SLO 7 – Deal with complex or challenging situations in the workplace

The Emergency Physician frequently needs to manage specific shop-floor situations or circumstances that have the potential to significantly impact upon patient care or the functioning of the Emergency Department. These may relate directly to interactions with patients attending the ED, other agencies attending the ED, challenging professional interactions or events that impact on the delivery of EM care. These can not necessarily be predicted, other than they will happen at some point and this learning outcome is concerned with readying the EM physician to deal with them effectively

These situations may involve issues pertaining to consent, capacity and confidentiality with the subsequent need to communicate decisions clearly and to effectively  resolve areas of disagreement or conflict. In managing these situations, the Emergency Physician needs to operate within a specific legal and ethical framework as defined by legislation and guidance from the General Medical Council, the Royal College of Emergency Medicine and other significant professional bodies.

The Emergency Physician needs at all times to behave in a professional manner with patient safety as a priority, whilst working in a multi-disciplinary team that interacts with personnel within and external to the Emergency Department.

Domain 1: Professional values and behaviours

Domain 2: Professional skills

  • practical skills
  • communication and interpersonal skills
  • dealing with complexity and uncertainty
  • clinical skills (history taking, diagnosis and medical management; consent; humane interventions; prescribing medicines safely; using medical devices safely; infection control and communicable disease)

Domain 5: Capabilities in leadership and team-working

Domain 6: Capabilities in patient safety and quality improvement

  • patient safety

Domain 7: capabilities in safeguarding vulnerable groups

Key ACCS capabilities

At completion of ACCS a trainee:

  • Will know how to reduce the risk of harm to themselves whilst working in acute care
  • Will understand the personal and professional attributes of an effective acute care clinician
  • Will be able to effectively manage their own clinical workload 
  • Will be able to deal with common challenging interactions in the work place 

Key EM capabilities

At completion of Intermediate training a trainee will:

  • be able to work effectively with patients who appear angry or distressed
  • be able to negotiate or manage complicated or troubling interactions 
  • behave professionally in dealings with colleagues and team members within the ED
  • work professionally and effectively with those outside the ED

with Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision

At completion of higher training a trainee will:

• have expert communication skills to negotiate manage complicated or troubling interactions 

• behave professionally in dealings with colleagues and team members within the ED

• work professionally and effectively with those outside the ED

and would be able to manage with no supervisor involvement.

ACCS descriptors

  • Know how to safely deal with violent or threatening situations
  • Able to handle common but challenging situations:
    • self-discharge against advice
    • capacity assessment 
    • adult safeguarding issue 
    • Police/FME enquiries 
  • Aware of national legislation and legal responsibilities, including safeguarding vulnerable groups 
  • Behave in accordance with ethical and legal requirements
  • Demonstrate ability to offer apology or explanation when appropriate
  • Demonstrate ability to lead the clinical team in ensuring that medical legal factors are considered openly and consistently
  • Interact effectively with hospital colleagues when handing over the care of patients, in particular when this appears troublesome.
  • Liaise effectively with healthcare professionals outside the hospital about patient care.

Intermediate & Higher Descriptors

All ACCS descriptors apply in intermediate and Higher training 

  • Understanding the effect on the team of stress and fatigue
  • Support EM team members in challenging or distressing circumstances
  • Working within a legal framework for shop floor work
    • Aware of specific legislation:
    • Data Protection Act,
    • Information Governance,
    • Freedom of Information Act
    • Caldicott Report.
    • Mental Health Act,
    • Mental Capacity Act,
    • Deprivation of Liberty Safeguards
    • Children’s Act.
    • Advance Directives
    • DNAR Decisions
    • DOLS
    • Organ and Tissue Donation
  • Able to judge issues of Safeguarding for adults and children.
  • Behave at all times in a professional manner
  • Aware of own limitations and ability to ask for help as necessary
  • RCEM learning/ FOAM material
  • Formal teaching in ACCS will include material mapped to the key capabilities in this SLO.
  • Trainees will need to record their interaction with learning material and reflection that maps to the key capabilities
  • Departmental/ regional teaching mapped to the key capabilities in this SLO
  • Simulation based training of challenging encounters in the ED
  • Leadership training materials including RCEM leadership programme
  • Departmental/ regional teaching mapped to the key capabilities in this SLO
  • Simulation based training of challenging encounters in the ED
  • Leadership training materials including RCEM leadership programme

In core training it would be appropriate to seek feedback on dealing with challenging situations. This might include patients who appear distressed or angry. This must be done with senior staff able to maintain patient and trainees safety. Feedback and reflection on challenging interprofessional encounters would demonstrate the practical application of approaches and concepts developed in the programme of learning.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG 
  • Mini-CEX
  • MCR
  • RCEM App

In intermediate training there is an expectation that any challenging encountered would be sought and feedback given. They also may be the subject for case based discussions. In this way the trainee will further develop their range of approaches to situations they will encounter as senior most clinician overnight. Trainees will be expected to gain a fuller insight of their tendencies to respond and reflect on effective approach for them as an individual.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG
  • Mini-CEX
  • MCR
  • RCEM App

In higher specialist training there is a greater complexity of situations that may arise that require a response, in readiness for consultant life. These may be discussed with trainers after the event, or observation and feedback may be invited if such scenarios arise at work when a consultant trainer is available to offer this.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG
  • Mini-CEX
  • MCR
  • RCEM App

Entrustment Decisions

End of core training level 2b :

At the end of core training a trainee should be entrusted to work effectively as a member of the acute care team, with appropriate personal professional attributes.

End of intermediate training level 3: 

At the end of intermediate training a trainee should be entrusted to deal with most challenging situations faced on the shop floor, with consultant support from home.

End of HST Level 4:

At the end of training an EM specialist will be entrusted to deal with any complex or challenging situation on the shop floor. This will be supported by a clear understanding of relevant medico legal considerations, and by advanced and effective communication skills.

RCEM examinations

MRCEM 
SBA
OSCE
FRCEM
SBA
MSO

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