect of uncertainty on objectives
Improving the safety of healthcare by identifying the circumstances that put patients at risk of
harm -prevent those risks.
1. Identify the risk
2. Assess the frequency and severity of the risk
3. Reduce/eliminate the risk
 4. Assess the costs saved by reducing the risk

Sentinel event: unexpected event that results in patient death/injury.

Risk: anything that threatens a healthcare team’s ability to achieve its clinical objectives or
increases the probability of patient harm.

Incident Reporting: After a patient safety incident has occurred it should be reported to risk
management. There is obligation to report incidents to State Claims Agency.
State Claims Agency (SCA) is the government agency which manages risk management
delegated under the National Treasury Management Agency (NTMA) Act.

An incident: unexpected event that leads to harm.

All data is held by State Claims Agency, reviewed and analysed.
Patterns of incidents can be identified.
The incident may become a claims against the hospital and the clinical claims team at the
SCA deal with these.
identify if the same incidents and errors are being made repeatedly over time .

An increasing clinical incident rate over time is considered to be consistent with a

strengthening patient safety culture: “increased awareness, leads to increasing reporting”.

• Operational environment (practice setting, infrastructure, systems and processes, clinical

standards, practices, organisational culture, practice management, staff education training,
professional development)
• Financial arrangements (practice budget, resource allocation, contract management)
• Legal factors (responsibilities, statutory liabilities, occupational health and safety)
• Political climate (changes to health legislation, regulations, funding, education/workforce
reform, public health campaigns, or media coverage).

Clinical Error: act of omission/commission in the planning/execution of a health service that

contributes to an unintended effect.
Clinical errors are events in your practice that make you think: “that was a threat to a
patient’s wellbeing and should not have happened. I do not want it to happen again”

Near-miss: event that could have resulted in an accident/injury/illness, but did not, either by
chance/intervention.
Instead of being forgotten, near-misses continue to play on the mind of those involved while
they try to identify what went wrong and how to prevent the incident from occurring again.
Patient Safety Incident
Incident: a circumstance that could have lead or already lead to unintended harm to a person.
“An incident which occurs during the course of a health service” which:
(a) has caused an unintended injury to the patient
(b) did not result in actual harm to the patient but the health provider has reasonable grounds
to believe that the patient is at risk of harm.
(c) unintended harm to the patient was prevented, but the incident was one which the health
provider has reasonable grounds to believe that it could result in injury if not prevented.
A patient safety incident includes harm events, no harm events and near miss event
Sentinel event: unexpected occurrence involving death/serious injury to a patient and any
recurrence has chance of adverse outcome.

Balancing “no blame” with responsibility

“Most errors are committed by ‘good people trying to do the right thing’ and to improve
safety we should focus on safe culture rather than identifying who is at fault”
Hand-hygiene non-compliance should be managed through an accountability framework(who
is at fault)- penalties for repeated non-compliance with hand hygiene.

MANAGING DISRUPTIVE BEHAVIOURS

 Managers and Supervisors: set a good example by treating all employees with respect.
look out for behaviour like bullying. Resolve any issues and ensure no recurrence
after a complaint has been resolved.
 Responsibilities of you as an employee: You are responsible for your own actions. It
is up to the individual to report incidents immediately .

Human Failure, two types:

 Human Error: unintentional
 Violations: intentional failure

Managing difficult employees

 distinguish the person from their behaviour.
 Focus “Your behaviours are effective here; they are not effective here.”
 Address the specific behaviour- Give specific examples of when the employee was
displaying the unacceptable behaviours so they don’t guess. For example, “I’ve heard
you talk negatively about Joe to other employees”
 Discuss appropriate behaviours with the employee.

Plagiarism • The practice of taking someone else’s work and passing it off as one’s own
“the appropriation of another person’s ideas, processes, results, or words without giving
appropriate credit.”
Consequences:
 Academic misconduct and can lead to dismissal from university
 Dismissal from other institutions
 Article rejections
 Decreased credibility as a student
Which characteristics in RCSI definition are relevant to plagiarism?
* Integrity, Honesty, Ethical Practice, Evidence Based Practice, Communication

Honesty & Integrity in Research

Results of research can directly improve patient outcomes
Failure to be honest can lead to:  public’s loss of trust  betrayal of patients, fellow
researchers loss of reputation

Responsible Conduct of Research (RCR) "the practice of scientific investigation with

integrity." awareness of professional norms and ethical principles in the performance of
scientific research..
1. Honesty 2. Rigour 3.Transparency 4. Fairness 5. Respect 6. Recognition
7.Accountability 8. Promotion

Research Misconduct
• Not everyone agrees that plagiarism is research misconduct
 fabrication, falsification, and plagiarism.
 Failing to get consent for research, Not admitting that some data are missing,
Ignoring outliers, Not including data on side effects, Conducting human research
without informed consent, Not attributing other authors, Not attempting to publish
completed research, Failure to do an adequate search of existing research before
beginning new research
 Research misconduct does not include honest error or differences of opinion

Leadership: an individual influences a group to achieve common goals.

• Clinical leadership is key variable in the effectiveness of healthcare development and the
implementation of change • The presence of clinical champions prepared to lead increases
likelihood of successful change. • The most important determinant of the development of an
organisation’s culture is current and future leadership.
POSITIVE LEADERSHIP: behaviours that result in followers’ experiencing positive
emotions
Behaviours such as Cheering people
up, Praising job performance,
Thanking individuals
Growth mindset: learn from their
mistakes, to develop their career-
encouraging learning and improving
employees, organisational innovation.
Fixed mindset: more interested in
‘looking good’ and may avoid
situations which may cause them to
make a mistake.

‘Positive Psychology: study of strengths that enable individual to thrive. The field is founded
on the belief that lead meaningful lives, to cultivate what is best within themselves, and to
enhance their experiences of love, work, and play.’
PERMA model: A model to measure wellbeing
Positive emotions: happiness, pleasure and comfort.
Engagement: feeling of connection
Relationships: Integration in society
Meaning: having a purpose in life.
Accomplishment: working toward goals.

e-Professionalism: the way you conduct yourself online in relation to your profession,
including your attitudes, and adherence to relevant codes of conduct.
 Protect patient confidentiality • Follow GMC guidance before taking & sharing
pictures of patients • Maintain boundaries • Think before you share • Think about
posting anonymously • Be cautious in giving medical advice on social media •
Manage your privacy settings • Be open about any conflicts of interest
Doctor should check social media profile • Doctors should never disclose their home address,
email address or connections. • Limit what sensitive data you publish in research papers.

Confidentiality, is a state of keeping secret

Doctors are under ethical and legal duties to protect patients’ information from improper
disclosure.
However, sharing information, is also important • You should protect your patients’ privacy
by keeping records about patients securely.
You should guard against accidental disclosures.
• Before disclosing any information about patients, you must also take into account the
Freedom of Information (FOI) Act.
You must be clear about the purpose of the disclosure and that you have the patient’s consent
anonymised information - You are certain that it is necessary to use identifiable information-
disclosing the minimum information- The person you are disclosing to knows that it is
confidential
Breaches can occur:
• ensure you do not leave patient lists in the cafeteria
• ensure when presenting a history that lay people cannot hear you
• do not discuss patients in open places
• never discuss patient on social media
Breaches can cause: • Loss of trust • Loss of public confidence in profession • Possible
disciplinary action by regulator

Doctor-patient confidentiality: The ethical/legal principle that a physician will keep patient
information secret, unless the patient gives consent for disclosure.

Health Insurance Portability & Accountability Act (HIPAA), a USA law designed to provide
privacy standards to protect patients' records and other health information provided to
doctors, and hospitals. Developed by the Department of Health and Human Services, these
new standards provide patients with access to their medical records and more control over
how their personal information is used and disclosed.

Consent is voluntary: the giving of permission for an intervention following a process of

communication about the proposed intervention.
Consent must be obtained before starting treatment, or investigation, or involving a patient in
research.
help patients make decisions that are informed
Consent PARQ Acronym • Procedure: what it entails • Alternatives: including doing nothing
• Risks: of procedure and alternatives • Questions: invite patients to ask questions

Consent is required by law • respect for patients’ autonomy. • Patients have the right to
decide. • They also have a right to refuse treatment.
Valid Consent, Competent: capacity is decision specific, Fully-Informed, Given Freely: time
to consider
Consent is not valid if the patient has not been given enough information to make a decision.

More information may be needed, for: Procedures that carry a high risk of failure. •
Investigation for a condition with impact on patient’s life.

Timing Consent • keep patient up-to-date with any changes in their condition and treatments
• Discuss treatment and risks at a time when the patient is best able to understand
• Give the patient time to consider options and reach a decision
• Don’t seek consent from a patient when they are stressed, sedated or in pain.

If you are the doctor providing treatment or investigation, it is your duty to make sure that the
patient has given consent.
If it is not possible, you may delegate process to another qualified person.
You should not delegate consent process to an intern.
Emergency : In an emergency, where consent cannot be obtained, you should provide
medical treatment to who needs it, provided the treatment is necessary to save a life or avoid
deterioration in the patient’s health.

Refusal/Withdrawal of Consent :
You must:
• respect a patient’s decision, even if you disagree
• explain clearly to the patient the possible consequences of refusing treatment
• record your discussion with the patient, the information you gave and the patient’s refusal
If you have concerns about patient’s capacity to refuse treatment, you should follow the
guidance in IMC 8th edition and seek legal advice.

ROLE of next of kin

- No other person give/refuse consent on behalf of an adult who lacks capacity unless
they have legal authority.
- Include ‘those who have a personal relationship’ in decision-making to provide
greater views of preferences of the person.
- A false belief persists among public that consent should be taken from the ‘next of
kin’ if a person can’t consent.

Document clearly the person’s agreement to the intervention and the discussions that led up
to that agreement. Signature on a consent form or documenting that they have given verbal
consent. A signature on a form is evidence that a process of communication has occurred

Maximum fixed time period for which consent remains valid, however there is no legal
authority to support the validity of time period.
• If there is a significant time-lapse between the consent and actual date of an intervention,
check if the patient can remember the treatment.
• If the patient cannot remember/ there is change in condition or intervention, a fresh consent
should be sought.

Clinical Negligence: when a medical practitioner breaches its duty of care to patient, who is
injured as a result of breach.—failure to take proper care.

The Bolam “reasonable man” or “10%” test

A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as
proper by a reasonable body of medical men.

CAUSATION: Resulting from negligent treatment, suffered an unexpected injury, pre-

existing injury or condition became worse, he failed to recover or the chances of recovering
diminished.

Consent: The Reasonable Patient Test

Patient has the right to know and the practitioner a duty to advise of all risks associated with
treatment.
“The reasonable man gives full information of risks , and he does not have impossible
expectations or impossible standards.”
Montgomery Judgement involves what a patient would consider to be Material Risk:
“The doctor is under a duty to ensure that the patient is aware of risks involved in treatment,
and of alternative treatment.”

If the medical practitioner acts without consent, this may lead to: • Criminal prosecution for
Battery, and to • Civil Proceedings.

If the practitioner seeks consent, but this is not fully “informed” consent, this may lead to
Civil Proceedings in Negligence.

If Emergency Treatment is required:

Principle of necessity says that you can treat patient without consent and make decision on
behalf of patient.
• Should be the Least Restrictive option. Where the treatment is necessary to save the life.
You should make efforts to communicate with Next-of-Kin.

Consequences of sub-standard consent: • patient does not fully understand • patient unaware
• patient feels under pressure• patient is not making an informed decision
i.e. Doctor found negligent, although they informed of Risks of angiography which led to her
stroke, they did not discuss the comparative risk of an Alternative Investigation by MRI

Informed Consent
Patient would expect to be told: • Side effects; • Chances that intervention will achieve
desired aim • The risks with taking no action • Need to say common side effects , even if
minor, and rare but serious adverse effects.

Capacity: Every adult has the capacity to make own decisions.

Adults without capacity to make a decision- listen to their views and involve them in
decisions to the extent that they are willing to be involved.
A lack of capacity may arise from a permanent condition/disability, or from temporary short-
term illness.
If an adult lacks capacity to make a decision, you must find out if anyone else has the legal
authority to make decisions on the patient’s behalf.
If no-one has legal authority to make decisions on the patient’s behalf, you will have to
decide.
A patient will lack the capacity to make a decision if they are unable to: • Understand
information needed for decision, or • Communicate their decision, even if helped

When assessing patient’s capacity, consider their: level of understanding • ability to apply the
information to come to a decision • ability to communicate their decision.

Nonmaleficence- ethical principle of doing no harm.

Beneficence: rules aimed at benefitting others. personal qualities of mercy, kindness,
generosity and charity.

Leadership is the most influential factor in shaping organisational culture and so, ensuring
the necessary leadership behaviours, strategies and qualities are delivered is fundamental.
Dimensions of Authentic Leadership • Purpose • Values • Relationships • Self-discipline •
Heart- Real or genuine leadership
The Clinical Leadership Competency Framework has five main domains:
By • Demonstrating personal qualities • Working with others • Managing services •
Improving services • Setting direction

Competency: knowledge, skills, and attitudes which health leaders require for effective
performance.
Competence: ability to produce outcomes required for effective achievement of goals.

Communication and patient safety

Kinesics Communication: physical cues that are visible and send a message about: Your
attitude; emotions; relationship with environment. These include: • Body posture • Gestures •
Facial expressions • Eye contact
Haptic communication is communicating by touch and is used when we come into physical
contact with other people. e.g. handshakes- Physical contact may give comfort, make
uncomfortable, or even be inappropriate?
Effective listening is listening to the words of the speaker and the meaning of the words.
Active listening: listener takes active responsibility to understand the feeling of what is
being said and then confirms with the speaker, by repeating/summarising.
Demonstrating interest in a speaker’s message through non-verbal signals.
• No judgment , paraphrase: ‘Correct me if I’m wrong, but what you’re saying is…’
• Asking the speaker to elaborate
“Tell me more about that...”
“Just to make sure that I understand, what you’re saying is...”
“How did you feel when that happened?”

Cross-cultural Communication
 Ability to communicate with people from different cultures.
 improve quality and eliminate racial and ethnic health disparities
 Cultural awareness is a reflective process • Background • Values • Beliefs • Biases •
Assumptions
 Cultural awareness: how culture impacts your communication.
 Sources of Miscommunication • Assume similarities • Language differences •
Nonverbal misinterpretation (dress-code)• Stereotypes • Tendency to evaluate based
on one’s culture • High anxiety (unfamiliarity with culture)
NHS Improvement commissioned report
Critical communication domains:
• Communication Environment • Information Exchange • Attitude and Listening • Aligning
and Responding • Creating the preconditions for effective team communication •
Communicating with unique groups

Communication Environment
Caring surroundings where physicians and patients “feel psychologically and physiologically
safe”.

Spoken communication: Information is exchanged between the right people at the right
time.
Effective communication with respect, commitment, positive regard, empathy, trust,
receptivity, honesty and an ongoing and collaborative focus on care.

Aligning and responding, is critical for nurturing the clinician–patient relationship, develop
mutual trust, confidence and “common ground”.

A team communicates effectively when team members feel “psychologically safe”, valued
and sufficiently confident to raise concerns or point out problems.

Greater care needs to be taken when communicating with groups such as: • Children and
young people • People with problems understanding spoken English (eg, limited-English
speakers, people with a hearing impairment, learning disabilities or cognitive impairment) •
People who are distressed or have mental health conditions • Be culturally aware and
sensitive

Asking patients open-ended questions, assessing their existing knowledge, before sharing
information.
Ask-Tell-Ask is a shift from “telling patients what to do” to “asking patients what they are
willing to do”.
• Ask permission to start a conversation
• Ask what the patient thinks
• Ask about what the patient already knows
• Tell the patient information
• Ask to gauge the patient’s understanding

Teach-back: To confirm that you explained information in a way that your patient
understood. Asks patients to explain back.

Situation-Background-Assessment-Recommendation (SBAR)- structured communication

S - situation • Identify yourself. • Identify the patient • Describe your concern
B - background • Give the patient’s reason for admission • Explain medical history • Inform
of the patient’s background: diagnosis, date of admission, prior procedures, medications,
allergies, laboratory and diagnostic results. You must review patient’s chart and notes.
A – assessment : Vital signs. • Trends and pattern. • Clinical impressions, concerns
R – recommendation : Your recommendation, what would you like to happen by the end of
the conversation. Advice given on phone needs to be repeated back. • Explain your request
and make suggestions

To build a relationship with your patients use the technique PEARLS • Partnership •
Empathy • Apology/Acknowledgement • Respect • Legitimisation • Support

BAD NEWS
Delivering: one-way transaction, in which a service is provided by one party to another.
Breaking, implies a transaction is conducted forcibly. Perhaps without Compassion
SPIKES can be used to deliver bad news
• S - Setting • P - Perception/Perspective • I - Invitation • K - Knowledge • E -
Empathy/Emotion • S - Summary/Strategy
S – Setting-
Choose the correct setting and time to speak to patient. Next, make sure that everyone who
needs to be present is present:
P – Perspective/Perception
Assess what the person knows about their situation and how the patient feels about their
condition. You may find that the patient is in denial or they don’t have a good understanding
of their health.
I – Invitation
Determine how much the patient want to know. Patients have the right to know or not know
things about their condition. Some only want broad strokes, no details, others every possible
detail
K – Knowledge
It’s time to deliver the news. Give a heads up that they are going to hear bad news. “This may
be more serious”. Give them information in small chunks, then pause to give time to digest
the information or ask questions.
E – Empathy
Empathy is “the ability to understand and share the feelings of another”
S – Summary/Strategy and Support

Human Factors: individual characteristics and capabilities.

 Personal qualities that individuals bring to their position of employment.

Absent-mindedness
 increases the risk of human error.
 Absent-mindedness can be prevented by being alert (being present-minded)
  Often we do not need to think too deeply about what we are doing if it is a simple task
or we have done before.
 HALT Acronym : Absent-mindedness occurs when you are Hungry,
Anxious/Angry, Late or Tired (HALT)

Present-mindedness
- Being aware of internal and external cues, error wise.
Our intuition prevent us acting in an absent-minded way.
 Internal cue: listen to intuition.
 External cue: respond quickly to external factors.
 Communicate well with others- “Being error-wise is recognising situations that have a
potential for causing harm.”

Human and Contextual Factors and Risk

Human Factors • Tired, Hungry, Pre-occupied
Resource Factors • Similar Names, Similar Colours, Same place
System Factors • No Second-Staff check
Environmental Factors • Busy, multiple patients
 A medication error is “any error occurring in the medication use process”
 Any preventable event that may lead to inappropriate medication use/patient harm,
while the medication is in the control of the health care professional, patient, or
consumer.

Look-Like Ampoules
few designs and colours to choose from, and so many injectable drugs to dispense.
Medicine and Healthcare Regulatory Agency of UK suggest an “innovative pack design that
may incorporate the use of colour is encouraged to ensure identification of the medicine”

Tall Man lettering involves highlighting the dissimilar letters in two names to aid in
distinguishing between the two for examples:
HumaLOG and HumuLIN, • oxyCODONE and OxyCONTIN • ceFAZolin and
cefTRIAXONE

Situational awareness
“the perception of environmental events with respect to time or space, the comprehension of
their meaning, and the projection of their future status”
Perception; Comprehension; Projection.

Loss of situational awareness: • Distraction • Fatigue • Breakdown in communications •

Failure to comply with plan • Violating rules
Patient Safety Priorities EXAMPLES
Know, Check, Ask Campaign (Medications)
National Early Warning Score (NEWS)
National Clinical Programme Sepsis (NCPS)
Antimicrobial Resistance Infection Control (AMRIC)
Venous Thrombo-Embolism Risk Assessment (VTE)
The Pressure Ulcer to Zero and Falls Collaboratives

The Three Bucket Theory

mix of positive and negative factors, • Add Positive • Remove Negative
SELF, CONTEXT, TASK

SWISS CHEESE MODEL- Swiss Cheese Model of system failure.

Every step in the treatment process is a slice of cheese:
• the holes: opportunities for error
• the cheese: defensive barrier.

In an ideal system, an error that passes through 1 hole is intercepted by the cheese in
the next layer. The more cheese and the fewer holes in each layer, the lower the risk of
an adverse event occurring.

Managing Risk in Everyday Practice

Anticipation involves thinking ahead about things that are most likely to contribute to risk
Vigilance - heightened sense of awareness
Responding: using data in relation to issues occurring,
e.g. if falls has been identified as a risk, what does this tell you about the controls to prevent
falls?
If controls are effective: you see reduction in falls, if not your controls may need to be
reviewed.
Learn and Improve: Take a look at available information from both within your service and
external.
Investigating Patient Safety Issues
 What happened?
 How/why did the event occur?
 What can be done to prevent it happening again?

Cause and Effect (Fishbone) Diagram : Looks at identifiable causes and then investigates the
causes to develop solutions.

Root Cause Analysis

 actual (root) cause of a problem is rarely recognizable at the time of incident.
 A biased assessment of any problem usually does not fix the problem and more
incidents will occur involving similar situations.

Saying sorry is: • always the right thing to do • acknowledges that something could have
gone better • the first step to learning from what happened and preventing it recurring

Duty of Candour (UK)

 requires all NHS staff to act in an open and transparent way.
 • informing people about the incident, • providing support, • truthful • apology.
Open Disclosure Policy (HSE)
Communication following Patient Safety Incidents
Open disclosure is where a health provider discloses:
•to a patient that a safety incident has occurred in providing health service to him/her
•to a relevant person that a safety incident has occurred.
•to a patient and a relevant person that a safety incident has occurred.

Protective Legislation
a) shall not constitute an implied admission of fault.
b) shall not be admissible as evidence of fault.
c) shall not invalidate insurance.
Open disclosure must be managed strictly in accordance with the procedure as set out and the
regulations that accompany Part 4 of the Act

Principles of Open Disclosure

1. Acknowledgement 2. Truthfulness 3. Apology 4. Recognise expectations 5. Staff
Support 6. Risk Management 7. Multidisciplinary Approach 8. Clinical Governance 9.
Confidentiality 10. Continuity of Care

Patient Safety Bill

Mandatory Open Disclosure
“A Bill to provide for mandatory open disclosure of serious patient safety incidents,
notification of reportable incidents, clinical audit to improve patient care and extend the
Health Information Quality Authority remit to private health services”

Unintended patient death which did not arise from illness:

Following wrong surgery, Following unintended retention of foreign object
Following elective surgery, transfusion of incompatible blood
Associated with medication error, Death of a woman while pregnant/within 42 days of
delivery, Still-born child, Perinatal death of a child who was alive at labour, Suicide of
patient while at healthcare
Baby referred for therapeutic hypothermia or considered for and did not undergo therapeutic
hypothermia.

National Study of Wellbeing of Doctors

Key recommendations : Doctors must care for themselves, and others • Staff Welfare must
be a priority for hospital management • Hospital doctors must be embedded into a clear
management structure to support and facilitate them to care for themselves and patients.
Second victims are “healthcare providers who are involved in an unintended adverse event,
and becomes victimized, the healthcare provider is traumatised by event.
Second victims often: • Feel personally responsible • Feel as though they have failed the
patient • Second-guess their knowledge.

Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have
experienced a shocking, scary, or dangerous event.
PTSD is diagnosed in adults with ALL the following for at least 1 month: • At least one re-
experiencing symptom • At least one avoidance symptom • At least two arousal/reactivity
symptoms • At least two mood symptoms

Resilience “The capacity to recover quickly from difficulties”

the RISE program prepares employees to provide support for Second-Victims with: • Skilled
• Non-judgmental • Confidential support

Communication failure
Organisational system failures: channels for communication do not exist.
Transmission failures channels: channels for communication exist but the information is not
transmitted. (e.g. sending unclear messages). May be due to background noise.
Physical problems in sending the message (e.g. wearing protective equipment).
Reception failure: channels for communication exist, the necessary information is sent, but is
misinterpreted by the recipient. May be due to equipment problems (e.g. poor radio
reception).

Patient-Centred Care: Definition

Providing care that is respectful of patient preferences and values, and ensuring that patient
values guide all decisions.
Altruism, is selfless concern for the well-being of others.
Direct benefits to the Individual • Beneficial Interactions with Unrelated-Individuals •
Preferential Interactions between Related-Individuals • Genetic predisposition to Altruism

Psychological altruism: "a motivational state with the goal of increasing another's welfare".
Psychological altruism is contrasted with Psychological Egoism, which refers to the
motivation to increase one's own welfare.
Volunteering does lower depression for those over 65, while prolonged exposure to
volunteering benefits both young and old.
Volunteering for religious causes is more beneficial than secular causes.

Altruism in research: benefit personally: • Opportunity for learning • Offering access to

treatment • Offering careful monitoring

Altruism and Organ-Donation (Live-Donors)

Before donating: - fear and confusion.
After-donation, most donors described a positive emotional state with self-satisfaction, pride,
and increased support of organ donation.
Most donors were motivated by social solidarity, and religious beliefs, and improving the
recipient's life

Egoism, is defined as “an ethical theory that treats self-interest as the foundation of
morality”
Altruism is the opposite of Egoism.

Duty is a commitment to perform action. Performing one's duty may require some sacrifice
of self-interest.
Heroism is bravery and selflessness. The Hero acts, whilst the Bystander watches. People
who risk their lives in the service of another are more likely to take risks and they also
possess a great deal of compassion, kindness, empathy, and altruism.

Empathy is “the ability to understand and share the feelings of another”, empathy in excess
is always beneficial to relationships. Leads to personal growth, career satisfaction, and
optimal outcomes.
Sympathy is “feelings of pity for someone else's misfortune”, sympathy in excess can be
detrimental to relationships. Leads to career burnout, compassion fatigue, exhaustion, and
trauma.
Burnout: depersonalisation, emotional exhaustion and a sense of low personal
accomplishment that leads to decreased effectiveness of work.
Burnout is an occupational phenomenon

Maslach Burnout Inventory (MBI)

assess Work Burnout: • Emotional Exhaustion (EE) • Depersonalisation (DP) • Personal
Accomplishments (PA) • Cynicism • Professional Efficiency

National study of wellbeing : finds 50% of doctors are emotionally exhausted and
overwhelmed by work
Recommendations : Doctors must care for themselves, Staff Welfare must be a priority
• doctors must be embedded into a clear management to care for themselves and others.
Major medical errors reported by surgeons are strongly related to a surgeon's degree of
burnout and their mental QOL.
1 physician commits suicide each day in the USA.
10 steps to prevent burnout
1. Make clinician satisfaction and wellbeing quality indicators.
2. Mindfulness
3. Decrease stress from electronic health records.
4. Allocate resources to clinics to reduce healthcare disparities.
5. Hire physician floats to cover life events.
6. Promote physician control of the work environment.
7. Maintain manageable primary care practice sizes and enhanced staffing ratios.
8. Preserve physician “career fit” for meaningful activities.
9. Promote part-time careers and job sharing.
10. Make self-care a part of Medical Professionalism

WHO defines Self-Care as: “the ability of individuals to promote health, prevent disease,
maintain health, and to cope with illness with/without the support of a healthcare provider”.
Self-Care Thinking/Positive Thinking, includes: • Realistic sm • Self-responsibility •
Gratitude • Purpose• Flexible thinking • Humour

“The most important patient we have to take care of is the one in the mirror”
Self-Care Behaviour, includes: • support networks • Activity: physical, social and mental •
Avoid negative people • Social skills• Enjoy the now

Self-care for Healthcare Professionals

5 Principles:
1. Boundaries
2. Move from reactive to creative, start day with a plan
3. Listen to your body
4. Find out what restores you, and gives joy
5. Give yourself permission to feel good

ACCURATE SELF-ASSESSMENT
have a true self-estimate, we commonly think we can do more than we really can
The idea is not to become trapped by idealism.
When someone points out a flaw in your actions, they’re not criticizing you, they’re
providing feedback

FORMING: communication on safe subjects

STORMING: More relaxed, differences, conflicts
Norming: Flexible, individuals and group is important
Performing: Group domination
FSNaP
DECISION PROCESS
STEP 1 : Establish a context for success
STEP 2: Frame the issue properly
STEP 3: Generate Alternatives
STEP 4: Evaluate the Alternatives
STEP 5: Choose the alternative that appears best
• Bounded reality
Due to our limited information processing capacity, most people reduce the
complexity of a decision to a level they can understand.
• Satisfice: seek solutions that are satisfactory, focus on choice that is “good enough”
Operate within bounded rationality
We construct simplified models and extract key features without capturing the full
complexity

A heuristic is a mental shortcut that allows people to solve problems quickly and
efficiently. These rule-of-thumb strategies shorten decision-making time

Overconfidence bias
Anchoring bias: Tendency to fixate on initial information and fail to adjust to subsequent
information.
Confirmation bias: SELECTIVELY gather information. We seek information that confirms
our choices and disregard information that contradicts them
Cognitive Dissonance
• We reduce or avoid psychological inconsistencies
• Self-perception theory indicates that people discover their own attitudes and
emotions by watching themselves behave in various situations