This is the sixth article in a series on management within the emergency department. This article focuses on disciplinary procedures and actions.
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The new ECG machine has been a great success and it seems that everyone who comes in to the department is having an ECG taken! This has certainly improved the care of those patients requiring an ECG but are there any problems with this indiscriminate use of an investigation? Perhaps this ECG craze will settle down as the new machine loses its novelty.
The SHO who you discovered was misusing heroin has caused you more problems. Should you break his confidentiality to protect patients? Are patients at risk? You read the advice in Standards of Practice on the GMC web site (www.gmc-uk.org) and see drug misuse described as a “serious problem”. The document confirms your duty to patients and to the doctor and it is clear you must tell somebody. You decide to speak to his consultant, an understanding paediatrician, and together you approach the occupational health consultant and the postgraduate dean. Unfortunately, while you are formulating a plan of action the SHO is admitted to A&E with a respiratory arrest and the cause is all too clear. After treatment the SHO self discharges and the next day he resigns from his position by post. The only contact addresses available are hospital accomodation and while the postgraduate dean has a home address his parents appear to have moved since he qualified. What can you do now?
In general patient confidentiality is paramount but there are several situations where you must break confidentiality, if asked, under United Kingdom law and others where you have to make a professional judgment. These are summarised in the box 1. It is always good practice to seek advice from a colleague, the clinical or medical director or your medical indemnity organisation.
Box 1 Breaking confidentiality
UK law insists
Suspected terrorist offence
Driver involved in accident (Road Traffic Act—name/address only)
By order of the court
Circumstances where it might be considered
Serious arrestable offence
Health problems in a health care professional that might lead to patient harm
Child protection issues
The GP notes for the personal injury case were missing. Those of you who have sent in reports may wish to amend your opinion. Those of you who have waited can now submit your report.
Examples of cases of need are given on the internet feedback section.
Maintaining discipline and standards within an A&E department are essential to its functioning. The majority of staff will naturally behave within agreed social boundaries and are aware of specific behaviour that is expected in the workplace. Sometimes, however, these boundaries are crossed and at this time management must be prepared to act appropriately to ensure the smooth running of the department.
Over the last five articles we have been getting to know the staff at St Jude's A&E and have followed their attempts to rebuild the team that is required to run a successful department. Unfortunately the incident involving Dr Wales and Staff Nurse Holly has the potential to divide the staff and threaten the team ethos that has evolved. A split could develop along nurse/doctor or male/female lines and a proper investigation and just conclusion are essential if the team is to be maintained.
Attempts to define the boundaries of acceptable behaviour in the workplace have increased in the past 20 years. It is now accepted that colleagues of all grades must respect each other, with particular attention being paid to issues concerning race or gender. The abuse of hierarchical power by bullying has also now been “outed” as unacceptable and poor performance or deliberate under performance may also result in disciplinary action. These types of behaviour are deemed unacceptable in any workplace but the position is not so clear when it comes to other issues.
Certain types of behaviour may be acceptable in some workplaces or circumstances but not deemed appropriate in others. An example of this would be the use of profanities in conversation. While this may be tolerated on a building site or in the staff room of a hospital it is unlikely that such language would be condoned during direct patient contact. It is important that staff are aware of such variable standards to prevent misunderstandings.
A further complication is whether behaviour outside the workplace can be considered relevant to the employer. This might be justified if it involves other employees, especially if it reflects behaviour within the workplace but what if the behaviour remains solely outside of work? Is heavy drinking outside of work relevant if performance at the workplace is unaffected? This may seem like a “Big Brother” employer but would you want your child at a school where the English department was found drunk in the gutter every Friday night? Certain self inflicted standards exist in many professions but are becoming more difficult to justify and maintain with the erosion of status occurring today.
Of course illegal behaviour can never be condoned in or out of the workplace but again the seriousness of the offence and its relevance will need to be considered. Few of us would continue to employ an armed robber but a minor speeding offence might only be relevant in an ambulance driver rather than an A&E SHO.
The consequence of this is that each employer will need to produce their own guidelines to define what is acceptable. These guidelines would at least cover harassment, misconduct and performance but it is impossible to cover every eventuality. Guidelines on the general standard of behaviour can be useful but over generalisation is unhelpful. It may also be felt appropriate to have guidelines on capability separate from those of conduct. Ultimately the guidelines produced should be clear and concise and made easily available to all staff.
The consequence of unacceptable behaviour is disciplining, a concept most of us learned in childhood. Rules governing discipline in the workplace are necessary to ensure fairness in the treatment of employees. Written information on these rules should be provided to workers in accordance with the Employment Rights Act 1996. Management is responsible for the setting of these standards and for disciplining those who fail to reach them but they must ensure that the rules and procedures involved are reasonable. A model disciplinary procedure should aim to correct unacceptable behaviour rather than punish it and employees must have faith in the process, which is seen to be thorough, fair and applied consistently. The Advisory, Conciliation and Arbirtation Service (ACAS) have produced guidance on disciplinary procedures1 and these are summarised in text box 2.
Box 2 Principles of disciplinary action
All hospitals will have written policy on disciplinary procedures. A copy of this should be in your “ policy and procedures reference section” of your work library (this will be discussed in a time out on “Administration and Time Management”)
When a disciplinary matter occurs, the manager responsible should gather all relevant facts as soon as possible and obtain written statements if necessary. In certain cases it may be appropriate to suspend an employee to allow an unhindered investigation or because of the nature of the offence. This suspension should be with pay and it should be made clear that the suspension is not part of the disciplinary procedure and does not indicate any degree of guilt. Unfortunately this is not always the case and the employee, their colleagues, the public and sometimes the media draw an unfair inference from this action. In the event that a suspension is being considered, the employee must be advised that he can bring a friend or union representative to any interview or hearing for support and advice. The information obtained should be investigated and a decision taken on what is the appropriate next step.
Applying the theory
So how does this help us at St Jude's? You will have read the statements of the relevant parties and had a chance to form an opinion. Was this just a drunken fumble at the Christmas party, or is it something more serious?
For doctors, disciplinary procedures fall into three categories;
In this case it is clearly a question of alleged personal misconduct. If an allegation of sexual indiscretion had come from a patient then this would have been investigated under professional misconduct procedures.
Does Dr Wales' alleged misbehaviour fall under our authority? The incident at the party happened outside of work but it was a departmental event and involved another member of staff. It must also be recognised that the complaint did not just refer to this one incident but to a pattern of behaviour that had occurred in the workplace. This being the case it was wholly appropriate for the senior staff to investigate the complaint further and Dr Wales was informed of this. It was felt that the delay from the main incident to the formal complaint was already too long and a swift conclusion to the affair would be to everyone's benefit.
The procedures should be in writing, specify to whom they apply and not discriminate
The investigation should be thorough and occur without undue delay
All records and statements should be kept confidential
Clear indication of the disciplinary action that may be taken should be given
The worker should be informed of the complaint and relevant statements in good time, given the opportunity to state their case and allowed representation at any procedure
Dismissal should not occur for a first offence except in a case of gross misconduct
Ensure a right of appeal and indicate the correct procedure for this
The information required for further investigation was gathered by written statement and during this time Dr Wales' suspension was considered. Sister Oak was in favour of this because of the atmosphere in the department and the nature of the case but Mr London felt that this might imply guilt and would serve very little purpose. As a compromise the nursing and middle grade rotas were adjusted to keep Dr Wales and Staff Nurse Holly apart. On examination of the statements it was felt that consistency and corroboration was on Staff Nurse Holly's side but ultimately it still came down to her word against Dr Wales'.
Advice was taken from the director for human resources, the medical director and the director of nursing. The consensus opinion was that while Dr Wales had probably acted inappropriately it would be difficult to take formal disciplinary action with the evidence available.
Mr London agreed to give Dr Wales “counselling” about the incident and ensured Sister Oak that it would not simply be a slap on the wrists. Mr London spoke with Dr Wales and explained that no formal action was being taken. He did, however, point out that there were major concerns that Dr Wales had behaved badly and that his future conduct in the department would be under close scrutiny. He also “suggested” that Dr Wales should write a letter of apology to Staff Nurse Holly as she could well have made more of the Christmas party incident, possibly threatening his career.
Sister Oak discussed the case with Staff Nurse Holly and explained that while no formal action was being taken Dr Wales was to be reprimanded for his behaviour. Staff Nurse Holly was content with this but expressed reservations at how she was to work in the department with Dr Wales now?
This was the conclusion of the St Jude's team. How does it compare with your own ideas on how this could have been handled? Do you think the outcome was satisfactory? How can we deal with Jenny Holly's concerns?
You have a letter from a local school asking to organise a visit for the children. This might be a chance to build relationships within the community but is it more trouble than it is worth?
A local pharmacy is opening a 24 hour branch and wishes to discuss sponsorship of departmental advice cards. Would this be useful to the department? How far are we prepared to let sponsorship or advertising go within the hospital setting?
Shane “Six Pack” Simons, the local pop star, has an unusual request for you: he wants to shoot part of his next video in your department!
The GP notes for the personal injury case have arrived.
Review the Standards of Practice Document from the GMC.
What action are you going to take over the runaway SHO?
Consider the pros and cons of advertising within the A&E department.
Decide whether to agree to a visit by the school children.
You can now complete the PI report (not in hospital time of course, we would not want to be subject to the professional misconduct procedures!).
Web info (emjonline.com/contents/SIMS6)
Letter from Green Mound School
Letter from Pills' Chemists
Letter to Staff Nurse Holly from Dr Wales
Letter from Shane Simon's agent
GP notes for personal injury report
Example of case of need
We would like to thank Mr P Driscoll and Mr C Perez-Avila for their helpful comments.
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 person or department.
SIMS ARTICLE 6: INTERNET PAGES
The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.
From Greenmound School
Dear Dr York,
I am the headmaster of Green Mound School in Jaemtown and I am hoping that you may be able to help us with one of our school projects. Our children regularly have to write about people in their community and we are hoping they could come and visit you at work and perhaps have a short talk about what you do. We have had a similar arrangement with the local police force for years and find it very rewarding. If you do not feel able to help us but know of one of your colleagues who could please feel free to pass this request on to them.
Mr H Harmond
Letter from Pills Chemist
Jaemtown AE1 4AL
01582 348 562
Dear Dr York,
We are a well-established local pharmacy and we are planning on opening a 24-hour pharmacy beside St Jude�s Hospital in the next few months. This will be able to dispense most of the drugs prescribed by local GPs or hospital practitioners outside normal working hours. As your department is likely to be a major prescriber during these hours we are making you aware of this facility for the use of your patients.
You are no doubt aware that many drugs are available cheaper over the counter than on prescription and this may be useful to your patients. We are able to advise patients on the purchase of simple analgesics, antacids and many topical treatments for dermatological conditions and then provide the drugs cheaper than the current prescription charges.
In an effort to raise our profile we would be willing to sponsor the advice cards your department uses to help patients with certain conditions such as head injuries or soft tissue injuries.
I am sure this could be an arrangement that would benefit us both.
Please feel free to contact me at anytime at our town centre branch.
Private letter from Dr Wales to Staff Nurse Holly
I am sorry that we have ended up in the middle of such a formal complaint. I am sorry that I upset you with my behaviour at work and the Christmas party. I am also sorry that you felt unable to approach me directly with your concerns as I have always felt that I had a good relationship with most of the nursing staff. In any case, no hard feelings and I look forward to working with you in the future.
Dr Philip Wales
LETTER FROM SHANE SIMONS
Dear Dr York,
My name is Polly Martin and I am wondering if you could help me.
I am the agent of Shane Simons and he is currently working on the video for his next single "High Charge Lover". During the video Shane will be rushed in to hospital with an apparent cardiac arrest and despite electric shock treatment would not be revived until he received a �High Charged� kiss from his girlfriend. We feel the image would be quite powerful and Shane feels it would be more realistic if it were shot in a real hospital with as many real staff as is possible.
You will probably be aware that Shane is a local lad and has supported St Jude�s hospital on a number of occasions with donations. He is willing to pay with a personal donation to your department in the form of equipment to the cost of �5000. As you can see this could be an arrangement of mutual benefit.
I hope I hear from you soon.
GP NOTES PERSONAL INJURY
The following is an extract from the notes of relevant entries of Susan Smith:
03/02/01 Seen following a RTA rear end shunt neck pain. Limited range of movement.Physiotherapy (2/52 sickness certificate)
17/02/01 Still neck pain not seen physio. (2/52 sick note)
3/02/01 improving (return to work 10/3/01)
5/09/00 3 weeks history of neck pain. Stiff in mornings no trauma. Range of movement good but with limitation of rotation and extension . Probable spondylosis. Analgesia Advice on mobilisation.
5/10/00 UTI - antibiotics. Neck much better. Now full range of movement.
Previous history. Back pain 1994, physio and 3 weeks off work.
No other significant entries.
Capital project application form.
Why do you need the equipment/building
The increasing medical workload is making it imperative that the A&E department has a readily accessible blood gas machine. Up to 20 patients per day need this investigation. Often these are the sickest patients in whom minutes may count in making vital life saving decisions. At present the blood gas analysis is performed in the Laboratory. This entails inevitable delays. The time and extra work involved also may be a factor in the under use of this investigation. A recent departmental audit (appendix 1) revealed that many patients with primary respiratory pathology, who would have benefited from blood gas analysis, were not having them taken. When inquires were made in to this it was discovered that many members of staff felt that there was no point in taking the samples as the results were irrelevant by the time they were returned.
The current situation requires samples to be sent to the laboratories using the portering service, a service that is already over stretched, and then results telephoned back to the department when a member of laboratory staff is free to do so. This complicated and unwieldy process is often extended during on-call hours when a technician may be called in from home to carry out the analysis. It is not uncommon for �emergency blood gases� to be phoned back to the Accident and Emergency department after the patient has already left for a ward.
Near patient blood gas analysis is one of the recommended practices in many Standards of Service for A&E departments (eg Health Services Accreditation 1997)
In summary the lack of a blood gas machine is giving rise to concerns about the level of clinical care we can deliver and also slows the running of the department.
We have discussed this proposal with laboratories have confirmed a willingness to cooperate.
Blood Gas Analyser (co-oximeter). �34,000
Installation costs. �500
Revenue costs (and who will be responsible)
Service contract �800
Daily servicing �2,400
The revenue costs are to be included as a service development in this year's SaFF plan.
It should be noted that current estimates for blood gases are �21.50 per sample but our near patient testing is estimated at �11.50 per sample.
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