Part 1 – Reflective account

Working as senior clinical research nurse at The Christie NHS foundation Trust I’m responsible for the co-ordination of clinical trials and the safety of patients. The delivery of high-quality research requires effective leadership and management of the nursing and admin team.

I embarked on this Mary Seacole programme to support my transition in to this new role, in recent years a focus has been on the nature and quality of leadership and its relationship to the quality of care (Lord Rose, 2015).  Poor quality of care has often been linked to poor leadership (Firth-Cozens and Mowbray, 2001; Walsh and Lynas, 2016).  This was supported in the King’s Fund (2012) report suggesting good leadership is always linked to engaged staff and high-quality care. It is therefore essential I develop the skills needed to be a good leader to ensure we provide excellent patient care.

From the very beginning of the programme my perceptions were challenged with new ways of thinking. I found the most influential content was the concept of reflexivity (Chris Lake, 2018)

“How does it feel to be on the end of you?” (Chris Lake, 2018)

This is not a question I had ever asked myself until starting the Mary Seacole Programme, yet it has been the most important for my development as a leader. I have become more self-aware, I have changed how I react to situations and communicate with the team. An example of my development prior to this programme a staff member was particularly demanding, everything needed to be completed urgently regardless of the workload of others, over time this caused me to be less responsive to her requests and emails and at times I found myself to be dismissive.

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Through knowledge gained from the programme I arranged a meeting and used the helping hand planner for a strategy about how I could influence this situation (Mary Seacole, 2016a). In the past a push influencing style was not successful with this member of staff so I changed approach and looked to build a relationship through a pull influencing style (Mary Seacole, 2016b). This was achieved through actively listening to her feelings, concerns and suggestions to understand her perspectives on the situation. The change of approach had a positive outcome on the situation, we agreed a plan that she has been working to achieve over the past few months, this has significantly improved the professional relationship and dynamics of the team. Recognising this need for change in approach and understanding its impact for individuals, the micro-culture or the wider organisational culture requires good political awareness (Mary Seacole, 2016c) and application of the skills is  described as the wise owl approach being political astute (Baddeley and James, 1987). I am confident this opportunity to change approach or understand I possessed the skills required to influence the situation would not have been possible without the Mary Seacole programme.

On reflection I’m disappointed I was acting in this manner, it’s not the leader I aspire to be as I aim to create a positive, supportive environment for all staff in keeping with the NHS Constitution (DOH, 2015) and The Christie values (Christie, 2018). I consider myself to be a good leader possessing many of the skills and qualities required, but I was letting a situation alter my character and I can see that I was developing unwanted behaviours as reported by (Dolan et al., 2012). A more worrying concern was how my behaviour could be influencing the culture within the department and the potential consequences this could have on patient care. It was reported by West et al (2014) every interaction by every leader at every level shapes the emerging culture of an organisation.  Having this insight, I can now see I was perpetuating an undesirable situation through avoiding conflict.

Dealing with conflict is not something that I have much experience with and could account for my handling of the situation, using the Thomas-Kilmann mode instrument referred to in the programme it was apparent I would avoid conflict rather than addressing the issue (Thomas and Kilmann, 1976). With hindsight I see this was related to my confidence and understanding of how to deal with conflict. In the literature dealing with conflict is considered one of the most difficult challenges for a leader (Ramsay, 2001).  I have learnt form the online virtual campus and face-to-face meetings using a framework or model can help guide the situation and lead to better outcomes (Mary Seacole, 2016d). To develop my practice in this area, I have been using the CEDAR model to facilitate feedback this provides structure with clear objectives through a balanced conversation (Anna Wldman, 2003). As a result, my confidence has increased though having difficult discussions and seeing the positive and productive outcomes for both myself and the team.

It is interesting that early in the programme I was able to recognise my confidence as an area for development as this was also highlighted within my 360 feedback. The 360 feedback tool is recognised as a one of the most effective methods for enabling personal development and behavioural change (NHS Leadership Academy, 2018). My 360 feedback was a beneficial experience with the facilitator and the feedback received. Across all the domains i under rated myself against my peers, direct reports and line managers. Doubting yourself and your ability or believing you are inadequate when the evidence suggests you are competent is recognised in the literature as imposter syndrome (Chris Lake, 2015). I had never heard of this syndrome previously however through further reading and at the face-to face discussion it is something other people have experienced though their career, this was reassuring that other leaders can experience these doubts and insecurities. This is an area for my future personal development, yet I have made progress towards this firstly by acknowledging my abilities and performance as a leader, I have also found a mentor to provide a support network outside of my team. Through this process I have gained knowledge and skills that have changed me as a leader and personally by improving my practice and understanding the impact I have on the team and its wider implications to patients and the service.

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Part 2 – Improving Services within your area of work

Clinical practice is driven by evidence-based research and within my role we support lung cancer patients participating in clinical trials. With research being so high on the NHS agenda (NHS England, 2018) it is essential we improve access and awareness of clinical trials (Cancer Research UK, 2018).  I recognised an opportunity for a service improvement through using technology to increase patient recruitment by matching patients to studies through a clinical trial finder.  This change would involve the team moving away from the current processes that involved updating a word document and sending via email monthly to the multidisciplinary team. See Appendix 1.

From the face-to-face meetings on the programme we discussed how introducing a new process can be met with resistance and the importance of establishing a buy in to the service improvement with key individuals. I therefore performed a stakeholder analysis to identify the key stakeholders and engaged with them to move this initiative forward (Mary Seacole, 2016c). Using my newly acquired political astuteness I was able to use the right language and strategy to gain support from the key stakeholders through advocating the benefits this could have for the patient. Evidence suggests when a change is linked to improved patient care people will be more engaged and supportive (King’s Fund, 2012). Being able to influence and negotiate with different stakeholders was successful within the micro-culture and the wider organisational culture as a result of the knowledge and skills I had acquired through the programme and understanding my impact as a leader.

My leadership style is evolving through this process, and this was evident in the approach I adopted to commence the service improvement. I used a collaborative leadership approach as this is the most effective way to manage change (The Kings Fund, 2015; Sullivan, 2018), As to achieve lasting and effective change requires the co-operation and involvement of the entire team not just an individual (Burnes, 2004). With staff feeling more valued and integral to the change initiative as discussed during the face-to-face meetings and supported throughout the literature (NICE, 2007; Lumbers, 2018; Sullivan, 2018). Through improved self-awareness my actions and decisions are being influenced by the understanding of my impact on the team, I’m more inclusive and open allowing me to utilise other people’s strengths, values and qualities. We formed a working group to review the current practice and discussed about using technology to develop a clinic trial finder, members of the team had experience with different applications and others had been involved with service improvements previous that could support the development of the trial finder through the improvement process.

The model for improvement was selected for this service improvement as it is widely accepted in healthcare improvement and are considered effective in generating lasting and relevant changes in health-care delivery and outcomes (Thor et al., 2007). The model for improvement was first introduced by (Langley, Nolan and Nolan, 1994) and is used by the Institute for Healthcare Improvement for accelerating improvements in health care. The tool consists of three fundamental questions to develop aims and measures followed by the PDSA cycle this provides a structure to test changes and improve the quality of systems (Institute for Healthcare Improvement, 2009; Taylor et al., 2014). See Appendix 2

The aim needs to be time-specific and measurable (Institute for Healthcare Improvement, 2009). We established an aim that by the end of 2018 we would develop a platform accessible via mobile and internet that will guide clinician’s treatment and referral decisions increasing patient recruitment in clinical trials for the lung cancer population. To assess if this service improvement is beneficial the work group established the appropriate measures to assess the outcome, process and balancing as suggested in the online content  (Mary Seacole, 2016e).

The PDSA cyclesupports testing out changes on a small scale before wholesale implementation (Institute for Healthcare Improvement 2009; Taylor et al., 2014) this is important in our area to ensure patient care is maintained. Using the PDSA model we were able to pilot the new trial finder with the lung nursing team with good success. When used by the medical team unfortunately it was less successful, it had a design issue not accounting for the different disease stages. Using this feedback, we adapted the trial finder using the PDSA approach to include the disease stages. This was piloted again with the nursing and medical team with success however the outcome of the improvement will not be available until June 2019.

Built in to the trial finder was a feedback form to allow professionals using the finder to send feedback on its functionality. See Appendix 3

As a result of feedback received further changes were made to the trial finder to ensure this was effective and useful for the service. An example of how this cycle of improvement benefited the design was several requests were received for a home page to highlight updates and important information, with the inclusion of this home page we have been able to communication vital changes to clinical trials quickly through the team. See Appendix 4

It is still too early to report how successful this service improvement has been having not formally been reviewed. Nonetheless the process measures have seen improvements, patient referrals have been more appropriate and trial specific, we have also seen better communication across the disease group with increased number of referrals between oncologists.  The feedback provided has been excellent and the change has been viewed by the team as a positive development for our service.

The trial finder has been received well by stakeholders who are keen for this to be developed across other disease groups. We have therefore worked closely with other disease groups in the research division to share our learning. Within our micro-culture we have seen a reduction in time spent updating changes to recruiting studies, we have also received less phone calls from the multidisciplinary team about studies open to recruitment. As a result, nursing staff have more time for patients and the clinical trial management improving the care and quality of the research.

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