A recent editorial on clinical leadership by Sisse Olsen and myself (BMJ 2005;330: 1219-20) has led to my being asked how transformational leadership might affect clinical practice. Perhaps a clinical story might help.
One Sunday afternoon, a decade ago, I slipped into the hospital to ensure that a patient with severe acute ulcerative colitis was making satisfactory progress on conventional medical treatment. He was doing well. His abdomen was no longer tender, his pulse rate was back to normal, and he was feeling hungry.
As I was leaving the ward, a junior staff nurse, who I did not recognise, touched my arm and asked, “Dr Neale, would you see a patient for me?”
I guess that, with my mind elsewhere, I hesitated momentarily before saying, “Of course,” and turned to go with her.
It was her turn to hesitate: “But she is not one of yours, and she was seen by the `medical on call' at lunch-time.”
“So...”
She led me to a woman in her 70s who was semiconscious but restless. She had been admitted a few days previously with a stroke. “It just that she is passing so little urine,” explained the nurse. “The SHO said that he thought that she was dehydrated and that I should turn up the drip. I am just not sure that is right. In the bag is all the urine she has passed today.”
A urinary catheter was attached to a bag that contained 200-300 ml of murky orange-brown fluid. The cause of the limited urine output seemed reasonably obvious to me, but I couldn't resist the temptation to go into teaching mode. Together, we traced the pathway of the fluid being infused to that appearing in the bag. Then I asked the nurse to lay her hand on the abdomen. As her hand came up against the fundus of a distended bladder, her eyes danced: “The catheter must be blocked.”
“OK. Would you care to lay up a trolley for catheterisation? Small gloves and don't forget the incontinence pads, a large kidney dish, and a jug.” Back she came with the trolley. “Now you scrub and glove up, and I will assist.” And so this nurse came to undertake her first catheterisation of bladder—and saw her patient relax into somnolence.
That nurse had been the leader. For her, the patient's wellbeing came first, and, as a result, she was prepared to break the traditional hierarchy of care. That is what transformational leadership is about: it motivates clinical staff to think and empowers them to enhance patient care. It has been widely applied in the management of effective businesses and needs to be encouraged in hospital practice.
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