Who should lead the burn care team?

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Bums (1993) 19, (6), 490-494

Printed in Great Britain

Who should lead the burn care team?* P. G. Shakespeare The Laing Laboratory, Odstock Hospital, &&bury, UK

Introduction It is widely accepted today that the care of the burn-injured patient is a team effort that demands the participation of the skills of many and various practices in cliical medicine and surgery. The idea of team care is perhaps stilI best exemplified by the seminal work of Artz and his colleagues, which still remains today as one of the best source books for all aspects of burn care. If we accept that a team effort is necessary and appropriate, then we are led to the conclusion that there should be a leader for this team in order that the, team may best express its potential to act within its proper sphere of interest for the benefit of the patient. How could we view a football side without a Captain, an Army without a General, a government without a Prime Minister? The concept of leadership is everywhere, having been adopted wholesale even into the Civil Service and, extensively, in hospital management where project teams for everything under the sun can be found, with a clearly identified Team Leader responsible for activities which may (or may not) merit the use of capital letters in their title.

The leader’s qualities It is the identity of the team leader in burn care, and perhaps more so his/her qualities that are necessary to the role, that is today the matter of concern. What are we to expect from such a person, one would hitherto perhaps have said man, to fulfil this demanding role? Perhaps some answers and clues to their identity may be divined by first looking at the general requirements of a leader’. A leader requires technical skills in that he/she is master of their craft. But this is obviously not enough. There are skills beyond this that are necessary. How can we identify these? One approach would be to study in detail the exigencies of the task itself and identify by rational and rigorous analysis (a systems orientated approach) the most appropriate person. My view is that this would not be the correct method. For one reason it is slow and it would be difficult to reach a consensus on anything other than a purely local basis. Secondly, it is difficult to identify all aspects of the task involved, or even to define the range of skills needed. For these reasons it seems more appropriate to take the more atavistic, emotional approach, and ask ourselves what, in burn care, we would expect from our leaders. We have in the last event to accept

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entry for the Laing Essay Prize.

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them as such and therefore will have to acknowledge that it is primarily their personal qualities as well as technical abilities that will determine ultimately their success or failure in the task. Accordingly in this essay 1shall not probe to any significant degree the literature concerning the overall approach to the treatment of burns. This overall approach is, in many units in the UK, still the result of the experience, knowledge, philosophy and prejudices of the established senior staff. Under these circumstances it is difficult to deal with the concept of leadership in a dispassionate, technocratic style and easier to draw first upon some of the widely accepted, though subjective, qualities of leadership that might be considered appropriate to answering the question Who should lead the burn care team?‘. Readers should also remember that the views expressed herein are those of the author and are thus the result of as much subjectivity, bias and prejudice as are to be found in any member of any health care profession.

The idea of leadership The concept of leadership is ancient and respected. It has perhaps in the very ancient past been a, if not fhe, method of ensuring the very survival of the group led. It certainly has been most closely identified with times of strife and war and has had, indeed still has, strong socially cohesive overtones, usually expressed in nationalistic terms, which are clear in most people’s minds today. Can we gain any insight into what are the requirements for a burn team leader from these historical considerations? I suggest that we can, especially if we look to the leadership of, in socially necessary terms, the ultimate teams, the military forces of the state. We do not simply need to look to the recent past for this, and it is probably easier to look to ancient history for the simplistic picture of the team leader that can be a starting point for the arguments.

A model from ancient history The best-known military leader of the ancient world was Alexander the Great. He transformed the fortunes of his society, using the foundations laid by his father, Philip of Macedon, by his leadership and personal qualities, so that the state became the most influential in the world. His fame lives today, even down to the cities founded by and named after him in the most remote regions of the ancient world, Kandahar, Secunderabad and the greatest of all, where he was buried, Alexandria. What ,features did he possess that

Shakespeare: Who should lead the bum care team? enabled him to lead his army through years of campaigning, remote from their home territory, against almost impossible odds at times? Obviously our judgements will be diluted by time but there still remain enough contemporary accounts to give us many clues to his success. First, Alexander was an accomplished manager of men. His organisation of the welfare of the army was masterful. He knew when to cajole his men into what they regarded as impossible military actions, such as the storming of the Persian positions at Issus and the Granicus where frontal assaults against the strongest points of Darius’ armies were made by the Greeks with Alexander himself in the van. He knew when to bribe them for their loyalty, as when he cancelled all debts to encourage the loyalty of the men before the Indian campaign. He knew how and when to act ruthlessly, as in his actions in personally killing dissenters. He knew how not to humiliate opponents thereby turning them into, at least, neutral allies. He knew when to exploit dissent, as when he ‘sulked in his tent for days until dissenters actually implored his forgiveness. He knew how to exploit the camaraderie that he engendered among his ‘inner circle’ to advantage, as in his replacement of his body companions by Persians, their former enemies. Effectively the supreme psychologist, his methods are the envy of many a team leader in competitive team activities today. Perhaps above all though Alexander was a great organizer of the working environment for his army and foresaw Napoleon’s famous dictum of the army marching on its stomach by some 2100 years. Throughout all his campaigns the army was always supplied with whatever food and equipment was necessary to the tasks in hand. Thus he exemplifies to the minds of many the ‘complete’ leader, shouldering, and indeed executing, all the responsibilities for the attainment of the leadership goals. How valid is this concept of the complete leader today? Is it actually possible to identify the leadership goals for a burn team leader? In Alexander’s case it is undoubtedly true that not only was he the leader of the army but also that the goals for his leadership were entirely specified by himself, in council of course with his senior commanders, among whom he was certainly more than primus infer pares. If we are to examine the conventional, if romantic, concept of the leader in terms of the leadership objectives of the burn team we shall need to examine what these leadership objectives are. In broadest terms it could be supposed that the leadership objectives for the bum team leader are to ensure that the burned patient receives the appropriate treatment to enable him (a gender-free term in this essay) to recover from his injuries in as rapid time as possible with as good a quality of life after recovery as possible. Can we then identify an individual, or a genus of specialist more likely, who can discharge this function, in an appropriate fashion. Perhaps we should ask ourselves firstly who constitutes the burn care team. Who

is in the Burn Care Team?

The answer to this question is not easily found in hard and fast terms. In general terms it could be said that the bum care team includes anyone whose skills are relevant to ensuring the patient’s recovery. This could include not only medical, surgical, nursing, paramedical, scientific and clerical staff, but also relatives and friends of the patient and even, Heavens forfend!, hospital administrative and managerial staff. It is evident that not all of these practitioners(?) will be involved with the care of the patient at all stages of their (hopeful)

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recovery from the injury. Some of them may never even see the patients, but, for example, their activities in the hospital kitchen may be vital to the quality of recovery of the patient. Perhaps we should confine our concept of the team leader to those specialists who are likely to have most influence on the patient’s progress and be involved with him at all stages of his recovery. This we could also limit to the stages of acute care when the patient’s level of dependency is high, rather than to the later, particularly postdischarge stages when the patient is effectively his own master. In this case it is reasonable to suggest that only two specialties emerge as strong contenders for the leadership role, the clinician and the nurse. Other specialties may be in contention, the burned patient is in absolute need of good physiotherapy for example, but most physiotherapists would accept that their claim to be the leader of the burn care team is substantially slimmer than that of the clinician or nurse. This is not to say that leadership in the delivery of their particular expertise is not required, nor would it be expected that this specialist leadership should be subsumed within the overall leadership. Similar considerations apply to other specialties, dietetics, occupational therapy, scientific and research staff, etc. All must accept that their own activities are practised within the overall clinical environment of the burn care system which is largely without their absolute control and are conditional, to a large extent, upon the requirements and also the consent of the clinical environment. Let us then look at the competing claims of the two major specialties so far identified, the clinician and the nurse.

The clinicianas leader Most people would instinctively turn to the clinician for leadership in this situation. But we should ask ourselves if this is appropriate when it comes to the treatment of burned patients. Does the doctor know best? or is he (again gender free) merely conditioned in training into believing that he does? The considerations of the question of the validity of the clinician’s candidacy as burn care team leader must also recognize the wide variety of skills necessary to care successfully for burned patients. The anaesthetist may be the lynchpin in the early stages of care where substantial knowledge and experience in dealing with impaired circulatory function and gas balance is required. The physician may be needed to assess and manage physiological disturbances associated with the intense stress following the injury. The paediatrician is an essential member of the team when particular problems are encountered in burned children. The surgeon is an obvious candidate to carry out the repair work associated with wounds that do not heal, and the long-term problems associated with scar contracture. The orthopaedic specialist may be needed to repair associated traumatic problems. A similar situation in fact to that appertaining with the other specialties mentioned previously, a plethora of skills required but a need for a clear identification of who is concerned overall, on a continuing basis, to ensure that patients receive the best possible care under the circumstances. Which clinician then should be the leader of the medical pack?

The surgeon’s claim Historically speaking there is has the strongest claim. The dislocations, etc. has always surgeon. A cursory glance at

no doubt that the surgeon care of wounds, fractures, been the province of the. the ancient and less ancient

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medical literature confirrns this. The position was reinforced to the point of virtual unassailability by the development of the split-thickness skin grafting technique, which made an active role possible in regard to wound repair. In addition surgeons have, at least since the 19th century, been regarded as leaders. Advances in surgery often appear to the outside observer to have been dependent upon the leadership, particularly upon the style of leadership of the great practitioners. Liston’s famous remark ‘Gentlemen, this Yankee dodge beats mesmerism hollow’ on witnessing a demonstration of the anaesthetic properties of ether, probably did more good for the welfare of patients than any double-blind, crossed-over, controlled trial before or since. The tradition of leadership still persists, the outside observer may witness the training of young surgeons by their experienced senior colleagues which carries all the marks of the relationship between the leader and his followers. Some of the leaders even go to the extent of discarding the traditional badge of office, the white coat, an action which actually enhances their status as leader rather as Alexander’s burnished helmet and embroidered cloak identified him in his army. Today the role of the clinician in the care of bums is still shaped by historical, and recent historical at that, factors. In the UK the surgeon is regarded as a ‘consultant’. This term implicitly carries a connotation that a continuing action in the concept of patient care is not necessarily part of the surgeon’s role. The popular image of the surgeon, perhaps shaped overly by film and television portrayals, is that he diagnoses what the patient’s problem is, skilfully operates on the patient to cure it, and moves on to the next patient. Life, as we all know, does not necessarily imitate art, but I would suggest that this is an ingrained image, with an element of truth in it, and one which is accepted to some degree by many surgeons. Perhaps one of the problems faced by all clinicians at present in the changing British National Health Service (NHS) stems from the concept of being a ‘consultant’ and having no mandatory commitment to the organization of the hospital environment beyond that of the immediacy of tending to the patient’s requirements. The continuing care of the patient has traditionally been the province of the junior medical staff and the nurses, with the post of consultant being to some extent the reward for having made it through the arduous years of being a junior doctor. Who could then blame the juniors themselves for relinquishing the commitment to organizing the clinical environment whenever they had a chance to do so? The cold wind of change blowing through the NHS structure at present poses problems for many clinicians who see the traditional ‘leadership’ that they had come to expect, in that the hospital environment organized itself on a consensus basis without their direct involvement, being eroded by Management. Doctors have been to some extent sidelined under these conditions, and the traditional status of clinicians in the hospital has been eroded to the extent that we read in the press all sorts of articles (e.g. Strnday Times 11 October 1992), usually based on utterly spurious statistics, which actually constitute a direct attack on their status, honesty and commitment to the patients. Many feel that the control of clinical practice has passed de facto to accountants and managers, in that the terms in which units are organized are now determined (in the UK at present) by the so-called ‘purchasers’ of health care, a process which is almost certainly guaranteed to substitute form for function, and leads many to feel substantial misgivings about the future of patient care.

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All this is perhaps a digression and may not be subject to dispassionate analysis, but will I hope indicate that the concept of bum care team leadership goes beyond that of simply delivering the clinical care at the point of contact and extends back into the hinterland of supply in its most broad terms, a point which had been supremely grasped by Alexander but which is often not appreciated by clinicians. Under these circumstances it is evident that clinical expertise, technical skill and observational accomplishments that are the proper accoutrements of the clinician may not be enough, and that a successful clinical leader will in the future be required to get his hands dirty, perhaps very dirty, in the waters of the organization in which his unit finds itself. Nor will it simply be a matter of participating in the management process of the hospital but will also involve the less than fraternal interactions with other specialties necessary to ensure that access to facilities appropriate to the proper conduct of the unit’s business in its broadest sense are carried out efficiently to the benefit of the patient. Will we find such clinicians now?

The nurse as burn care team leader So much for the clinician, particularly the surgeon - an obvious and strong leadership candidate. Let us now examine the claims of the other candidate group identified, the nurses. It must be said at the outset that nurses are not regarded as leaders. The popular image of the nurse is of the ‘carer’. This has not always been so. In the 19th century the profession, or rather occupation, of nurse was looked upon as little higher than that of the common drudge. The most famous of all our nurses, Florence Nightingale, was not able to train in the UK owing to the reputation of nurses in general. In one of her letters she reports the hysteria generated in her mother at the suggestion by the wellrespected Dr John Fowler that she might train at the Salisbury General Infirmary. A hysteria generated by the ‘moral rather than health risks to her. Nevertheless she succeeded, almost single handed, in raising the status of the nursing profession to the present high ground that it occupies today. A similar example can be found in the work of Dorothea Dix in the US Civil War, whose Sanitary Corps appears in hindsight to have been one of the greatest humanitarian achievements of that conflict.

A model from more recent history To evaluate the example of Florence Nightingale as a leader of her profession is an interesting exercise and again bears though in an inverted fashion, with our comparison, historical precedent. For a start her style was utterly non-heroic. This lady was a permanent invalid, at deaths door for most of her life, yet lived to the age of 90. She was accorded an almost unprecedented honour from the Army at her funeral, in that a party of sergeants acted as her pall-bearers. Her memory is still alive today and her grave still well-kept and visited. This cannot be said for many of our well-known surgeons and physicians. Thus she must have been able to exert a very considerable influence over her fellow women, and men in particular, to achieve her leadership objectives. What were these leadership objectives? Perhaps it is a truism to state that we would now see these objectives as organizational. Primarily she worked to promote the provision of an appropriate environment for the care of the sick. She paid particular attention to the disadvantaged injured soldier, who has traditionally in all

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Who should lead the bum care team?

armies, the British being no worse than others in this regard, never been the object of attention from his own organization. Perhaps she, of all famous Victorian women, created the most enduring historical legacy in her struggle to influence the most conservative governmental department of all, the War Office. There are amusing twists to her encounters with famous soldiery. She records her opinions of an inspector general of the Army Medical Service in less than complimentary terms, an incident which has the added retrospective irony that the general was actually a transvestite who spent all her life as a man, not being discovered (in a medical corps mark) as a woman until being laid out for burial. Much of her legacy is still with us, the Nightingale’ wards which are still the feature of many of our hospitals. Some of her legacy has gone; the matron being one good example, perhaps unlamented by many but regretted by others who perhaps now see only a vacuum where once genuine, if often a little remote and unapproachable, commitment and leadership was to be found.

The nurses claim to leadership It is in this Nightingale’ philosophy that the strongest claim to leadership of the bums team by the nursing profession is to be found. The nurse is fhe carer for the patient. This is not to say that the surgeons and physicians do not care for the patient, but everyone must accept that the nurse spends the longest time with the burned patient, How many clinicians actually physically care for the patients, change their dressings, jolly them along to eat when they don’t really want to, clean up after them and perform the ultimate courtesy of being with them when they die. Not many, is probably the answer. The nurse also carries responsibility for ensuring that the dressings are always available, the meals provided, the unit cleaned to standard, the information about the patients gathered on a day-to-day or hour-to-hour basis as necessary, the instruments are to hand, the drugs controlled and administered, all the ‘trivial routine of care that is perhaps most important to the recovery of the patients. The skilled hands of the surgeon may set up the resuscitation line, but it is almost invariably the nurse who ensures that it works and that the fluid is given. The surgeon’s technique may repair, more or less successfully, the bum wound, but it is the nurse who has prepared the wound for him to operate upon and who must be responsible for ensuring that the grafts are properly cared for after the operation. It is the nurses who, including the mediumand long-term care and rehabilitation of the patient as well, perhaps through the medium of community follow-ups, or scar revision clinics and so on, undoubtedly contribute supremely to the system of care enjoyed (perhaps the wrong word) by the bum-injured patient. It is not possible to identify anyone with a greater commitment to the patient than the nurse. The question to be asked is; does this role and commitment qualify the nurse to lead the burn care team? Why should the answer to this question be no? Is there really any group which has a greater claim to the leadership of the team? Indeed in practice does not the situation often occur - that the senior nurses on the bum ward are actually so much in control of the transmission of information to medical and paramedical staff that they are de facto the leaders in the delivery of care to the patient and hence the accepted leaders of the bum care team? Readers (if there are any) of this essay will perhaps recognize this system in their own units. One might also observe that in practice the time of the senior clinicians cannot, by virtue of their contracts of

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employment, be wholly dedicated to bum care. In the UK many of the bums unit ‘directors’ are plastic surgeons whose time may well be split between the performance of other surgical and clinical duties to such an extent that the bums unit becomes unavoidably a minor part of their everyday routine. It is very difficult to become identified as the leader if you are not available to perform the details of the duty for much of the time. This has always been recognized in situations where leadership is required. Perhaps the greatest failings of leadership in our history, for example Lord Cardigan in the Crimea, have arisen not so much from lack of intelligence but from lack of availability at all stages of the task, a situation recognized in the old farming adage that ‘there is no fertilizer like the master’s foot’. This may lead to the bum care team leadership becoming filled, unobtrusively perhaps, by the nearest available candidates, the senior nurses. It may also be true to say that this is not unrecognized by the clinicians themselves who may, dare one say it, actually welcome the detachment from the humdrum requirements of the leader’s role with the resultant freedom gained to exercise what they properly regard as the skills with which their long and (sometimes) arduous training has equipped them. So we should therefore wonder why are we even considering the question of leadership when it is evident that the problem is so complex and that in so many cases solved to what one hopes is the mutual benefit of all involved in the delivery of care to the bum-injured patient? Perhaps in this last sentence do we find the real problem that we are addressing in this oeuvre - fhe burn-injured patient.

What about the patients? The bum-injured patient introduces a complication into the cosy equation of Doctor + Nurse = (Good)Patient Care. It is difficult to know on which side of the equation the patient should be placed. Should he (or she of course) be found on the left or the right of this equation. Is he a recipient of care pure and simple or is he in himself a contributory factor in this delivery of care. I suggest that it is the latter and that the equation should in actuality read Doctor+Nurse+ Patient = (Good)Patient Care. What we have not yet considered is that the burned patient is not a mass product with identifiable needs and limited aetiology such as could be considered to be the case with, for example, patients with fractured neck of femur. Such patients fall into definite categories of severity and usually undergo a predictable and controllable course of recovery. There are always exceptions of course but there is the element of ‘supermarket medicine’ in such cases so beloved of our managers and accountants. With burned patients there are no such clear expectations. Indeed the exception is the rule as far as burned patients are concerned. It could be considered that the patient is actually part of the bum care team. This is a very strong consideration. All involved in bum care will not find it difficult to accept the assertion that the patient contributes actively to his own recovery. This is probably true in all areas of clinical practice, but probably most notably in bum-injured patients. If this is the case then it is necessary that we must be more specific about the leadership objectives for the bum care team. These were stated previously as to ensure that the burned patient receives the appropriate treatment to enable him to recover from his injuries in as rapid time as possible with as good a quality of life after recovery as possible. The acceptance of this objective implies that the patient’s clinical condition will

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dictate to some extent the nature of this ‘recovery environment’. There will be a world of difference between the needs of, say, a child with a small but deep electrical burn, and an elderly patient with a scald burn to the perineum. The burn care team must accommodate these objectives whatever they are. Perhaps we are dealiig with the wrong concept. Perhaps we should not think of either the clinician or the nurse leading the burn care team perhaps we should examine the proposition that the patient is actually the leader of the team.

The patient as a paradoxical leader Is this such a far-out proposition? The object of the system actually being its leader? The answer to this conundrum (if there is one) must be looked for in terms of who defines the leadership objectives. In our historical examples we find that the objectives are simpler to define. Alexander formulated and defined his own objectives, perhaps the easiest of all leadership situations, especially when there are no effective constraints upon your activities as leader. The leading surgeons of the 19th century were in a similar situation, in that there was a whole world waiting to be conquered. Florence Nightingale’s leadership achievements perhaps come closest to the system we are examining, but again the objectives were to change a system that was effectively unformed and chaotic, with the imposition of order being the main objective. In regard to the burned patient we have, we believe, an efficient and humane system in sifu which is complicated by the intrusion of patients who have extensively varying requirements of it. A difficult situation in which to exert leadership since the day-to-day tactical objectives, which are the bread and butter of the strategic objectives, vary so much for individuals. The assessment of the success of attainiig any leadership objectives rests on the evaluation of the sum of the component parts. Our leadership objectives then, so clear and high flown in all our minds, may well founder on the trivial problems arising from the rapid adaptations of the system necessary to accommodate the variation in tactical objectives generated by the patients, the sum of whose requirements constitutes the ‘Universal Set’of care to be delivered. It therefore seems that we should answer the question as to who should lead the burn care team by stating categorically that the leader of the burn care team should be the patient. This may seem a rather inverted answer to the question and shatteringly undermine our cherished conceptions about our own roles in burn care. I would suggest however that this is the correct answer based on historical precedent. We should recall that the first bums unit at Edinburgh arose out of patient pressure for the segregation of burned patients on aesthetic grounds. The development of the concept of the regional burns unit in the UK arose out of the experience of the leading surgeons in burn care at the time, from their observations of the the needs of patients within the health care system. In any clinical specialty the clinician is very foolish to set a rigid routine of care, as the progress of the patient cannot be predicted with certainty. Everyone in burn care will have had experiences of patients who should have died, but didn’t and, more distressin ly, those who should have lived and didn’t. It is there Pore obvious to all that the burn care team is actually being led on a day-today basis by the individual patients on the unit.

The public face of the burn care team So much for the day-today

aspects of burn care. Is there

anything beyond this which requires the identification of a leader in the burn care team? The answer must be yes and that there are several levels at which this leadership is given. There is an evident need for leadership within the individual clinical professions to ensure that their role in the care of the patients is being discharged at its most efficient, humane and considerate level. To identify all the requirements for individual specialities would be an enormous task and outside the scope of this essay, which is dealing with the wider connotations of the task. So what are we left with? To the world outside the burn care team this probably reduces to a face or name who is identified as personifying the system of care and who has a personal identity with the burns unit. This person will not necessarily be he/she who actually does most practically to ensure the delivery of care to the leader of the team already identified above. The most likely person to fulfil this role, and the most appropriate in my own view, is the senior clinician holding a long-term appointment at the burns unit. The respect in which the clinician is held by the world at large will undoubtedly be of more benefit to the concept of burn care than would the status of any other profession involved in this complex task. The task of being ‘Mr(or Mrs) Burn Care’within one’s own region is demanding but rewarding. All the rest of us should do our best to ensure that his/her skills in fronting the operation receive our greatest support and commitment. What we should expect from him/her is the tacit acknowledgement that it is not really they who are the ‘ultimate leader’ of the team, but that this role resides in the object of the professional activities of all who are involved in the delivery of care - the burn-injured patients themselves.

Finale and apologia Readers may well disagree with the views set down in this essay, perhaps quite a few toes will be bruised by my assertions. None the less I hope that this will be treated as a sincere (if perhaps misguided) contribution to the continuing goal of ensuring that we all work towards a system of care which does the greatest good to the maximum number of patients.

Acknowledgements I wish to acknowledge the opportunities afforded to me by all staff at the Wessex Regional Bums Unit over the time (too long in some opinions!) that I have had to observe the delivery of burn care in the real world. It has been a particular privilege to work there with the late Jim Laing and currently with Tony Rossi and all other members of staff.

References I have made no formal reference to the literature in this essay, written as it is from opinion rather than fact. If the reader is interested an entertaining account of the leadership and achievements of Alexander the Great can be found in The h/lask of Cmm~& by John Keegan. For the life of Florence Nightingale 1 have I,& Woodham-Smith’s FlornzfeNightingak, now out of print but occasionally found in second-hand shops and bazaars, as is also the case with 27~ Century offIzeSurgeonby Jurgen Thorwald, which I have used to find formal expression for my views of the surgical profession.

Paper accepted 8 June 1993. Correspondenceshould be akkssed to: Dr P. G. Shakespeare, Laing Laboratory, Odstock Hospital, Salisbury SP2 8BJ, Wiltshire, UK.