Table 3

Examples of poor and good behaviour observed during the study

SkillExamples of positive behaviourExamples of poor behaviour
Maintenance of Standards
  • Checked list of medication for possible interactions when asked to write up a drug chart

  • Insisted an ECG is repeated because of incorrect lead placement

  • Transferred patient to CDU with no documentation despite an acute vertebral fracture being detected on x-ray

  • Allowed serious self-harm patient to go to toilet unsupervised and no risk assessment.

Workload Management
  • Prioritised a sickle patient with abnormal observations

  • Put post-it notes on cards of patients that needed review

  • Encouraged specialty doctor to make decisions early while offering assistance

  • Bleeped anaesthetist to assist with a fitting patient and then, while the patient was still fitting, left to sort out another patient.

  • Told a nurse he was not available to see an arrhythmia patient, while seeing non-urgent head injury patient. No attempt to help find alternative doctor.

Supervision & Feedback
  • Asked ‘What needs ruling out?’ rather than simply providing the answer when discussing patient management plan with a junior

  • Gave feedback to ambulance crew about patient they had bought in

  • Spoke to Plastics when referral refused from SHO

  • Pointed out a pneumothorax on x-ray without giving junior opportunity to spot it

  • SHO was clearly not confident suturing pre-tibial lacerationM but registrar did not offer help, so SHO found another senior doctor

  • Asked a medical student to assist log roll without assessing capabilities

Team Building
  • Provided emotional support for a nurse who was upset about a patient

  • Praised an SHO for identifying a ureteric stone on CT

  • Appeared dismissive of a junior doctor asking for help

  • Rolled his eyes when a nurse said they were not trained to do cannulation.

Quality of communication
  • Used very specific questions like ‘What's your concern?’ when giving advice to junior doctor

  • Reiterated need to give nebuliser via air not oxygen

  • Encouraged the use of check-back communication when giving verbal order to a nurse

  • Failed to use appropriate medical terminology giving a poor description of facial wound when discussing over telephone with Max-Fax doctor.

  • Failed to listen, so had to clarify numerous points that had been mentioned

  • Said ‘let's get a bag of fluid’ during an emergency without specifying which fluid or who was expected to get it

Authority & Assertiveness
  • Said firmly to surgical registrar “You need to see this patient”

  • Registrar only acted as a scribe for a trauma call but pointed out lack of timely review of observations to consultant

  • Was appropriately assertive with SHO who was late returning from teaching

  • SHO appeared intimidated by a registrar who questioned aggressively

  • Failed to assert herself with radiologist and unsuccessful getting out-of-hours CT abdomen. Patient later found to have traumatic splenic rupture

  • Confrontational with anaesthetist who was reluctant to intubate a fitting patient without waiting to review impact of treatment

DM option generation
  • Asked about patient's age and status when asked to prescribe intravenous fluids

  • Reviewed facial injuries in person when SHO gave vague history

  • Briefly reviewed severe PR bleed patient before delegating to SHO

  • Did not get collateral history from witness of possible seizure

  • Appeared to ignore nurse who said a patient's wound smelled of pseudomonas

  • Nurse said patient was unwell and registrar prescribed IV fluids without reviewing patient in person

DM selecting & Communicating
  • Asked nurse to insert catheter and explains indication as apparent

  • Gave clear plan to SHO and explained under what circumstances the patient was safe to go home

  • The registrar was unsure so he stated his concerns to the resuscitation team ‘We still don't know why she's short of breath’

  • Nurse suggests IV dextrose. Reg says ‘No, normal saline’, but no explanation

  • Hesitant dealing with resuscitation patient and SHO says, ‘I don't know, you're the reg.’

  • No discussion of risk or indications for return when registrar suggested a new SHO send home a pregnant PV bleed patient

DM outcome review
  • Checked resuscitation patient's bloods were en route to laboratory

  • Reviewed pain of patient who had been prescribed analgesia in the queue to be seen

  • Checked SHO has been successful making referral

  • Failed to assess the impact of morphine for patient with abdominal pain

  • Significant delay reassessing patient presenting with status epilepticus

  • Did not check if SHO was successful referring patient to vascular team when already discussed they may be reluctant to accept

SA-Gathering Information
  • Overheard charge nurse and nurse discuss a patient with low blood pressure and offered to help

  • Noticed asthma patient using own inhaler and made an assessment

  • Had a quick look at a trauma patient who was waiting to be seen

  • Failed to notice no BP check for >25 min in unstable trauma patient

  • Heard a tannoy requesting a doctor to the resuscitation room and the registrar failed to make any enquiries

  • Caught up with a single patient and fails to notice long wait in department

SA Anticipating
  • Anticipates difficult procedure and asks consultant to supervise

  • Identified early a patient needing social input to aid discharge

  • Transfers bleeding patient to resus anticipating deterioration

  • No consideration of potential deterioration in stable trauma patient but with a significant mechanism of injury–later found to have multiple internal injuries

  • Nurse needs to prompt reg to move drunk patient to CDU to clear a cubicle

SA Informing the Team
  • Told CDU nurses about anticipated transfers

  • Told nurse to inform ward nurses of patient's psychiatric issues

  • Registrar speaks out patient's vital signs during resuscitation

  • No handover at board round that Occupational Therapist was unavailable

  • Did not inform team that she was going to the CT scanner with a patient

  • Asked SHO to see PR bleed patient but failed to mention patient on warfarin