Toxicidad de la cocaína y sus complicaciones

Reference has been made to knowledge management134 _{that ‘adopts a technical approach} aimed at creating ways of disseminating and leveraging knowledge in order to enhance organizational performance’ (Easterby-Smith and Lyles 2003:3). I have also mentioned the considerable number of policies and protocols135 _{that appeared on this intranet over the} period of my fieldwork. Following the meeting, I spent some considerable time in looking at the Trust intranet, which I can only describe as cumbersome and slow. There appeared to be no logic or order (at that time) to the one-hundred-and-fifty Trust policies relating to various local guidelines, twenty-one infection control and seventy-six patient group directives. A search for ‘clinical governance’ located hundreds of documents, many untitled, again in no obvious order. Following the search, it appeared that if one needed to find the ‘clinical governance’ intranet site the word ‘clinical’ was the search word to go for, as it was not listed under ‘clinical governance.’ ‘Clinical’ would bring up the designated site, which, when found; only contained six out-of-date documents relating to clinical governance.

From my own difficulties, and the time I spent in trying to find documents, I questioned the extent to which policies are utilised in practice on a day-to-day basis for knowledge management purposes. I was still interested in establishing if these policies were acting to ‘improve quality,’ ‘regulate professionals,’ or, more importantly, if the information provided was in fact used and beneficial in practice. Based on my own experience, I am sure there would not be the time for any busy ward-based nurse to find them, which would not be a surprising finding. I identified this as a further point for investigation in the questioning of stakeholders and nurses and subsequently asked if matrons could give an example of a situation, in which they, or a colleague, might consult a protocol, guideline or a policy:

(Long pause).

KS “Do you want me to come back to that one?” “Yes please”

(Some time later)

“OK adult protection. If you had somebody that you suspected was being abused then I would refer to guidelines how a referral should be made and what should be done.” KS “And these are the guidelines on the intranet?”

“Yes.”

KS “OK. Do you find them easy to use?”

“No they’re very difficult to find, even the simplest thing like the work wear policy,

134 See Chapter 2:4 Knowledge Management, Organizational Learning, The Learning Organization and Organizational Knowledge 135 See Appendix B1 List of Intranet Policies

you have to trawl through things and you can’t immediately put your hands on it.” KS “Have you ever complained about it at all?”

“I think we have complained as a directorate, particularly the medical staff find it very difficult to find policies and protocols on there” (EC 8a 2).

These were surprising examples, as the rate of adult abuse is relatively low in terms of other occurring policy events and if work wear policy is regarded as ‘the simplest thing’ one might wonder why it was being referred to. The comment: “I think we have complained as a directorate” is significant as an indication that despite her own concern, the matron had not pursued this issue any further, leaving it to ’the directorate’ which reflects the notion of hierarchy and nursing still as a subordinate profession. It is, however, also an indication that the matron would look at policies when she was not sure of how to proceed. Other matrons were more explicit:

“Whenever I was unsure about an area of practice” (N 8a 1)

“I think we do, well I look at protocols and guidelines quite regularly, one because I’m involved in the development of some of them even though I’m not in clinical practice such things would be like last offices, pulses and things like that. But investigating a complaint or an adverse incident we look at all the protocols that are in place for that, so we would look at them and see where we had, where we didn’t follow protocol procedures, or if we did where it went wrong and if the protocol needs reviewing” (SN 8a 3).

There was a point made here that there was a use for policies and protocols to check practice in the event of a complaint or adverse incident. However, the assumption was, in this instance, that protocols and policies were there to provide an evidence-base for working practice. I pursued this with ward-based nursing staff, as to whether they could give me an example of a situation in which they or a colleague might consult a protocol, guideline or a policy. I found, as might be expected, the examples given related more to the issues apparent within everyday practice, as in a G grade ward sister’s response:

“Yep, NG (nasal-gastric) tube feeding, they’ve just changed the indicator. Levels of NG feeding and how you establish that it’s in the right place or not” (EC 7 3).

Another G grade used this example:

“Tracheostomy care, we have a lot of ‘traches’ through here so that’s one guideline that’s quite regularly consulted by the junior staff if they are not sure…” (N 7 1)

However, none of the junior nurses questioned could give me a specific example of any one situation in which they would consult a guideline or protocol, although an E grade nurse contradicted herself:

“I always look at nursing skills; I haven’t done for a while” (EC 5 1). “We have printed off a lot of policies recently” (N 5 2).

Three issues arose from these answers; the first is that, of all the protocols placed on the intranet specifically under the remit of clinical governance, there was only one practical example (tracheostomy care) mentioned by any grade of nursing staff. The rest of the protocols mentioned were already on the intranet, located there outside the remit of clinical governance. The second issue is the practical difficulty nurses have in finding relevant documentation on the intranet. The third, that there is ‘a hit and miss system’ within the Trust for notifying staff about new policies on the intranet in that ‘sometimes’136 _{they are} informed via the email system, sometimes they are not informed. Whilst these were ‘flagged up’ as ‘new’ on the site, the knowledge management system of keeping staff informed about new policies is clearly unreliable. These findings are consistent with other studies: for example, Berti and Grilli (2003) found that guideline developers do not pay sufficient attention to the issues of implementation and that practice guidelines do not change professional behaviour. Therefore, the issue of the auditing of practice as to whether personnel are following relevant guidelines becomes apparent.

I then raised this aspect with all of the stakeholders, in order to establish their knowledge and use of these documents. It became evident that managers were concerned with ‘legitimacy’ and ‘regulation’ in the approval of protocols, but tended to avoid the implementation issues: “I am more involved in making sure that the right levels of approval have been achieved…I basically control the final stage of the authorisation process. If I say that you haven’t got the right authorisation or endorsement then obviously it does not go through” (GM 4).

“If there are complaints coming in and I see the complaint is about our chief executive, then we’d refer to a protocol there, and obviously want to just check the protocol beyond clinical issues regularly ” (GM 1).

As these senior managers were both instrumental in the implementation of clinical governance, supported by an evidence-base placed on the hospital intranet, the situation was confused as to whose responsibility it was to ensure that the right knowledge management systems were in place for dissemination of these policies. If the managers avoided this, then implementation and dissemination of these policies appeared to me to be an unaddressed issue, so in essence, there was no effective Trust ‘learning organization.’

Consultants did appear to consult guidelines

“I consult protocols, guidelines, policies fairly frequently as a result of a failing memory….I take part in acute general medical take; I frequently encounter problems that are not part of my day-to-day practice” (C 2).

Overall, senior members of the medical staff in identifying that the systems did not work nevertheless appeared unconcerned, using expressions such as “in situations where I am aware’ ‘unless it was flagged up.”

The professions allied to health indicated that where there was an established body of knowledge, as in for instance drugs, national protocols were frequently utilised as part of everyday working practice but that this also related to tangible types of effectiveness:

“On an almost daily basis pretty much” (AP 2).

A frequent complaint made by nursing staff was that policies and protocols were difficult to locate on the intranet.137 _{In order to ascertain whether other health care professionals} encountered this issue, I asked a senior physiotherapist if the policies were easy to find on the intranet:

“Now I know where they are on the system, yes. I am not saying everybody would, but I have had quite a lot of time practising using them so it…..some of them are easier to find than others…..” (AP 4).

As identified from the nursing responses similar issues arose from these answers; there were few practical examples mentioned by any health care professional about clinical governance protocols. Again, there was identification of the difficulty in finding relevant protocols quickly and that finding relevant protocols required practice. There was not a robust system for notifying staff about new policies on the intranet within the organization.

Managers had a slightly different perspective on the use of policies, as indicated in responses to my question as to whether they found the intranet site easy to use:

“No it’s often quite hard, because some protocols. I suppose clinical protocols, most of those are there and they actually are quite easy if you are looking for something if you know what you are looking for, it’s knowing what you are looking for and what heading it’s been put under or someone will say, it’s pasted on the website, so you will go and look. I think the search engine could probably be better” (GM 2).

KS I’m thinking about a busy D grade or band 5 (nurse).

137 See Appendix B 1 List of Intranet Policies

“ I don’t think it’s that easy to follow, when I go in to look for things, because we’ve had a complaint or a coroners report and we say, where’s your policy and that sort of thing and it isn’t that easy to find things” (GM 2).

Interestingly, the focus of the use of a protocol changed here from the manager’s perspective, with a hint of a regulatory function (which will be discussed later), but he missed the point of my comment:

“Again it depends I think, I don’t think, I don’t think the way its presented its always clear that new policies and new protocols are there. I think that I’ve had recent examples of that…. I find the front page cluttered really, and I think there must be a better way of presenting….. I think it, some of it, when you do get in can actually get to new policies relatively easily but I think then It is quite variable getting, getting into other elements of the sign ups and the finding things. And I don’t think it’s you know that easy to get around for people” (GM 3). KS: Taking an example like that, how would you express concern, what would be the system that you would express concern about - the front page of protocols?

“I think I would go to the web master, but also maybe to our own governance. Depending on how urgent or what it was” (GM 3).

Yet this site structure and appearance remained unchanged throughout my fieldwork. Another Manager responded by informing me about a recent written protocol:

“We’ve recently written for external clinics referring into us. Within neurosurgical we have peripheral clinics within general hospitals and unless their admin processes are robust and ours are robust, patients can get missed….so recently we’ve written a little protocol which is in line with our Trust waiting list processes, which we’ve been sending out to all the other Trusts to try and adhere to. It’s got some safety nets built in to ensure that if they don’t hear from us within seven days they’ve got ownership to phone us ….so that’s something we’ve gone down recently around communication improving pathway” (GM 2).

Despite the fact that all groups had identified different uses and difficulties with the intranet system, it was evident from these responses that no manager had been proactive in changing the appearance of the intranet to enable easier use, the view being that it was ‘Somebody Else’s Job,’138 _{a theme I will pick up later. I would argue, then, that if Trust staff} were dependent on a system that did not function efficiently in their everyday practice this would appear to be a highly significant issue. If, however, they were not dependent on this system, in that it did not influence their working practice, it would be insignificant if it failed to operate, apart from time wasting, which was highly significant. This is further evidence of the ‘ceremonial conformity,’ in that a system was there in order to show that the organization was legitimate. There was acknowledgement that it did not work but this did not appear to matter. The culture of the organization, to use an evidence-base for practice, had not been changed by the introduction of the system.

I established that, whilst meetings took place at all levels of the organization, the major dissemination of written information about clinical governance activities to all Trust staff was (at the start of my fieldwork) by the clinical governance intranet website. Part of the clinical governance facilitator’s role was to keep the site updated. It contained information about members of the corporate clinical governance committee,139 _{the terms of reference for this} meeting, protected time dates and some minutes of meetings. However, when the clinical governance facilitator left and the clinical governance activities were delegated within the Trust, with new facilitators appointed, nobody appeared to be responsible for updating this site and it still contained outdated, inaccurate information from March 2003, visible to all members of staff at the time the semi-structured interviews took place two years later. Yet at the Trust induction for new members of staff, the clinical governance facilitators still urged staff members to use the clinical governance intranet website. I was interested, therefore, to know how staff identified with this out-of-date information. It soon became clear. The greatest consensus of agreement in the semi-structured interviews was in relation to the Trust clinical governance website. Nobody used it as a working resource, but, more significantly, nobody could use it as a working or information resource because the content was so out of date. Indeed, the answers from two senior nurses were casual:

“I look at it thinking we must do something about it” (8a 2). From another:

“It’s not been updated for 3 years, it’s not accurate” (8a 1).

Before my interviews took place, the clinical governance facilitator for the neurosurgical directorate was so concerned about this poor Trust resource that he had developed another very comprehensive detailed neurosurgical intranet website for all neuroscience staff to use. He informed me that he had spent considerable time visiting the wards and orientating nursing staff to the neurosurgical clinical governance website. I was therefore interested to learn from the neurosurgical interviewee respondents whether this had specifically made a difference to the nursing staff knowledge of clinical governance. One neuroscience ward sister did give an indication that she used it:

“It’s quite clear and concise, quite informative. I’ve not been on it for a few, if I’m honest, I’ve not been on it for a few weeks, but I just click on it now and again just to see what’s going and just get the general updates. I don’t think that’s been updated either for a while, I think we’ve got the same general information for the last couple of months. It’s quite good” (N 7 1).

Nevertheless, when I asked her to show it to me, this interviewee could not find, or had forgotten how to access, the relevant site. The grades below F within the neurosurgical directorate did not use or display any knowledge of what was on the intranet yet the Clinical Governance Coordinator had spent a great deal of effort developing this site:

“No, no it’s on the list” (N 6 3). “No” (N 5 2).

Elderly care nurses gave similar responses:

“I’ve looked at it, but not had time to read it” (E C 7 2) “No, I can’t say I knew there was one” (EC 5 1)

“To be honest I haven’t looked at it for a while” (EC 6 2)

However, the neurosurgical unit’s own clinical governance website had clearly made a difference to their manager when I asked if she looked at it:

“Not the Trust one, I look at ours, well our website, we’ve set up, I’m the chair for it, and so our minutes are posted on there” (GM 2).

KS Do you put those on.

“( ), the secretary does. So, I if I’m looking for a minute, I will go onto there and we have an operational governance website that will enable me to get into our complaints report, adverse incidents reports any adverse incident. I will find an action plan, so there’s quite a few, that’s why I use the operational governance one more than the clinical governance one” (GM 2).

KS Who has access to that one, just the managers or..?

”No all the ward, down to ward sister level, we’re encouraging them to access and get the information, so the minutes are posted on there as well” (GM 2).

KS Is it an easy to follow website?