Article Text

Article 5. Strategic decision making, motivation theory, and junior doctor interviews
  1. J Wardrope,
  2. S McCormick
  1. Department of Accident and Emergency Medicine, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
  1. Correspondence to: Mr Wardrope (Jim.Wardrope{at}

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Those of you who are avid readers of the internet section “St Jude's diary” will have seen a situation developing regarding possible sexual harassment. However, many may have missed the last instalment where a staff nurse has made a formal complaint about sexual harassment by one of the staff grade doctors. Review the St Jude's diary sections for articles 3 and 4 (emjonline/contents/SIMS3, SIMS4). Were there warning signs of this problem? Could this have been handled differently? A major in tray task this edition is to set out the management action of this complaint (emjonline/contents/SIMS5).

The psychotic patient was a significant problem. He did not want treatment but obviously needed help. He was restrained and then sedated and is now doing well under the care of the psychiatrists. What is the legal context for this action of treating patients against their will? We will examine this in a later time out. How would this differ in North America, Europe or Austalasia. E-mail responses welcome.

Candidates OP, SJ and CB were popular choices for short listing. For the other five there was less agreement. A tight person specification should make this process much easier and fairer. The person specification used for the shortlist is on the internet in the feedback section along with the shortlist.

The preparation for the independent review has taken a great deal of time and effort and had a definite effect on staff morale. For the first time all parties involved have met to establish the facts of the case. Statements have been given. The A&E staff involved have required a lot of support as they became very anxious about the process. Re-assurance and encouraging a fully open and honest approach have been helpful.

The independent review has reported and a copy of the report is given on the internet. Staff are relieved but it seems the matter is not going to rest here as the complainant is still not happy. It seems the case is going to the Ombudsman.

The problem with the ECG machine has been resolved. This was a key piece of equipment whose replacement was urgent and important. The “normal” procedures had failed so you went to see the medical director to discuss the issue. You took with you a draft letter to the medical director that stated the department could not safely see patients with chest pain and that the hospital's ability to meet the standards for thrombolysis were seriously compromised. This direct approach to the medical director has resulted in a new ECG machine. One small battle over but does this show a worrying lack of general equipment in the department?

The memo regarding a request for information from the police contained an interesting typo (they had “found blood on a widow, oops window”) (emjonline/contents/SIMS4). Finding a widow with blood all over her might well represent a “serious arrestable offence” where it might be justifiable to break patient confidentiality. Blood found on the window after a simple burglary is unlikely to meet the criteria. Guidelines concerning the release of information to the police were agreed by the British Association for A&E Medicine, the Association of Chief Police Officers and the Central Consultants and Specialist Committee of the British Medical Association.1

These rules apply to the UK. It would be interesting to hear how this problem might be tackled in other countries.

The request for an expert opinion in a case of personal injury is not NHS work but represents a variable workload for many A&E consultants. It is important that if you are undertaking this work then you should have the necessary training and expertise. There are a number of training courses designed specifically for this task. Dr York has been trained and is a member of one of the professional organisations of expert witnesses. The report is another in tray task in this edition, a task that of course will not be carried out to the detriment of NHS work.

Time out—people


Motivation of groups of individuals to reach agreed objectives is at the heart of management. The variety of theories that try and explain motivation shows how difficult it is to encapsulate basic, human drives. These theories all help to explain different aspects of motivation and are useful in considering the issue. They are summarised in table 1 and are well described in Cole.2 They range from the “Jekyll and Hyde” view of Theory X and Theory Y (some workers need to be driven and constantly monitored while others are driven by internal desire to serve and to do a good job) to the very functional model of Herzhberg who examines the positive and negative drivers in any work situation (motivators and hygiene factors). This article will not re-iterate these theories but attempt to examine how they might be used to explain the behaviours of some of the key figures in St Jude's.

Table 1

Summary of some of the many theories that help describe different aspects of motivation (derived from references 2,3)

Most people entering medicine and nursing do so with some belief that they will be able to help people and that the force of Theory Y should be stronger in individuals than Theory X (they should be more internally driven by the desire to do a good job than need constant external monitoring). Indeed over the past 50 years the NHS has depended on individuals putting much more into the job than their contract. However, such commitment needs some reward. In the past this was given in terms of respect and positive feedback from patients. However, as medicine becomes ever more pressured, time available for the less technical areas of patient care reduces the “quality time” that permitted such human interactions in the past. While the doctors and nurses are still regarded with respect by many members of the population there have been increasing attacks on the professions by the media and at times by politicians and managers. Some of the speeches of high ranking politicians in the current UK government have not been models of how to motivate people. Let us examine the current behaviours of some of the staff of St Jude's.

Mr London has obviously given many years of hard service to the department. He achieved a lot, obviously worked very hard and was initially driven to succeed by the positive motivators of respect and recognition for running a good unit and of turning around a failing department. However over the years the “hygiene factors” (Herzberg's theory the factors that lead to dissatisfaction) have started to build up. Hertzberg points out that it takes a lot more motivators to achieve balance if there are negative factors around. He is now bearing a number of scars, complaints, battles lost with management over badly needed increases in resource, battles with colleagues over support for the department and criticism when things go wrong. Also the negative effects on family life, of being called even when off duty, the feeling that now someone is always looking over your shoulder and one mistake is not allowable are taking their toll. Even the Equity Theory is becoming important. He has always known the earning potential of some other colleagues is much greater but he made a definite career choice despite this disparity. It still chafes to see the young plastic surgeon in his very expensive sports car but it hurt even more to see a younger colleague in A&E get a merit award. He feels that he has given a lot and received no thanks. He has become cynical and embittered. However, he still cares about patients, especially children and will still respond with skill when the chips are down although he finds it increasingly difficult to tolerate the increasing demands of routine work. How do we change this situation, and more importantly how do we stop it happening in ourselves and in colleagues?

Dr York is starting out with enthusiasm and zeal. She has the same drive to make things better that Mr London had in his early days. She is also, perhaps, very aware of her illness and is keen to show that this does not have an impact. The negative factors of the job have not had time to accumulate and balance the motivators of the new role.

Dr Wales sees medicine very much as a job to earn a reasonable living. He will do this to a reasonable standard but is unlikely to put much extra effort into his post. He is likely to have a stronger influence of the Theory X mentality. He will not tolerate many negative factors and he may be likely to “soldier” (to do the bare minimum to prevent any disciplinary action).

Sister Oak has a strong adherence to tradition and professionalism. She has a large amount of experience and has seen a number of fashions come and go. Her motivation is possibly directed at keeping the unit running as smoothly as possible, perhaps overemphasising the need to process patients quickly. In terms of McClelland's Achievement/Motivation theory her need for Affiliation (n-Aff) might be a stronger motivator than the need for Achievement (n-Ach). Loyalty to a department is commendable but it can sometimes stand in the way of progress.

Sister Ash is highly ambitious. While she has a high level of care for patients she also wants to see her profession advance and to increase her own skills and potential. She is willing to work hard and to “go the extra mile” as long as this involves challenge and innovation. Routine repetitive work she will do well but will not put in any extra effort.

It is not constructive merely to use motivation theory to perform amateur psychoanalysis. The key is to use this analysis to improve performance. Analyse the motivation of some of the staff in your unit. What are the main motivators for SHOs, nurses, reception staff? How might you use some of the motivation theories to identify issues that motivate staff and those that cause disenchantment? How would you approach some of the motivation problems in St Jude's? In this area there are probably no “right answers” but some feedback discussion will be given in the next article.

Time out—strategy


Life is full of choices and when you are considering long term projects that are going to require a large amount of time, effort and resource then it is crucial that the correct path is followed at the outset. The process of moving an organisation from the present reality to the future vision is complex but aided by some simple management techniques. The first step is to make the right decision and plan overall strategy, strategic decision making.4 The second is to analyse the changes involved and get key people to “sign up to” the plan. The third phase is implementation or detailed “project planning”.

These techniques have already been used in examining the waiting time problem and we will use this to examine the process more closely.

Define the problem and/or objectives—This is the key step. What are the objectives for improving waiting time? New government targets in the NHS plan give very concrete objectives.5 Are these also the views of the local purchasers of the service?

Generate options—This is the “creative” phase where lateral thinking is paramount. This stage should be inclusive and all ideas should be put down no matter how impractical. The solutions for waiting time problems will vary but table 2 shows some of the ideas at this stage.

Table 2

Option appraisal process for reduction of waiting time. The long list after option generation, the short list after option refinement, and the choice of options after option appraisal

Assess/test options—The first stage is to refine the option list by examining the “long list” and removing those that are not practical or feasible. Be careful at this stage not to discard an option because it is radical but some sifting will have to take place. The second phase is to examine options in greater detail to look at the details of cost, implementation and risks. The third phase may be to test some options, usually in a theoretical model but this may entail some “market research” and sounding out key stakeholders.

Option appraisal—This first step is to define the criteria against which the option will be judged. Common criteria include cost, acceptability to staff and other stakeholders, risk of not achieving objectives (risk analysis). Often these criteria are given different weights to emphasise the key criteria. The other key part of this process is stakeholder involvement. There is no point in deciding on an option that a key stakeholder will not support. For example, if the chief executive vetos your chosen option all your work will be wasted.

Choose option—This is the crunch time when a decision has to be made. By this time often there is a clear leading option but at times the choice can be difficult. This is where leadership and decision making skills come to the fore. Despite all the process it will often be judgement that counts. However, it may be possible to merge some options to provide a package that combines the strengths of two or more of the options and often reduces the risks.

Process review—Critique the process. What went well, what could have been done better? Has it taken too much effort? What lessons might we learn for the future? Those who carried out the decision management exercise in SIMS article 3, review how to conduct the exercise. Do you follow all the steps? What shortcuts did you take? Would this work in reality?

Those experienced in real strategic decisions will recognise that this approach is not always needed. However, if the problem is difficult, or if it is hard to motivate staff to change then option generation and appraisal is a good way of setting out the consequences of no change. Involvement of staff is again key to making the next steps of implementing change happen.

In tray


  • The internet section contains the statements from staff involved in the allegations of sexual harassment.

  • Reply to the Ombudsman's office regarding the complaint.

  • Notes from interview with personal injury claimant.

  • NHS plan (www/

  • Letter from ophthalmologist

  • A junior doctor has come to the department with an infection on the back of his hand. During the examination you note bruises on the arm and antecubital fossa. On direct questioning he confirms that he has been under a lot of stress recently and has been injecting street heroin. He pleads with you not to break his right to confidentiality as a patient and promises that he will seek help, take a week's sick leave and stop injecting


  • What action is needed over the allegation of sexual harassment? What are the policies and procedures for possible disciplinary action?

  • Review your own department's equipment “wish list”. Write a case of need for the first two items.

  • Draft a report following your interview with the personal injury claimant, is there other information missing?

  • Outline your actions in the case of the junior doctor with the drug problem.

  • Consider the case of the psychotic patient. When can you treat patients against their will? Examine the legal position. Do you have a “game plan” to manage these rare but critical events?

  • Prepare for the interview for the junior doctors.


The characters and incidents in this series are mostly fictional and any resemblance to persons or departments is coincidental. Some situations are based on real problems but in no case have names or details been used that might identify a department or person.

Web info (

Staff statements

Notes from personal injury patient

Letter from ophthalmologist

Report of independent review

Further letter from Mrs Green


NHS Plan


We would like to thank Peter Driscoll, Robin Illingworth and Carlos Perez-Avila for their detailed comments.


Supplementary materials


    The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.

    Article 5 - FEEDBACK



    Dear Dr York,

    Welcome to St Jude's hospital and I hope you are settling in well. I understand that as A&E departments go this one is quite busy and you are going to have an interesting time here. I hope I can start our working relations off on a good foot by giving you a pleasant task rather than a problem. I have just seen a young lady in clinic with a dentritic ulcer that was referred on to us by one of your SHOs. Apparently the patient gave a vague history of having a FB blow in to her eye but when the cornea was stained the SHO was suspicious of the corneal damage seen. Unfortunately our on-call SHO advised, over the phone, the use of a mixed antibiotic/steroid eye drop and suggested discharge. Your SHO has recorded: ???dendritic ulcer. Plan - Hold off on the drops for tonight and Ophthalmic review in the morning. I need not explain to you how badly wrong this could have gone. Pass on my thanks to your SHO and please remind them all that we are more than happy to review any ophthalmic patients the following day if they are unsure of a diagnosis.

    Welcome once again.

    Yours sincerely

    Mr U V Itis
    Consultant Ophthalmic Surgeon

    P.S. We did agree with your department 5 years ago to remove all steroid eye preparations from the A&E eye room stock. Could you please check that this is still the case? I think this case shows the value of our joint SHO teaching sessions and I will be happy to continue to help.



    On the 20th of December of last year I was at the staff Christmas party and was the subject of an unpleasant advance by Dr Philip Wales.

    During the last few months I have worked with Dr Wales in the A&E department and found him quite pleasant but unfortunately he thinks that I have some feelings for him. He has often made suggestive remarks of a sexual nature to me but he also directs comments of a similar nature to other female members of staff. I am not against this behaviour necessarily but recently I felt that I had been the subject of these comments more than others.

    At the Christmas party he had clearly been drinking and whilst I was on my way to the toilet I encountered him in the hotel lobby. He once again made suggestive comments saying that he fancied something really sweet for dessert! I was a little scared as I was alone and he was standing to close to me for my comfort. As I backed away from him I stumbled against a cloakroom door and fell backwards in to the room. When I got up I discovered that Dr Wales had entered the cloakroom and closed the door behind him. As I tried to push past him he reached down and put his had up my skirt on to my thigh. Just then there was a banging at the door and Dr Wales stopped suddenly. He turned around and walked out as if nothing had happened. I just sat down and cried as I was scared by what had happened. When I had gathered my thoughts I went across to the ladies toilet and fixed my make up as my crying had spoilt it. While I was there I spoke with Sister Ash who helped me gather my thoughts. Following this incident I avoided Dr Wales but noticed that he continued in his normal behaviour with other women at the party. Unfortunately I could not get the incident out of my mind and again became tearful. At this time Sister Ash helped me again and organised a lift home for me with Mr London.

    Recently Dr. Wales has again made some suggestive comments that I feel are inappropriate and unwelcome. I am most upset by these incidents and whilst it would be easier to ignore this situation, I feel that a stand must be taken against such behaviour.

    Staff Nurse Jenny Holly



    As a Sister at St Jude�s A&E department I was at the staff Christmas party last year. Like many people I had been drinking and at one point needed some fresh air. As I left the party and walked through the lobby I became dizzy and stumbled, bumping my elbow on a door. I decided to run my bruised elbow under a cold tap so went to the ladies toilets. When I was there Staff Nurse Jenny Holly entered the room and seemed very distressed. When I asked her what was wrong she was reluctant to say but admitted to having had a disagreement with Philip Wales. I saw her again later when she was upset and she explained to me what had happened. At this time I asked Mr London for help and he kindly gave Jenny a lift home.

    It is unfortunate that such an incident has occurred in our department. Our staff work closely together in a stressful working environment and this is unlikely to help the situation. It is unsurprising to me that Dr Wales is involved in such an incident. His behaviour and risky comments, whilst generally tolerated by those of us who know him, are open to misinterpretation and whatever the outcome of this investigation I would hope he changes his manner.

    Sister Lisa Ash



    I am a receptionist at St Jude�s A&E department and was at the Christmas party on December 20th 2000. Whilst I was there I needed to check on my babysitter and left the main hall to use my mobile phone. As I returned, Jenny Holly was just leaving the hall and held the door open for me. As I turned to say thank you to her Dr Wales pushed past me and followed her in to the lobby. They then began talking and I went back to the party. I understand that some people claim that Staff Nurse Holly initiated this conversation but it was clear to me that Dr Wales started it.

    Mrs Vera Watson



    As a Specialist Registrar in A&E I was at the staff Christmas party on 20th December last year. I understand that an incident occurred between Dr Philip Wales and Staff Nurse Jenny Holly. Whilst I did not see anything of the actual incident I was with Philip for most of the evening and at no time did his behaviour give me any cause for concern. Philip is popular with most of the members of staff in this unit and obviously spent time with many of them that night. It is unsurprising that a single man would spend much of that night with female colleagues, especially one with Philip�s charm. He is acutely aware of the attraction a successful man like himself can be and would never abuse this position for any form of sexual gain.

    I am aware that Philip has a reputation amongst some of the female staff in this hospital, one that I feel is undeserved. It would appear that there may be bad feeling rooted in past indiscretion but more likely it is an unwillingness to accept the lifestyle that Philip has chosen, that of a single man who wants to enjoy himself.

    Dr Jacob Ireland



    I am an SHO working at St Jude�s A&E department and as such attended the Christmas party for staff at the Golden Hotel. Whilst I was there I noticed Jenny Holly and Dr Philip Wales talking in the lobby when I was on my way out for a cigarette. Jenny did seem a little unsettled by Dr Wales� presence but then people at a Christmas party often end up having conversations with people they don�t really want to! I went outside for my cigarette and when I returned later they had both gone. I saw nothing else that night that I feel was relevant.

    Dr Harriet Brown



    I was at the St Jude�s Hospital A&E department staff Christmas Party on December 20th 2000 and whilst there spent time with a number of the nursing staff, male and female. Unfortunately one of the junior staff nurses became enamoured with me and tried to get me to go out with her socially. Whilst I have never felt the need to avoid relationships based within the department I was not interested in Staff Nurse Holly�s advances. It would appear that she felt the Christmas Party would be a good chance to try again and regrettably as I had consumed a fair amount of alcohol I was in a more receptive frame of mind. The incident that Staff Nurse Holly refers to occurred shortly after deserts were served. I was leaving to go to the toilet when she approached me from behind and whispered "Fancy something a little sweeter" in my ear. She then guided me towards the unattended cloakroom and began kissing me. One thing lead to another and whilst we were there I began to slip my hand up her skirt. Suddenly there was a noise as someone banged in to the cloakroom door and this brought me to my senses. I explained that we shouldn�t really do this and that when Staff Nurse Holly sobered up she would regret the incident. She was very annoyed at my rejection and then suddenly became tearful. At this point I left her and continued on my way to the toilet but I remember that as I was entering the toilets she was leaving the cloakroom and looked to be heading for the ladies. I had no further dealings directly with Staff Nurse Holly that night but do remember her looking upset when she saw myself and Fiona Smith dancing together later that night.

    I am shocked at the allegation being levelled at me and can only say that Staff Nurse Holly was a more than complicit party in what was a regrettable drunken fumble. I can only assume that this is sparked off by some wish for revenge at her rejection by me.

    Dr Philip Wales MRCP



    Name Mrs. Susan Smith

    DOB 29.2.55

    Address 16, Plane View, Jamestown

    Occupation Shop Assistant.

    Right handed

    Married. Two children

    Date of accident 2.2.01

    Date of interview 1.11.01

    Mechanism of injury Mrs. Smith was the driver of a Fiesta car. She was wearing a sear belt and a head rest was present and correctly positioned. The car was not fitted with air bags. She was stationary at traffic lights when her care was struck in the rear by another car. Mrs. Smith was thrown forward by the impact, restrained by the seat belt and then recoiled backwards. She did not strike the steering wheel or any other part of the car. She was able to get out of the car and exchanged details. Her car was still driveable.

    Injury She did have some aching in her neck at the time of the accident but the following morning the pain was much worse. She had some pain in the right arm and hand with tingling in the fingers.

    Treatment She attended her general practitioner who advised her to take pain killers . She was certified as unfit for work. She had continuing pain and saw her GP again and physiotherapy was organised and was signed off work for another two weeks.

    Work Prior to the accident Mrs. Smith was a full time shop assistant. She was off work for 4 weeks. When she returned to work she was unable to do any heavy lifting. It took about three months before she was able to do her job normally. She has had no further time off work.

    Activities of daily living The neck was very painful initially. Her sleep was disturbed for 4 weeks. She took regular painkillers for 4 weeks. She was able to dress/wash/eat and cook. She required help with heavier household tasks for a six week period. She still has some problems in doing her shopping. She was unable to drive for a five week period and when she did return she was very anxious and would avoid driving if possible.

    Hobbies and Leisure Mrs. Smith went to the gym once a week and swimming once a week. She was unable to do these for 4 months. She has returned to the gym but is still not doing all her normal exercises.

    Progress and present positionThe neck was very painful initially with pain across the base of the neck, shoulders and down the right arm. The neck was very stiff. The symptoms improved after physiotherapy and after about 6 weeks she was able to do most things apart form heavy lifting. It took about 3 months before she could lift/hoover/shop although these did cause an increase in aching in the neck.

    At present the neck is much improved. She still has aching in the neck on most days and this is worse if she has been doing a lot of activity the day before. It is stiff in the mornings. The pain is at the base of the neck and between the shoulders. There is no longer any arm pain or parasthesia.

    She is still anxious when driving but this is mostly at traffic lights. She is has no flashbacks/nightmares and she does not avoid driving.

    Past Medical History Mrs Smith has been fit and healthy in the past, no previous neck problems. No medication at present. No other bone/joint problems.

    Mrs. Smith is 1.67 meters tall and weighs 74 Kg. She appears a pleasant and straightforward lady.

    General She can talk freely about the accident and the injury with no evident distress or anxiety. She walks normally, sits normally and moves normally.

    Neck There is no swelling or deformity. There is tenderness over C6/7 in the midline, the right paraspinal muscles. Flexion is full. Extension is full with pain at end point. Rotation to the right is reduced by 20 degrees and is painful. Rotation to the left is to 85 degrees. Lateral flexion to the left is painful and reduced by 10 degrees.

    Neurological examination shows normal power/tone/reflexes and normal sensation. Balance and gait are normal.



    Report of Independent Review Panel.

    Mr. R. Bristol, Consultant A&E, St Elsewhere.
    Dr. F. Whitehaven. Consultant Physician, Dunromin District General.
    Convenor. Mr. S. Wheelright. Non Executive Director. St. Jude's.

    Documents examined

    Accident and Emergency records
    Medical records, St. Jude's
    Complaint correspondence from Mrs. Green, Dr. York, Dr. Canterbury, Mrs Penny and Ms Butcher
    Statements of A&E SHO, Medical Registrar, Dr. York, Dr. Canterbury, A&E nurse


    A&E SHO
    Medical Registrar
    Dr. York
    Dr Canterbury
    Mrs. Green.

    (The first eight pages of this document deal with the factual context of the complaint and no-one disputes the facts and therefore they are omitted from this summary.)
    For details of previous correspondence see SIMS articles 1, 2, 3, and 4


    1. The staff in the accident and emergency department carried out a reasonable assessment and rightly came to the conclusion that meningitis was in the differential diagnosis as was a urinary tract infection.
    2. They correctly referred the patient to the General Medical team.
    3. The communication between the A&E doctors and the medical registrar could have been better. Specifically they should have emphasised the concerns regarding possible meningitis.
    4. The A&E junior doctor handbook does emphasise the important of proper hand over and communication to the inpatient teams.
    5. The medical registrar was faced with a difficult clinical problem. The diagnosis of meningitis can be difficult. A urinary tract infection was a possibility. The medical registrar cannot remember the A&E staff informing him that they though meningitis was a possibility. If he had been made aware of this he says he would have admitted the patient.
    6. The nursing staff in A&E were correct in questioning the registrar's decision. It might have been wise for the registrar to review the patient in light of the nursing concerns.
    7. We found no evidence that any of the staff regard patients with learning difficulties in a negative light. Indeed the A&E department has a very positive attitude and the junior doctor handbook highlights the problems of diagnosis in patients with learning difficulties.



    There should be even more emphasis placed on the handover of patients to inpatient teams when a referral is made.

    Clear differential diagnoses should be made in A&E notes.

    Relatives should be fully informed of treatment plans for patients.

    If a relative questions a treatment then it is good practice to fully review the patient and seek a more senior opinion.


    Dear Ms. Butcher,

    Thank you for a copy of the Independent Review. I do not think this report answers my questions fully. I have taken advice and I am writing to the Ombudsman for Health too ask that this complaint has a more thorough investigation.

    Your sincerely

    Mrs. Green.


  • To understand this article fully you must read the extra information on the journal internet site

  • Conflicts of interest: JW is an editor of the EMJ but this series was conceived and approved before he took up post.