Free Nursing Essays - “A Critical Analysis And Evaluation Of Clinical Leadership And Management Issues Relating To The Lone Worker Policy For A Primary Care Trust”
Introduction and Background
During the 2002/2003 period, the NHS estimated that there were 116,000 incidents of violence against staff, which ranged from verbal abuse, to serious assault. Although it is not known what proportion related to Lone Workers, it is generally accepted that this group of staff is at high risk. (NHS, 2005) The Department of Health suggests that the situation is mirrored in the social care sector and that statistics are significantly under reported. Reasons include lack of management support, self blame, and a belief that violence and abuse is part of the job. (DOH, 2005)
Lone workers are defined by the London Hazards Centre (LHC) “as any work activity which is intended to be carried out in isolation from other workers by an individual or small team of individuals for extended periods of time.” The NHS, 2005, p4 extends this definition to include staff “who work regularly or occasionally on their own, or without access to immediate support from managers or other colleagues” At a Primary Care Trust (PCT) level, employers have a general duty of care under section 2 of the Health and Safety at Work Act and under Regulation 3 of the Management if Health and Safety at Work regulations to carry out, and record a comprehensive risk assessment of hazards to which employees are exposed. There are further obligations in terms of the NHS Human Resources Performance Framework, (NHS, 2001), and the NHS Security Management Services has released a “Guideline for Good Practice for the Better Protection of Lone Workers in the NHS” on 2 March 2005. Against this background, this essay critically explores areas of improvement to the Lone Worker policy at a PCT. After considering ethical issues by means of an ethical grid construct, it applies change management tools to improve the current policy and align it with the new 2005 guidelines for Lone Workers. Note that the PCT identity has been disguised for confidentiality purposes given the sensitive nature of the disclosed situation.
Ethical Considerations
Seedhouse’s (1998) suggests, “work for health is a moral endeavour” the outcomes of which should include enhancing the potential and well being of individuals. His Ethical Grid model considers ethical decision-making at four different levels: in relation to the principles behind health work, duties of the health professional, beneficial outcomes for the recipients of care, and external considerations such as resources, (the law, risks, codes of practice) and certainty of evidence available. Its use allows the identification of significant principles relevant to the situation and justification of a course of action. (Seedhouse, 1998)
The emergence of patient centric models over the past decade in the NHS implies a balance of professional versus patient needs from a moral perspective. It is therefore essential that Lone Worker policies consider the continuum of balancing beneficial outcomes for the recipients of care against the support and training required within limited resources to minimise risk to the provider of that care.
Current Lone Worker Policy Practice and Need for Change
A Lone Worker policy for a typical PCT was evaluated against the checklist for Lone Worker policies shown in the “Guideline for Good Practice for the Better Protection of Lone Workers in the NHS.” (NHS, 2005) The policy needed updating in the following areas:
· Training strategies for the prevention and avoidance of violence,
· Availability of updated risk information for identified areas,
· The availability and means of accessing safety equipment,
· Maintenance procedures in respect of safety equipment,
· Means of previewing cases,
· Detail regarding emergency procedure,
· Role of spouse or partner in after hours emergencies,
· Training for spouse or partner,
· Detail regarding the support provided by the Trust and mechanisms to access that support,
· Details of local prevention and reduction plans.
The policy document was lacking in a direct pledge to staff to provide protection and a clear definition of violence and or aggression. (NHS, 2001)
In addition, Carver and Lehane’s (2002) study of typical issues across six trusts showed that staff generally were unaware of the content and procedures in their Lone Worker policy. Where the policy required movement sheets and diary updates, the staff reaction was that the system reflected a hidden management agenda in monitoring staff movement. Staff perceived the process to be a “waste of time” (Carver and Lehane, 2002, p40) and were concerned that the information was used to compare work schedules and hence to measure productivity. The confidentiality of the central register of staff details for emergency use was also questioned because the register was used for non-emergency purposes such as telephone contact by the PCT to discuss routine work issues. This in turn led to neglect in making client and patient contact information available in diary sheets because of data confidentiality concerns. A final issue was the contravention of the rule to contact a nominated safety officer after completing work and to merely leave a message at the PCT switchboard. (Carver and Lehane, 2002)
This clearly undermined the credibility of a robust Lone Work policy and requires an updating of policy documents as well as a change management process to implement it.
Change Management
Change management is a process that can occur at an individual, team, or organisational level. This essay focuses on the organisation. Change programmes involve analysing the causes of the presenting problem, designing the change programme, implementing and evaluating it. (Iles and Sutherland, 2001) Leaders have a crucial role to play in this process if the change is to be effective, efficient, and permanent.
Strong transformational leadership that balances outcomes, stakeholder interests, and emotions in a positive fashion, with the ongoing management of operational requirements is essential, if a genuine change in policy is to be achieved. (Cameron and Green, 2003)
There is clearly a need to update and revise the existing Lone Worker policy to comply with new NHS requirements, but there is equally an operational requirement to translate the policy change into working reality. Change in a Lone Worker policy must also be balanced within the quadrants of the Ethical Grid to ensure a balanced and moral outcome for the patient, care provider, organisation and hence society. (Seedhouse, 1998)
Change Management Tools
This essay considers two change management tools appropriate to introduce a change in Lone Worker policy. The first is Kurt Lewin’s Force Field Analysis (FFA) and the second a Strength, Weakness, Threat, Opportunity (SWOT) analysis.
The FFA analysis is designed to facilitate change through a three stage process of unfreeze, move and refreeze. The requirement is defining the current state, surfacing the driving and resisting forces, and visioning a desired end state. A crucial component is collaboration and involvement of affected stakeholders in the process. (Cameron and Green, 2003)
The process would be communicating the gap between the current and end state to all players in the change process, the identification of the work required to minimise resisting forces, and lastly consensus on a time line for achieving the end state.
Driving Forces include but are not limited to:
· NHS policy change,
· Safety of workers,
· Moral issues,
· Quality of patient service,
· Performance targets.
Resisting Forces include but are not limited to:
· PCT culture,
· Poor communication,
· Distrust of management,
· Inadequate training,
· Inadequate policy.
In the PCT Lone Worker policy context it is suggested that a bottom up inclusive approach to the FFA, employing techniques such as brainstorming be employed to create a participative change environment whereby management and staff collaborate in identifying the drivers of change and the desired future state as a precursor to redevelopment of the policy guidelines.
The second, a SWOT analysis is designed to match environmental opportunities and threats with internal strengths and weaknesses. Although it is sometime criticised because it is rooted in organisational perceptions, it is a widely used planning tool. (Iles and Sutherland, 2001, and Proctor, 2000) The SWOT should be used to complement the FFA and the two analyses not be seen as mutually exclusive. A SWOT is carried out in the context of the organisation’s mission statement which can be described as an enduring statement of purpose.
An example of a PCT mission statement for the purposes of SWOT could be: a commitment to providing high quality community and healthcare services to the people of the region. The scope of this essay does not allow a detailed review and hence high level examples have been used for the SWOT analysis.
According to Iles and Sutherland, (2001) the questions asked in determining strengths and weaknesses are:
· What are the consequences of changing policy? Will it help or hinder in achieving the PCT’s mission? If the factor does genuinely help the achievement of the mission then it can be identified as a strength. Similarly if it hinders achievement of the mission then is it a weakness.
Strengths could include:
-Management willingness to embark upon a change process,
-Internal resources and budget to fund change process,
-Competent clinical staff.
Weaknesses could include:
-Limited training capacity,
-Limited management time,
-Unsatisfactory organisational culture,
-Poor vertical and horizontal communication.
For opportunities and threats the questions are slightly different.
· What impact is this change likely to have? Will it help or hinder in achievement of the PCT mission? Again, only if the opportunity helps achieve the mission can it be considered such. What is the response to this opportunity or threat?
Threats could include:
-Unsafe work environment,
-Poor PCT rating,
-Sanction from NHS,
-Poor clinical outcomes in treatment.
Opportunities could include:
-Enhanced training capacity that can be leveraged into other PCT areas requiring improvement.
-Safe working environment,
-Motivated staff,
-Driver of improved organisational culture.
The key element in the mission statement is “quality care” that is driven by the critical success factor of an empowered productive work force. The revision of the Lone Worker policy may send a strong message to the organisation that there is a genuine commitment to create a safe and secure environment within which a quality service can be delivered. The McKinsey 7S model of planning organisational change may be a useful model to test the impact the organisation and in so doing consider the interconnected and interrelated nature of the knock on effects of any change process. (Cameron and Green, 2003)
Action Plan and Programme
The current unsatisfactory and dangerous situation at the PCT requires urgent action. Management approval of process and funding should be a priority and an inclusive working group encouraged to start the process of establishing the requirement to change policies in the short term. Best practice guidelines can be accessed from NHS sources and sites such as the Suzy Lamplugh Trust, a registered charity, which is the leading authority on personal safety, as a benchmark to compare current versus appropriate practice and the future desired state. A stakeholder analysis and assembly of a work group to commence the process could happen within a short period.
Reflection and Conclusion
The scope of this essay reflects the range of activities required to implement policy change and this essay should be seen as preliminary and a highly summarised overview of a complex change process. The process of change management is comprehensive and far reaching in its potential effect on safety and capacity within a PCT. Strategic leadership and bottom up participation are vital success factors without which the policy change will be ineffective, and the changes embarked upon unsuccessful.
Reference List:
Cameron, E. and Green, M. (2004) Making Sense of Change Management. Kogan Page.
Carver, L. and Lehane, M. (2002) Protection Policy. Community Care. Issue 1413
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Dowrick, C. and Frith, L. (1999) General Practice and Ethics: Uncertainty and Responsibility. Routledge.
Gillon, R, (1986) Philosophical Medical Ethics. John Wiley and Sons.
Green, B. (2004) Medical Ethics. www.priory.com. Accessed 8 June 2005
Maclaren, P. and Seedhouse, D. (2001) Computer Mediated Communication with Integrated Graphical Tools Used for Health Care Decision Making. Ascilite.
LHC, (2000) Lone Working. www.lhc.org.uk. Accessed 8 June 2005.
NHS (2001) 2000/2001 Survey of Reported Violent or Abusive Incidents, Accidents Involving Staff and Sickness Absence in NHS Trusts and Health Authorities, in England. www.nhs.uk/zerotolerance
Iles, V. and Sutherland, K. (2001) Managing Change in the NHS: Organisational Change. NHS Service Delivery and Organisation.
NHS (2005) Not Alone: A Good Practice Guide for the Better Protection of Lone Workers in the NHS. NHS Security Management Services
Proctor, T. (2000) Strategic Marketing Management for Health Management. Journal of Management in Medicine. Volume 14, 1.
Seedhouse, D. (1998) Ethics: The Heart of Medicine Second Edition. John Wiley and Sons.
Simpson S. (2000) Managing The Personal Safety Of Lone Workers
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