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Critical reflection on the issues of leading improvement in practice

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Extensive research into leadership with many published statements describing, a clear definition is difficult to pinpoint…  “leadership is the process whereby an individual influences a group of individuals to achieve a common goal” ( Northouse , 2010:3)  “Leadership is the process of influencing others to understand and agree about what needs to be done and how to do it, and the process of facilitating individual and collective efforts to accomplish shared objectives.” ( Yukl , 2010:8)

New model of leadership, Storey & Holti (2013)

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Nasogastric   tube (NGT) Feeding is fraught with risk and it was acknowledged by the National Patient safety Agency (NPSA) in 2011 that there were patient safety issues with regards to a  miisplaced   nasogastric  feeding tubes. Recommendations within the alert for more robust safety measures surrounding delivery of NG feeding including decision making criteria..

NHS
Matbnal Patient Safety Agency
Patient safety Alen NPSA/20111PSAü:
Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and hfants
Supprtü'g hfMNtion
Contents
R VTER

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Alert
Patient Safety Alert
NPSA,QOI 1/PSA002
10 March 2011
Reducing the harm caused
by misplaced nasogastric
feeding tubes in adults,
children and infants
This Alert updates and strengthens Patient Safety Alert
OS (Reducing the harm caused by misplaced nasogastric
feeding tubes) and is based on national learning since
then. It does not replace Reducing the harm caused by
misplaced naso and orogastric feeding tubes in babies
under the care Of neonatal units, issued in August 2005.
Panent Safety Alert 05 guida ce
n the NHS O n Checking a
confirming that a had inserted into the right place,
i.e. the stomach.
This reports to the NPSAX National and Learning
System (NRLS) of patient as
a of into lung through
misplaced nasogastric
e the date that Alert's (1 September ZOOS). the
NRLS has
of a further 21 deaths and 79
of ham
due to into the lungs through nasoqastric tubes. The
main caus
al factor to har
misinterpretation of x-rayS This was
in 4S incidents. 1 2 01 which
the death of patient, The
focus for this new Alert thereftve safe
Other Caus
of harm related to to the guidance in Patient
Safety Alert OS including: feed.nq despite obtaining pH6
and pH8 incidents including two deaths), instilling mter
the tube Obtaining aspirate (two ne
i ide nts), Of tube
pluement by any (nine incidents iruluding
one deathb A
finding in local t
a ions was that
was made Of pH
obtained or Of x-ray
This Alert does not Change advice given in Patient Safety Alert OS that
pH testing first and remains the
For the purpose Of this Alert definition Of •to feed • 'feeding •
includes the introduct&' of any liquid or medication thmugh the
nasogastric
be æad in conjunction with the Supporting
available at WWW.nrIS.npsa.nhs.uk'aIorts
National Pat
Safety Age
Action for the
For action by orga
NHS
tubes a
and used for f æding
with
nursing staff should
staff training that 12
4.
A —d clinical is
A" and
are t
complia«e (a) to
and to
fluids Or fæd.
An
in plæ to
Staff training.
ensure
with
POSitirn
competent.
A ænple
for
tube BO-Sit&'
Qfer to guide to
3 of this
Purchasing
st«k
all for
p urEm of feeding
length and
visible th
Old stxk s,stematiealiy
pH CE
by the manufactuæ
human gastric

Tea ms.
a result of recent incidents and a Coroners aegulation
report it has
ent that further clarity
initial pla
and tubes. Therefore
a reso is being shared to provide clarity on the steps
The resource "t provides a of 3uppot•t health
boards tru sts to whether previous
tube guidance has been implemented and
within their organisations
itiA1_
It includes briefings to help understand the
Of critical requirement g Of past
checklists, and learninz from
reported
of n-isplac
ga stric and orogastric tube
pat nt
e bv the Nat
ional patient
Safety in three alerts were
issued 201 1 and 2013
Introducing fluids or
medication into the tract Or ple Via a rrisplaced
nasogastric o r tube isa Never
Events a Olly preventable where
guidance or safely that provide strong
bamers
nal level. and
aæ ayailable at
• pl mented by all h
Sop te 201 1 and March incidents Were
reported to the National Reporting and Learning SY glom (N AL S)
and/or the serious incident rep Orting 8V3te
a misplaced astric or orogastric tube.
atient Safety Alert
Nasogastric tube continuing risk Of death and
To: All NHS VVales Chiel eg. Medical Oire Directors or Nur sing .and patient Safety
2 _ Provid
re i i nto the respiratory ct pl
GIG
Gove„-,
Act i O nS
d be cornpleted by
30 2017
Org
used f or p tl t
•en s receiving NHS
funded care,
I _ ld a named
take
for the delive
ry of the actions
required in this alert;-
e —rety
t reflect all th
critical requirements summarised in
the resource
e the supply and
equ
used for ding be
op ague throughout their length and
have Visible length
ma p H paper should be C E
marked for use on human aspirate
4 _ the provision and uptake
d training Wh.ch
s to reflect all the safety-critical
summarised in this;
resource pack, Traimng in the X-ray
interpretation and pH Sting Should
be provided for staff who
un de 'take
regardless of the level or seniority,
Queries be to: SL

Scene 5

Is   nasogastric  tube feeding the  right decision  for this patient?

The document highlighted the clinical actions that were a requirement within the Alert based on the following questions :

Is  this the  right time  to place the  nasogastric  tube and is the appropriate equipment available?

Is  there sufficient  knowledge/expertise  available at this time to test for safe placement of the  nasogastric  tube?

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Identifying  stakeholders ....  Nutritional Support Team, Dietetics, Nursing management, Medical staffing, Governance leads & Radiology.

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Lewin  (1951)Three key stages for change: Unfreeze Change Refreeze

Lippet  et al (1958) 3 phas e  model Clarification Examination Transformation

Kotter’s  8 stage model for change (1996) Create a sense of urgency Form a guiding coalition Create a vision Communicate the vision Empower others to act  Create quick wins Build on change Institionalise  the change

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New decision making tool and safety checklists…  Health board specific NG Decision Tree

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New Leadership era Compassionate Leadership

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Leadership models : Transformational leadership V Compassionate leadership

Compassionate leadership behaviours 4 key behaviours; Attending Understanding Empathising Helping    (West, 2019)

Core values …  Compassion…  Wisdom…  Humanity (West, 2017)

Transformational  leadership  behavious  (Northouse,2010) Attending Understanding Empathising Helping    (West, 2019)

Core values …4 I’s Idealised influence… Individualised consideration Inspirational motivation Intellectual stimulation ( Northouse , 2001)

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With the use of compassionate leadership successful roll out acknowledging cultural challenges may have made roll out of change smoother and within shorter time frame Patient safety was achieved with the   sucessful  roll out of the intended change Staff awareness around the importance of patient safety was instrumental in the success. Staff engagement  has been maintained following  the initial roll out.

The King’s fund through extensive research and analysing evidence of the failures within the NHS identifies best practice by acknowledging leadership as “the most influential factor in shaping organisational culture” ( Westt  et al, 2015)

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Alimo -Metcalfe, B. A, Alban-Metcalfe,  J.   B.  Alimo -Metcalfe (2009)The impact of engaging leadership on performance, attitudes to work and wellbeing at work: A longitudinal study  Bass, B.M. (1985)  Leadership and performance beyond expectations . New York: The Free Press.  Bass, B.M. and  Avolio , B.J. (1993) Transformational leadership  Bass &  Avolio  (1998) Avolio , B. J., & Bass, B. M. (1995). Individual consideration viewed at multiple levels of analysis: A multi-level framework for examining the influence of transformational leadership. The Leadership Quarterly,6, 199– 218.  Beckhard , R. & Harris, R. (1987) Organizational transitions.

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Berwick (2013)   Independent report Berwick review into patient safety  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf  (accessed May 2021) Francis (in 2010, 2013) Kelly- Heidenthal , P. (2004) Essentials of Nursing Leadership and Management. New York, Thomson Delmar Learning.  DIxon -Woods et al, 2014) Culture and behaviour in the English National Health Service: overview of lessons from a large  multimethod   studyDixon -Woods M, et al. BMJ  Qual   Saf  2014;23:106–115.  https://qualitysafety.bmj.com/content/qhc/23/2/106.full.pdf  (Accessed May 2021)

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Kotter , J.P (1990) A force  for change, London: The Free Press.  Kotter  (1996)  Leading Change. Harvard Business School Press, Boston Kotter  (2008) A Sense of Urgency. Harvard Business Press, Boston  Kouzes , J.M  and  posner , B.Z. (2007) The leadership Challenge (4th  ed ) San Francisco, CA,  Jossey -Bass.  Lewin  (1951) Field Theory in Social Science. New York: Harper  Lippitt  R, Watson J,  Westley  B and Spalding WB (1958) The Dynamics of Planned Change: A Comparative Study of Principles and Techniques. New York: Harcourt Brace

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Northouse , P.G. (2011) Introduction to  Leadership:Concepts  and Practice (2nd  ed ) London. Sage.  Northouse , P.G. (2010).  Leadership: Theory and practice  (5th  ed ). Thousand Oaks, CA: Sage Publications.  NPSA/2011/PSA002  Storey, J. &  Holti , R. (2013) NHS  Leadership Academy Towards a New Model of Leadership for the NHS  https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/05/Towards-a-New-Model-of-Leadership-  (accessed May 2021)

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West et al (2015) Leadership and Leadership development in HealthCare: The Evidence Base. London, Faculty of Medical Leadership and  Managment . Fmlm.ac.uk  West et al (2017) The Kings Fund Caring to change How compassionate leadership can stimulate innovation in Health.  Yukl , G. (2010).  Leadership in organizations  (7th  ed ). Upper Saddle River, NJ: Prentice Hall

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Any individual involved with NGT position checks has to be able to demonstrate  FORMAL  competency through theoretical and practical learning Healthboard (HB) has specific risk assessments that must be completed before NGT therapy is commenced. HB pH threshold to confirm positive position is  4.5  or less  There are restricted times where NGT insertion is supported in HB 07.00-15.00(exclusions include access for critical meds) and in OOH situations NGT should  NOT  be routinely placed and alternative methods for support should be sought (refer to NEWT guidance for administration of medication advice for patients with swallowing difficulties log on credentials and password available from pharmacy)

avatar

 Alimo -Metcalfe, B. A, Alban-Metcalfe,  J.   B.  Alimo -Metcalfe (2009)The impact of engaging leadership on performance, attitudes to work and wellbeing at work: A longitudinal study  Bass, B.M. (1985)  Leadership and performance beyond expectations . New York: The Free Press.  Bass, B.M. and  Avolio , B.J. (1993) Transformational leadership  Bass &  Avolio  (1998) Avolio , B. J., & Bass, B. M. (1995). Individual consideration viewed at multiple levels of analysis: A multi-level framework for examining the influence of transformational leadership. The Leadership Quarterly,6, 199– 218.  Beckhard , R. & Harris, R. (1987) Organizational transitions.

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 Berwick (2013)   Independent report Berwick review into patient safety  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf  (accessed May 2021) Francis (in 2010, 2013) Kelly- Heidenthal , P. (2004) Essentials of Nursing Leadership and Management. New York, Thomson Delmar Learning.  DIxon -Woods et al, 2014) Culture and behaviour in the English National Health Service: overview of lessons from a large  multimethod   studyDixon -Woods M, et al. BMJ  Qual   Saf  2014;23:106–115.  https://qualitysafety.bmj.com/content/qhc/23/2/106.full.pdf  (Accessed May 2021)

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 Northouse , P.G. (2011) Introduction to  Leadership:Concepts  and Practice (2nd  ed ) London. Sage.  Northouse , P.G. (2010).  Leadership: Theory and practice  (5th  ed ). Thousand Oaks, CA: Sage Publications.  NPSA/2011/PSA002  Storey, J. &  Holti , R. (2013) NHS  Leadership Academy Towards a New Model of Leadership for the NHS  https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/05/Towards-a-New-Model-of-Leadership-  (accessed May 2021) 

Critical reflection on the issues of leading improvement in practice

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