01.06.15
How a broken chain of hospital communication is impacting elderly care
Source: NHE May/June 15
Graeme Currie, professor of public management at Warwick Business School, discusses the findings of his latest research, which suggests that elderly patients are enduring poor care in hospitals because of a communication block between the frontline and NHS management.
Communication is vital in any organisation but in a hospital it can literally be the difference between life and death. That is why it is so concerning that our research found a broken chain of communication within three hospitals we studied.
Take this quote from a nurse who is now a middle manager. She said: “I went onto a ward a few months ago and one of the non-registered nurses asked me if I wanted a Mars bar. She stopped me and said, ‘Have you had anything to eat today?’ I said, ‘No.’ She said, ‘Do you want my Mars bar?’ It was a really nice conversation.
“When I went back to that ward later on, she came over and said, ‘I’m really sorry if I offended you on the Mars bar.’ Her [nurse] team leader had told her that it was inappropriate to talk to me that way.
“I tell this story to illustrate communication blockages when we are disseminating knowledge. Team leaders don’t want me to hear things, because that’s a reflection on them. So I have to circumvent and go round and look at the data. You know, I was the same when I was at that level in the organisation. I did not want my boss to know everything, because it might reflect failure on me.”
This is just part of one of 127 interviews and 16 hours of focus group discussions with 48 clinical staff and 60 hours of observation concentrated on elderly care.
They paint a disturbing picture of hybrid middle managers – that is, nurses and doctors that have moved from the frontline into management roles – being ignored by their peers, making it difficult to share knowledge up the chain of command due to a professional hierarchy, not only in nursing, but also in the medical ranks, where high status doctors ‘shut down’ peers of a ‘lower’ status.
There has been a sustained attack on management – especially middle management – in the media, with any cuts often targeting them to save frontline services. When times get tough, the knives inevitably come out for what the Conservative MP John Redwood, then secretary of state for Wales in the mid-1990s, called ‘the men in grey suits’.
But our research found these middle managers – like clinical directors, senior nurse managers, diagnostic unit managers or ward managers – are vital in the flow of information from the frontline to senior management.
They are particularly disposed towards driving change so that the quality of care for older people in hospitals is improved. They are uniquely placed to translate strategic management initiatives to improve the care of older people into practical applications in a clinical setting, and to inform those strategic management initiatives in the first place by their understanding of the realities of frontline delivery of care.
But we found a dysfunctional chain of communication where the voice of hybrid middle managers is commonly ignored in hospitals in terms of their suggestions for change to improve elderly care.
Another example of a middle manager with a nursing background highlights how they struggled to engage doctors in improving prevention of falls amongst older people in hospitals. They said: “I have seen instances where doctors have been on the ward and patients have fallen and they’ve paid no attention, which is alarming. They perceive it as a patient safety issue that lies within the domain of nursing and it’s nothing to do with them.”
Even doctors in middle managerial roles are finding their opinions ignored, like geriatricians who take the managerial lead in the delivery of clinical care to older people.
One geriatrician said: “There are still a lot of specialist doctors working within a hospital that don’t see elderly care as part of their business, even though loads of our patients in every area are elderly. For some specialists in areas other than the elderly care department, they don’t seek out knowledge about prevention of falls.”
To combat this breakdown in communication first, we identified social capital – an individual’s understanding, trust and reciprocity with others – as a key factor in helping hybrid middle managers getting their voice heard and thereby exert a level of strategic influence upon care of older people.
Second, we did find examples of hybrid middle managers influencing quality improvement in the care of older people. This happens where teams have developed a collective identity that extends across professional divides.
The challenge derived from our study is one that requires greater support for, rather than criticism of, middle managers, specifically those with a hybrid background, so their voices inform change. It is unfortunate that the current political climate is one that seeks to scapegoat middle manager ranks.
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