2.1 Essential Principles

Time frame

Whether the situation allows time for full discussion, or the patient needs time critical care will influence the response taken. In every situation the health professionals involved should be empowered to speak up about any concerns they have.

Multidisciplinary (MDT) approach

An open discussion should take place with key members of the MDT which focuses on providing safe care for the patient.

Be objective

Differences in opinion can cause frustration and an emotional response. It is important to take a holistic view of the situation, using assessment tools where appropriate and communicating concerns clearly.

Involve the patient

In all situations it is best practice to sensitively involve the patient in decisions about their care.

Communicate effectively

The key to escalating and resolving concerns is effective communication.

Documentation

A summary should be documented in the patient’s medical records including: the concerns raised; the points discussed and who was involved; and a clear agreed plan.

Incident Reporting

The difference of clinical opinion should be reported formally via the Local Incident Reporting System, so it can be reviewed independently which supports learning both for the professionals involved and the clinical team.

2.2 Informed Choice

Rather than dictating a ‘one size fits all’ rule, guidelines should provide information about different treatment options and their benefits based on current evidence.

Health professionals have a responsibility to effectively interpret the evidence-based recommendations of guidelines and ensure shared decision making with patients.

Where there is a conflict of clinical opinion, health professionals should have open and honest discussions with the patient.

This promotes shared decision making and enables the patient’s preferences to be included in any discussions about their care.

2.3 Tools to Support Objectivity

There are many tools which support healthcare professionals to be factual when raising their concerns. For example, Early Warning Scores and the Sepsis 6 pathway.

Assessment of the patient’s condition with a recognised tool should be used in conjunction with professional judgement when communicating concerns.

Clinical practice guidelines relevant to the situation can also be useful, along with current research or national resources (for example NICE or speciality specific bodies), in presenting your concerns.

2.4 Effective Communication

The SBAR communication tool is designed to structure information sharing between healthcare professions (NHSE&I 2021).

The SBAR tool also supports professionals who are less confident or experienced in escalating their concerns through the need to state their recommendations. Healthcare professionals do not work in isolation and can ask for support and advice if they are unsure about any aspect of escalating their concerns.

Communication will be most effective if it includes the professionals who have the difference of opinion. If it is not possible to leave the patient, the SBAR tool can support escalation with accurate information.

2.5 Evaluation

Ongoing clinical evaluation is an integral part of patient care. Assessing the patient should continue in line with the relevant clinical guidance to review the effectiveness of the agreed plan with further MDT discussion as required.

2.6 Reflection and Learning

Conflicts of clinical opinion can feel stressful resulting in reflection after the event. It is important that we learn as individuals and as a team. Support available includes Professional Midwifery/Nurse Advocates, clinical supervisors and Medical Education Team.

There may be a need for a formal debrief session to support team members to understand each other’s rationale for decision making during challenging clinical situations. Learning from differences in opinion may also result in the need to update clinical practice guidelines.

It may be that a professional recognises a difference of opinion on reflection following an event. It is never too late to have an open clinical discussion where any concern is highlighted. If an incident is raised using the Datix system, the clinical risk coordinator can support this and escalate it as required.

If you do not feel you have been treated with respect when you have shared your concerns, speak to your line manager or clinical supervisor.

2.7 Escalation Process

Refer to Appendix.

The majority of situations will be resolved quickly at the time of the disagreement. When required, the appropriate person to escalate to will depend on the health professional’s role and the clinical situation.

People you can escalate to for support in resolving differences of clinical opinion include (but not exclusive to):

• Senior Nurse/Midwife present in the clinical area
• Senior clinician present in the clinical area
• Bleep holder / hospital co-ordinator
• Senior Nurse/Midwife
• Consultant / Heads of Service
• Other members of the multidisciplinary team involved in the patient’s care
• Clinical duty manager

Note: Resolution is not about winning an argument; it is about understanding each other’s clinical opinions and agreeing a safe plan of care for the patient. It may be that both points of view offer safe care options resulting in an opportunity to discuss choices with the patient.

Supporting a resolution

If you are asked to support staff to resolve a difference of clinical opinion, the key skill is in facilitating a respectful discussion.

Essential principles

• Use a quiet area away from the patient and where the discussions cannot be overheard by other patients/visitors
• Refocus on the best outcome for the patient and the need to be objective
• Remind those involved of the need to respect one another. Facilitate the conversation so everyone has the opportunity to express their views and encourage them to listen and understand one another
• Use open questioning to support those involved to describe their concerns
• Invite others to join the conversation where appropriate. For example, a specialist clinical opinion may be useful if not already involved
• Be mindful of the wellbeing of those involved, signposting to additional support such as Professional Midwifery/Nurse Advocates, clinical supervisors and the education team.

The importance of escalating clinical concerns for patient safety is embedded within all clinical training programs in addition to being taught as part of pre-registration courses.

Human factors and health and wellbeing is also being incorporated for all professionals.

NHS GGC support the development of clinical leaders where courses focus on developing positive learning cultures.

Not at present

NHS GGC recognises the diversity of the local communities served by the board and aims to provide a safe environment, free from discrimination, treat all individuals fairly with dignity and appropriately according to their needs.

As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

Escalation toolkit from the Royal College of Obstetricians & Gynaecologists

Overall aims of the RCOG campaign

 The overall aims of the campaign to improve clinical escalation are:

• To reduce delays in escalation by improving the response escalation and action taken
• To standardise the use of safety critical language
• To reduce feelings of hierarchy, creating a supportive environment which empowers staff of all levels to speak up when they identify deterioration or a potential mistake
• To promote a culture of respect, kindness and civility amongst staff members, normalising positive feedback and saying thank you to each other
• To improve the ways in which we listen to women