Getting the balance right- Nursing leadership in a digital age.

As we move into the winter months in a year that has presented challenges beyond anything ever faced, we must refocus and ensure that we learn from what has happened. Challenges are also opportunities to do things differently and collaboratively and can result in positive change.

In this last month when we have been informed of an investigative review alongside the push for a national care service. There is undoubtedly real concerns on how this will impact the sector, especially when sustainability is already fragile for many providers. Some may dispute that the timing of this review is not best placed and will not serve to support the future stability of the social care sector.  The real hope for such reviews is that they allow a collaborative approach which provides choice and control for the people of Scotland and to ensure the future of health and social care integration.

We understand the care sector is extremely complex and tightly regulated to ensure that care is delivered in a way that edifies the safety of all residents and that the care delivered within a framework through real professionalism by meeting all standards around personal outcomes. Ensuring personalisation is central to realistic care and is something the care home sector prides itself on, and rightly so.

For a mutual agreement to happen it is key to ensure mutual respect and understanding exists. Many of the frustrations the sector has felt have been as a result of not working in sync, making changes at one end with little regard on how this may impact across the care sector.

The mutual aid and care assurance provided by NHS boards and HSCP’s was initially viewed by some  with skepticism, however in the main this has now been shown to be supportive in nature and also provides a recognition of the professional care being delivered across our care at home and care home services. Despite the inequalities that have existed in relation to accessing PPE, testing for staff and residents, alongside visiting restrictions there is a real desire to get problems resolved as quickly as possible to reduce the risks to residents and staff, especially round stress and distress.

 It is completely understandable that we must be stringent and inspected to protect against the risks of spreading infections as we care for the most vulnerable groups and have come through the greatest loss of life. The care sector requires prompt and workable guidance, and this has not been the case over the last several months, often being left in a state of limbo, spinning plates until the next piece of guidance or legislation is advised, which often conflicted with the previous guidance.

So, it’s important to concentrate therefore on what we can control.

It is people that make things happen and therefore we must ensure that there is leadership that will be strong and appropriate to take our staff through and out the other side. Staff are without question our greatest asset and as such we must ensure we prepare them to work to the top of their roles and that they are fully supported to understand their responsibilities alongside promoting a creative environment to enhance change to best fit the needs of our older people, who make care homes their homes, either through need or choice.

One thing that has been paramount during these last few months is that our care homes are our residents’ homes, their homely settings, not a hospital ward and as a sector it is important that this continues to be raised in relation to impractical, unworkable guidance and to protect people’s human based rights.

This is reliant on our professional care home managers feeling empowered and ensuring the needs of residents and families remain the key priority. This requires resilience demonstrated through leadership and professional integrity.We fully understand that transformational leadership in care homes can improve staff job satisfaction and retention and enhance the delivery of effective care for residents but this needs to be future proofed including in the context of the new digital age in order to succeed. Leadership needs to be promoted at all staff levels as part of ensuring the development of healthy work cultures and behaviours. Throughout this pandemic the words all in it together have been mentioned often and are truly the way to promote true compassionate leadership.

As we understand and learn from the effects of unhealthy work environments and the detrimental impact these can ultimately have on care outcomes then we must focus on leadership that is compassionate, is empathetic and supportive. This style of leadership is what provides trust and safety for staff to develop and to feel motivated and valued and ultimately drives service improvements and best value.

The wellbeing of staff therefore needs to be at the fore-front and this is as important for managers just as it should for all other staff. Managers can often feel isolated and pressured to feel like they are coping when they may be struggling. The need for self -care therefore needs to be recognised as a key determinant to ensure stability during a time of uncertainty.

Leadership historically is viewed through a lens of a ranges of styles, which may be interchangeable to enhance and ensure safe practice, and should promote access to information resulting in a motivated high performing efficient and effective team.

Over the years we have seen a leaning towards a more empathic style of leadership (humanity based) which ensure the manager and the staff are integrated in the aims and ambitions of the team through a mutual trust and open culture. Gone are the days of traditional bureaucratic leadership of command and control within a hierarchical approach. As we develop a transformational approach to service redesign so does the leadership style transform. Therefore, based on this it seems natural that our leadership style requires to be mindful of the gains that leadership could have by the use of e-health, social media and digital progression.

There has been a real push for the development of digital platforms to ensure live information around care and the conversion from paper-based processes to digital. This has been escalated during the pandemic to ensure tighter safeguards. An example of such is the introduction of the daily digital safety huddle management tool, rolled out to care homes in line with the platforms used by NHS nursing staff. The purpose being to be able to deliver excellent care and take appropriate escalation procedures around staff and patient safety and monitoring. During the last few months we have witnessed visually and in practice the real benefits in the use of digital platform to access information and deliver services through virtual technology such as Near Me. Although for some scenarios the preference would still be to be a face to face conversation, it definitely allows for a speedier decision making process and ensures better time management.

So, to lead into the future it is important our staff embrace the technology and make it intrinsic to their working practice whether this is through teaching, providing clinical supervision or promoting e-care planning, or rostering to ensure a capable workforce. This will require financial support and time invested to rectify digital poverty across the sector to ensure national equitable approaches which do not put our residents at risk. It also requires enhanced knowledge and skills to be developed around data analysis and quality improvement processes. The sector has innovative staff but requires this collaborative consideration to achieve a meaningful vision for care home nursing.

When I took up the post of transforming workforce lead for nursing, I didn’t envisage how the term transforming would truly be brought to life, during this exceptional year of the nurse. What a year indeed. The speed and pace of work has been exceptional and has managed to move nursing to the forefront of the future integration plans, with the true value of nurses recognised through their resilience and compassionate care. On a personal level until last year I had never written a blog nor was I an active participant on social media however the professional benefits gained by keeping updated and reflective practice are priceless and I would recommend all nurses to let your voice be heard.

I truly believe all nurses are transformers and leaders, we all have a journey, some just starting off and others nearing the end of their professional careers with a legacy to leave and be taken forward. Lead by example, be true to yourself and your patients/residents and ensure you advocate to ensure care is never compromised and our communities have the opportunities to thrive and our vulnerable receive the best care possible through leading from the heart.

Jacqui Neil

Transforming Workforce Lead 

@TransformNurse

I noticed in my calendar this morning that Monday is International Peace Day. It’s a day designed to promote peace among nations and peoples. The UN established the day and its website describes the day by stating that ‘peace is recognized as both an innate state of being, and a dynamic evolutionary process wherein constructive growth can occur and the children of this and future generations may gain hope for a better world to inherit.’

A bit wordy but in essence peace is both internal and relational. Reading the description reminded me of a phrase from the work of one of my favourites, the contemporary American novelist and short-story writer Veronica Roth, who wrote that:

“In order to have peace, we must first have trust.”

I will leave world peace to the Nobel prize winners but there is a truth in the linking of peace and trust which is inescapable. Whether in the realm of international politics, in the interactions of lovers, in the contracts of care or during a pandemic there is a profound interconnection between a sense of peace and ease and the extent to which trust is present.

But the problem is that if there cannot be peace and what comes with it without trust then there has been very little trust both before and during the pandemic in the realm of social care.

Where else would you get the extent of mistrust as in some of the contractual terms and practices between local authorities and social care providers. Explicitly what does it say of trust when electronic call monitoring systems originally designed to keep lone workers safe are used in homecare services to effectively electronically tag workers, to pay providers only for their contact time and to penalise for late arrivals or only to pay for a proportion of attendance. As one colleague put it – it is almost like saying to a nurse in a hospital you only get paid for the time you are at a patient’s bed but not your walking between them. There is little trust in the way we contract and provide care at home and housing support in Scotland. Without trust there can be no maturity of relationship.

Where else but in social care in the community would we treat workers with so little respect and maturity that we clock them in and out like some sort of Victorian factory, failing to give them autonomy and the capacity to make professional decisions? So, if they come across someone who is distressed by loneliness and simply wants company they have no capacity to sit and have a cuppa which restores. Why do we not have a system that instead of clock-watching care enables a worker to design their day around the needs of the supported person  rather than the demands of the system? Instead we have a system  of mistrust designed to drive down costs as much as possible.

This lack of trust was endemic during the last few months not least in relation to additional financial support for social care providers where in some local authorities the support and collaboration has been remarkable but in far too many the level of forensic examination of applications for financial support for things like PPE, extra staffing and additional costs, has been equivalent to trying to get money out of the Royal Mint. Without trust there can be no growth in relationship.

In all the talk in the last 24 hours about a second wave of Coronavirus I think that we need to reflect on the nature of trust both in the last few months and as we move forward. For perhaps the evidence of lack of trust and therefore absence of peace can be seen at its sharpest during some of our responses during the pandemic.

Much has been and no doubt will be written about the way in which as a society we failed to protect the most vulnerable in our care homes; the prioritisation of the NHS, confused Guidance, misuse of DNACPR forms, the absence of testing till late in the day and so on. But where a trust deficit has been perhaps seen most acutely is in the degree to which we have responded to the issue of allowing families in to see their loved ones in care homes.

This morning one of the main stories on the BBC website along with news of a second wave was from the English social care minister talking about visiting into care homes and making it very clear that all visits would require to be strictly supervised. This is all about trust. There is no trust when you have to police the love and care of family for their loved one. There is no trust when you have to have care wardens dressed in PPE to remove the privacy of individuals and disproportionally limit their rights of exchange. There is no trust when it is assumed that more harm will come from family rather than, at least for the last two weeks, the risks of a failed and broken testing regime designed to protect staff and residents alike.

It is time to start trusting rather than on the edge of a second wave to retreat back into positions which put up the walls of defensiveness. It is time for all to start to trust the professionalism and dedication of care home staff and providers rather than assume ignorance, lack of professionalism and ability. I have heard this week of one nurse manager who after 40 years of dedicated professionalism has resigned because in essence there is a lack of trust in her professionalism which has kept people safe from Covid from those who know nothing of what a care home is and does. Without trust there can be no community of care.

Trust is that most elusive and intangible of human emotions and characteristics. It is, however a fundamental for human relationship and community cohesion. It is an essential requirement for social care. Trust is diminished by lack of knowledge, by fear and the absence of relationship. It is fostered and grows by being alongside, by asking questions rather than knowing all the answers, and by taking proportionate risk.

I think as well as all the work we are doing in directly fighting the virus we also need to do the necessary work to build trust collectively as politician and commentator, carer and family, community and provider.

The psychologist Dr Andrea Bonior argued that there are some six requirements for building trust – I suspect they have a place in these days on the edge of a second wave:

1. Say what you mean and mean what you say – In the noise of conflicting priorities there is a need for clarity and clear communication. We often hear what we want to hear rather than that which is said. I hope in the weeks ahead as we face new challenge we can be clear and concise, truthful and honest.

2. Be vulnerable – Vulnerability is often used to describe that which is fragile and broken, limited and unwhole, but rather, I believe, our vulnerability should be seen as part and parcel of our humanity. It only becomes a weakness when someone uses that vulnerability for their own negative ends, it is a strength when we live through that vulnerability to be authentically who we are. So, in the days and weeks ahead let us not pretend to be who we are not, to know what we do not have the knowledge of, but rather to own our limitations and lack of certitude.

3. Remember the role of respect – Respect comes from an ability to understand the other and to see the value and essence of who they are. It is also rooted in a mature understanding of our own self. So, in facing the next few weeks I hope we can as professionals and colleagues come out from positions of defensiveness to recognise the ability in the other, the knowledge and expertise in that which we do not know, and to be honest in admitting our own frailties.

4. Give the benefit of the doubt – There are times in human relationships when we simply have to go into the unknown trusting that the other will not hurt or harm us. This is perhaps the hardest thing to do especially if there have been reasons for a lack of trust in the past. When pressure comes it is of the ultimate importance to be able to take a risk that the other will be true to their word, will adhere to what they say and walk their talk.

5. Express your feelings functionally, especially when it’s tough – it may not surprise many that there is a real emotional illiteracy in much of society and those who work in and around social care are no stranger to that lack of maturity. To hide emotions to the extent to which they overwhelm and overcome is not a sign of strength or ability but rather the reverse. One of the insights that I have gained from the last six months is that it is only by the honest display of feelings and emotions in all their raw pain and reality, that we can meet the challenges of a virus which can overwhelm and of emotions of grief and loss which can become so all consuming.

6. Take a risk  – I wrote last week about risk – but it is important to recognise that risk is not a solo activity but a mutual journey. Trusting the other that they are able to take a risk but one grounded in a mutual concern is the essence of being together in all human relationships. In facing challenges there are always moments and times when we venture into the unknown and the fearful, it is at such times and moments that we need to have the certainty that our risk-taking is upheld by the regard and support of others – we all need to know that there is someone there to have our back.

I hope as we move into the next stage of this pandemic, into days which will have their times of darkness and fear, that we seek to build the trust that gives us peace; that we work together to respect the knowledge and professionalism of the other, and that critically we work as hard as we can to continue to foster connection and contact between care home residents and the co-carers who are their families.

There will be many pressures in both community and care homes, upon our staff and families, but these will not be overcome by retreating into fear and blame, but only through trust and developing relationship. The future of social care in Scotland whether in community or care home can only be one built on trust and then perhaps we might have the peace we all seek.

Donald Macaskill

This weekly blog is a day later than normal. I spent yesterday cutting a hedge or to be more accurate doing the manual labour when my suitably qualified and certificated brother used two vicious large petrol hedge cutters! This happens about twice a year – it is a big hedge! Conditions were not ideal – a sharp wind and not so occasional showers but the job is now completed  – even the tidying! Only when I put the machines away do I realise what dangerous and risky pieces of machinery they are.

I have been thinking a lot about risk in the last couple of days. Risk is part and parcel of everyday living. There is no context which is completely risk free. The way in which we grow from children into adults usually teaches us how to manage and deal with risks, having been protected from them as children to a greater or lesser extent. We learn strategies for dealing with risk, we develop models and systems and we fashion an internal risk management system! For there is, in reality, no such thing as total safety but rather there are degrees of safety and levels of risk. Risk is therefore a given of human living and relationships.

It is also a truism that risk is highly personal. I may make judgements and undertake activities and consider them normal and safe e.g. going skiing or mountain climbing but another person may consider those to be highly risky and never to be touched.

The influencers on how we manage our approach to risk are numerous. The way we have been brought up, the extent to which we have taken risks and things have worked out well, the impact of our behaviour upon others, especially those who are important to us – all are factors which influence our approach to risk. But by in large, part of adulthood is that we develop strategies that enable us to have a healthy approach to risk and to develop an acceptance that safety is often illusory and subjective.

Life is all about risk and risk is all about relationship. As someone who worked in both child and adult protection and having trained hundreds of staff in safeguarding I have always been acutely aware of how important it is to get the management of risk right. The failure to analyse and assess, to take action, to guard and protect can be literally a matter of life and death. But equally there are dangers of over-protection and risk avoidance which can result in care and support which suffocates with kindness and which serves to limit individual autonomy and personal control.

In conversation last week with colleagues from around the United Kingdom I reflected that where we are now in our current response to Covid is all about risk management. How we manage the obvious risks around us and the decisions we make and take will have a profound impact on the way we control the disease and also the nature of the communities and societies we are forming in that response. But whilst risk may frequently be an individual decision and action, it is influenced by and in turn affects relationships. I can make and take decisions which are appropriate for myself but when those decisions are impacting upon others or are made on behalf of another for whatever reason then the management of risk needs to be forensically examined and transparently justified.

The debate which is for so many of us the most critical and crucial discussion we are having these days is how do we improve and increase the access to care homes to allow families to get back together. In essence that debate is all about risk and how we manage risk. It is far from an easy consideration, in fact it is heart-breaking.

Yesterday’s Big Interview in ‘The Times’  newspaper was on Prof Sir David Spiegelhalter from Cambridge University, who has impressed me every time I have seen him on television during the last few months. But he is also someone whose work I have known for some time because he is an ‘expert on risk.’

Spiegelhalter a long time before the pandemic said:

 “The media want to make things exciting and usually alarming, so there’s a tendency to present figures in a way that makes them look dramatic, and we should be able to take these stories apart…it’s important that it’s not just left to the very senior people to draw attention to the misuse of evidence or statistics.”

And how true has that been in the last few months! –  don’t we all know the truth of the deception of statistics and the perversion of data.

In his book, The Art of Statistics,  Spiegelhalter argues that there is an onus on scientists like him to explain risk to the general public in a way that achieves the appropriate balance between informing and causing alarm. He appreciates that we all understand risk in  an often very individual way and even two scientists looking at the same data may come up with a diverse interpretation because of the moral paradigm of risk that they are working with.

At the present time we are witnessing an alarming increase in daily cases in Scotland in no small part generated by the risks which those of a younger age have taken around house gatherings and behaviours in hospitality settings. There are so many ways in which I can understand their behaviour. The data seems on the surface to present the risk of Covid to them as one which is relatively low and so the accompanying warnings that it is still a virus that can result in crippling long-term damage to young people are not heard. What dominates is the desire to get back to normality, to live life to the fullest, to reconnect and to enjoy. All perfectly understandable. But as Spiegelhalter states:

“The point is that risk is not just risk to yourself it’s risk to others as well,”

The challenge is, in part, that our understanding of risk as a younger person is palpably different from risk as we deal with it when we are older. At times I think the psychology of our public messaging has failed to appreciate that risk really does feel different dependant on the age you happen to be. So rather than an emphasis on risk the narrative should rather focus on our mutual responsibility one to the other not in order to ‘guilt out’ folks but in order to tap into the altruism and humanity which so many showed during the depth of the pandemic in the spring. For me in the last few weeks the biggest impact on local lockdowns has been on our older population and especially those families prevented from visiting residents in care homes which have had to close to indoor visiting just as they were beginning to open up. Individual actions can lead to a real desolation for others at this time perhaps to a degree that individual risk-taking has never impacted on others before. But I am not convinced those taking ‘risks’ truly understand the consequences upon others.

When we consider the issue of care homes I think we are getting to the heart of the risk debate that many of us are daily struggling with. The continual debate I have with clinicians and advisors is how do we get the balance right between protecting people from the virus and enabling them to have a quality of life which is enhanced by contact with their families and the wider community.

Spiegelhalter states:

“This whole crisis has turned into an issue of risk management. That means perpetually a balance of potential harms and benefits. There’s no such thing as safe, there’s no such thing as right or wrong. Everyone has to carry out that balancing act.”

As we move into winter and face the challenges of weather and potential increased instances of lockdown we need to find a better risk balance to enable people to be reconnected. I think we can learn some lessons from the world of safeguarding as we pursue that balance. At times I fear that maybe not surprisingly during a pandemic we have become automatically risk avoidant rather than risk enabling. We need to correct that imbalance.

In ‘normal’ times in health and social care a traditional risk aversion approach has gradually been replaced in the last few years with talk about enabling risk, and with the development of new models and ways of working which enable individuals to re-develop strategies for risk-talking and managing risk even in situations and contexts where familiar securities are no longer there, such as post illness or with declining capacity.

A major Department of Health consultation ‘No Secrets’ examined their approach to adult safeguarding and risk, and stated:

‘A balance needs to be established between empowerment and protection and between the rights for self-determination and the duty to ensure safety of people… We want to support people to be citizens and take risks that they understand. ‘

Good adult protection and safeguarding is about balancing risk. We all live within environments which are not risk neutral, but we have developed the skills and tactics to minimise, control and live in the face of such risks. That is part and parcel of what good support should be.

Risk enablement is about proportionality. It’s about nurturing within those who might be more vulnerable the insights and abilities which enable us to live in the world.

During a pandemic and especially now it is as we struggle to get a better and more proportionate balance between risk avoidance and risk enablement that I think we need to appreciate that for those who are at the end stages of their lives that seeing family, being able to be held, being together  – all with appropriate protection – trumps an approach to  risk which is in danger of adding to the number of days lived but diminishing the quality of those hours to a point at which they cease to have any real value. There really is more to life than chronology; more to our life than mere existence. There are no easy answers but simply asserting data and science as the sole predicators for decision-taking on risk is no longer sufficient or responsible, not least as it fails to value the rights of individuals.

I will let Spiegelhalter have the last word:

“Experts aren’t always right, they disagree, scientific disagreement is an integral part of science. When I hear a politician saying, ‘We are following the science’, that is when I start screaming at the radio. You do not follow science because it doesn’t tell you what to do. It is sitting there beside you humming and hawing.”

Dr Donald Macaskill