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Mhm. All done. I, hi. Um it's Elana. I'm just checking. Can everybody hear me? This is the first time we've used metal instead of teams. So I'm just, it's a bit different. I just wanted to make sure folk can hear us and then I was like I um share my screen for the flights. Perfect. Perfect. Thank you. Uh Right. I'm just gonna mute myself again until I share my slides. Ok? Um um I think we're just gonna have to share it like this, but I will play it as a um as a slice show. Um assuming people can still hear me because I can't see the actual metal screen now for the chat, but Rachel's here and she's going to keep an eye on the chat. And in fact, do you want to do this? And I'll do the chat. Do you want to do the quiz? We do it together together. You'll hear both of us that we're going to do it together and I will, we're going to do a prescribing quiz. Um Oh no, I can hear that. Can you still hear? Sorry guys. Yeah. Yes. Perfect. Right. We're going to do a prescribing quiz. We've kind of copied Jilly's idea. She did that. She's got the Liver Who Wants to be a Millionaire. Um, and we've just, yeah, it's our version that you might know a lot of this. Um, and if you don't, we've kind of directed you to useful apps and websites and stuff like that. So it's just a bit of fun and I will play it as a slideshow. So it fills your screen a bit better. And literally what we're going to do is get you to type the answer ABC or D into the text box. And if there's a majority, then we can, we'll ask you if you want to go with that. If there's a bit of a split decision, then you can use a lifeline. So the lifelines are 5050 we'll just choose to, to remove, you can ask a host so you can ask Rachel and I or you can phone a consultant and we've got a consultant on standby to phone and answer one of the questions which is jelly. Um So we will, I'll get started uh for them. We need to know we'll play it by ear. And I should say that after this session, Jelly Flem. Doctor July Fleming is going to talk about critical care recovery. Um and then call Arthur will be our third speaker um at three o'clock and he's going to talk about personal leadership styles and c and things and sort of tease out what your strengths and weaknesses are as a leader. Um, not all sessions will be an hour, so there'll be comfort breaks and maybe 10 minutes go make yourself a cup of tea and things in between. Anyway, I will stop waffling and start playing. Here we go. Has that come up? I just got a delay. There's a wee bit of a delay with the slides guys. So just bear with us with that and I'll just move these on to the start. I'm hoping the sound works at the other side cos it's got a millionaire sound. Does the signed work? Perfect. It just adds to the drama. It's better than just looking at blank screens and silence. Ok. So question number one, I can't remember how much it's for it. It's four C I as a function anticholinergic bronchodilator which is uh ap two agonist B muscular acetylcholine antagonist, C Musculin, acetylcholine agonist or D with a two antagonist. Yeah, is gonna keep an eye on the chat. So pop your chat, pop your answers, your chat, pop your answers in there. You'll open up. Ok. I indeed, one four be coming at it. So I think how are you doing or something? I mean, like that especially. Yeah, really means right. And the answer is um so I've turned the music down a little bit, partly it's a bit loud. Um So and just, and just text me. Thanks Andrew. Um So we've got a little teaching slide. It's literally quite wordy but basically acts as an antagonist and the muscarinic acetylcholine receptor which produces inhibition of the parasympathetic nervous system and the airways. And when these are in, when it inhibits their function, and that means that they stop generating bronchial secretions and constrictions. So it vasodilates and helps people breathe and, and, and sort of association with like um salbutamol. Is that two agonist? Um So next question, that was one. That was the easy one. Yeah. Um Do you want to do the next one? Yeah, I'm excited. OK. So this is for $1000. So Aminophylline is a bronchodilator used in the treatment of bronchospasm and ac severe acute, severe asthma. What is the therapeutic plasma concentration of theophylline? So, is it a 5 to 15 mg? A liter b 15 to 25 same 10 to 20 or D 20 to 30 same again, just answer c this came up with a war when I was on one recently. None of the doctors knew the answer and that I only notice some extra, but I was surprised that no one else really knew the answer. I'm gonna say that is, so that's the word for it. And you're right. The answer is see. And then we've just for educational purposes, put a wee blurb there, just explaining. And basically the, the short version of that is that if it's over 20 you can get side effects like convulsions and hyas. Um And you can sometimes get a therapeutic level in smaller adults between five and 15. Uh ok. Next question. Well, we just take a turn about, go for it. So the next question for, yes, this is probably another easy question. But magnesium sulfate is a standard treatment in severe acute asthma. The recommended dose is 2 g over 20 minutes. What is this dose in MS straight away? Yeah, we've started easy and everyone but uh so yeah, 1 g is about four millimoles. There is such a lady somewhere. OK. So the $3000 so nonadrenaline works on alpha one and two a generic receptors to stimulate basal constriction in addition to beta receptors, which of these vasoactive drugs target purely beta receptors. The A diamine B isoprenaline C dopamine or D adrenaline. So we've got in a couple of days so far more days. OK. Some shirt they little be be like six or 76 be. Yeah, I think that's yeah, IRB. Yeah, the rest of the night and then we've got a wee bit here. The picture at the top is not that readable from your end, I don't think, but it's basically a nonselective beta a genetic receptor um used to treat heart block. Um and yeah, about beta one and beta two receptors there which I'm sure you know. Uh OK. Next question. Uh there was a delay. So, OK, so vaso vasopressin is a peptide hormone used in vasodilatory shock. It works on B1 and B2 receptors. Where are V two receptors located? Are they in a, the kidneys? B in the brain? C vascular smooth muscle or D in the heart? And again, we just go with the majority. So we've got ad we've got a couple a lots of a s Yeah. So yeah, vast majority of just want to cover. You are. Um Yeah, please factors in the kidneys and then we have a, we just a wee um So about a five second delay, isn't it? We slide there. Um And they work, they kind of complement each other. So B1 works in the heart to increase systemic vascular resistance and afterload and B2 in the kidneys to retain water and between increasing your volume and then your systemic vascular resistance and that's how they raise your BP. Um OK. Next question. Mm OK. So this is $7000. This is a question but one of her, I think we gave the answer away in two questions. So Billy was admitted to the ICU post by hospital cardiac arrest. It was assumed to primary primary arrhythmia and he never got any PC. He was in sign of them on admission it soon to develop complete heart block. So what drug did cardiology recommend whilst discussing whether or not they needed a piece of wires? Was it a Milone? You don't even need a question at all. Um Email the room BC like OK or G IP and yeah, everybody need to G IP. Yeah, that's up guys. I II thought, yeah, I know we stupidly spoke about is two questions ago and although you might have got it anyway. Um and the patient did end up getting pa and wi to be fair. Um OK. Next question. So the ST fish is for 10,000 lbs. It is. So as per the snap protocol for the early management of paracetamol toxicity, which of the following is not part of the criteria for discontinuation of treatment. After the second bag bag of N A lactate of less than two, an inr of less than 1.3 A paracetamol level of less than 10 or a normal A LT quite a few days. Ok. Ok. So all these, so far you may want to use a lifeline for this one. We could, you could go 5050 or probably want to keep your consulted one for later. You think in the wording of which of the following is not part of the criteria for discontinuing treatment for somebody said it, you finish, you do a 5050 you wanna do a 5050. Ok. Coming. So if we tell you this, you're kind of 5050 yourselves between A and B. What, what do you wanna go for? Anyone wanna rethink their, the atmosphere? Oh, look it change. Yeah. Well, do. Um and the answer is a lactate of less than two. we have a little blurb from, it's the NHS Lanarkshire Snap protocol, which I think are all the same. It's a standard, a standardized national protocol. But, um, this is more like front door knock, which is why we threw in just to be a bit. Um, naughty. Uh, so 10 hours after the start of the infusion, um, two hours before the second bag finishes if the inr is 1.3 or less and the alt is within normal age and the paracetamol level is less than 10 and there's no other symptoms of liver damage, then you can stop it. Ok. Next question. Two. Ok. So for $20,000 in acute liver failure on admission, assuming that the patient only has peripheral access. What fluid should be prescribed in the first instance, should it be a mixed bag of naught? 0.18% saline, 4% dextrose b5 percent dextrose C naught 0.9% saline or D 5% Saline for and. Ok. And A and Jack. So A S and C sa and CSI would say actually probably who sees the names? It's another A. Um So do you want to use a 5050 here or do you want to use or use another one of your lifelines? Um You're a bit torn between A and C. Um We could give you a 5050 if you like for 70. Ok. So we tell you it's between B and C this is our help. So it's 85% Dextros we're seeing at 0.9% failing Applebee's CS. I think that we see, I'd say it's especially on the season. Be, yeah, it's been there. They've shown that I see that tips the balance and then there's another, see, I think it sees out. We, we outweigh the bees I have and the answer is point. And I don't know. Did we put a teaching? Uh did we know, I think we were just going to talk them through. So the reason for that is you want someone's sodium to be slightly higher, which will as covered in another question later um to prevent cerebral edema. So you can't. So there's not enough sodium in baggy, dextrose is bad for cerebral edema and um too much water for the brain saline. 0.9% saline is the only one we can give peripherally between that and the 5%. And you want to push someone's sodium up to a higher level because if they've got a higher plasma sodium, then that pulls water from the brain and therefore helps reduce the risk of cerebral edema. Um So yeah, so 0.9% saline until you can get central access and then you revisit it and think about how you then try and aim for hypernatremia in these acute liver failure patients. Um OK. Next question. Yeah, just bear with a delay. Yeah. OK. So following on from that last question. Fluid management of and hepatic failure or acute liver failure is complex. We prescribe fluids to maintain hypernatremia and reduce cerebral edema. What sodium level should you target in these patients? A 135 from 148 b1, 45 to 150 C 150 to 155 or D 1 41 45. Say everybody's straight from 145 to 150. Lots of be all, all, all that's changed recently. So we used to aim for 1 41 45. And I think in the last like two years it's changed to 145 to 150. Yeah, perfect. Right. Ok. And I think that we have a wee slide. Oh, we've just got to um you can revisit these slides. They'll be, we can the, the thing will be recorded. So there's two papers there that just um sort of support the recommended 145 to 150 sodium level in these patients. Next question. I'm just. Ok. So for $50,000 in a patient with an acute kidney injury with a reduced creatinine clearance, which of the following antibiotics would not need to be dosed, adjusted the Ali B Gentamicin C or D PTAs CCS and a couple of E mhm. More recent seasonably. Yeah. Mhm I that's the main answer. Yeah. And it is, it is um and again, um there's a bit of a delay here but just um for your own yes, there's like the renal dose in the database, but it's also a renal dose app, which is very good. Obviously you've probably all got it anyway. Um ok. Yeah. Ok. For 100,000 lbs. The next question um in a 149 kg male patient with a creatinine clearance of 20 mils a minute. What is the recommended pharmacological prophylaxis dose? Is it a 7500 units once a day? B7 1005 100 units twice a day. C 5000 units twice a day or D 5000 units once a day? Ok. I OK. Some funny Jack please. The the one a go go see. Ok, so you're a bit torn here. Um Do you what's his life like? There's like different of fun. There's a BMC S coming in. Yeah. Mhm. Um As the post life like Jack. Ok. Um So we believe that obviously there's a way at the creatinine clearance and influence on what dose you give that at. Um And based this is based on our guideline, I have to say so it might not be the same but this is definitely based on our load one. So for a for a male patient who is 100 and 49 kg and has a creatinine clearance of 20 mills a minute, the recommended dose is C so there was a delay. I pressed that and thought it was gonna show straight away. Um and there's just this, we've got a slide here. So you actually, unless the patient is very smaller, um very, very large, you only really reduce the dose for creatinine clearance if it's less than 10, which I didn't know. Um And the 7500 dose is for patients over 100 and 50 kg. So, but again, that's just our loading guideline. Um So anyway, let's move on. Sorry guys, I'm choked for the cold. So I'm sorry if it's a bit nasally. Um Let's move on to the next one. What's this, the quarter of another? Um So for 250,000 lbs or dollars. So we've moved on to or immuno questions now. So in myasthenia gravis drugs which affect nerve to muscle transmission should be avoided. So which of the following drugs would be safe to prescribe in a patient with Myasthenia Gravis. Would it be a carvedilol and b socializing sulfas? I can't say it. That's the word CJ and my or D? Ok. It's quite, it's quite OK. Eat more. We, any other guesses. You can, you do have a uh you do have a lifeline. You can um two questions. So we've got A and D. So which of the following drugs is safe to prescribe at my house a little bit torn. So you have, we've used the 5050 we've used one of the, as the bo you can ask us both, I suppose I answered the last one. So you can ask Rachel or you can phone him and consult it. Would you like to do that one or each other? The leg that cor in? Yeah, everyone happy if we use our lifeline. Um She, she's corrected her answer and go for me. You can do what do you wanna do guys? Do you wanna phone a consultant or ask them who you are? Just a little bit torn back. I oh, that's not bad. It's a 250 basis, but it's not like 30 question. 13. Yeah. Ok. So steps gone for the M Michelle. It probably will, will be there. So that's like five Bs then Emma Michelle stay and be bye. Yeah. Go with the majority. Yeah. The one that II don't think anybody would have known that off the top of their head. Um And then just for awareness for the Myasthenia gravis patients and we've put a link there to the my aware website and there's, I think there's also an app, there's definitely a website where you can check what drugs are safe to give and what are um if you get one of these patients in your unit? Um ok. So are we on the second last question? So for half a million pounds or dollars, that's a big difference on your catch up. So a lot of you might know this as well. Actually, um Ethylene Glycol ingestion requires treatment with an alcohol dehydrogenase inhibitor to prevent its metabolites from forming what drug is used in ethylene glycol poisoning? So, what's the a in there like stage career? I will get you back to the last question. I know. I know somebody might know that. Um Right. Everyone says it. Yeah. Yeah. Um And we don't have an education life for this, but we were just going to go through them all and say like flumazenil is obviously benzos, methylene blue is the antidote for cyanide and carbon monoxide. Omeprazole is obviously ethylene glycol and dimer Carol. Carol. Carol is heavy metal. So like arsenic gold or lead poisoning. So on the final question and then it'll be time to grab a coffee or whatever because Jilly is going to do her session at um but here we go. Final question. Ok. So it's a bit mean it's a million but it's for a million dollars. Exactly. Midazolam is frequently used in the intensive care unit. So for $1 million can you guess what its chemical formula is from? That was listed below? And you do still have a lifeline. So you can't still phone a consultant cos you can't quote them yet so you can use your lifeline if you like show us in your A. Mhm. Oh, how do you know that? You must be googling it? There's come be, it really is. Yeah. One b anyone else? There's still a few people haven't. The, the other answers are chemical formulas for other drugs as Well, they're not just made up, that's probably these houses in the. No. Yeah. Do you wanna confirm it with your phone and friend? No idea. I'm just going for a AA, I mean, a couple days, I think the majority have lovely. Yeah, I see. Yeah. Like, let's see if she, she has clinical. So, but she likes her food. Mhm. This, ok. Hi, Julie. Hi, Julie. It's Alana. Can you speak? Oh, hello? Hello. Hello. Hi, Jolie. Can you hear me? Hello? Hi. Hi. It's a, hi. Can, um, all right. So we are on the million pound question on who wants to be on Who Wants to be a Millionaire. Um, I'm hoping that everyone can hear you. I'll try and hold you next to the mic. Um, so, uh, we're a bit stuck although some, there's a kind of mix of um, answers but the, the million pound question is Midazolam is frequently used in the ICU. What is its chemical formula? So the, so the answers are a which is C 18 H 13 CL FN three. Er, B which is C 15 H, 12 N 2 O2 C which is C 12 H 18 0 and then D which is C eight H 11. No, three. Ok. I think what you think the answer is. So some of them, they all consist of like carbon and hydrogen and some have nitrogen and oxygen and then there's chloride and whatever else. So by a process of elimination. I know that is because I learned that. So that's definitely not the right answer and I am not sure about B and D but I do know that my dad has a heavy carbon based in um and has some rings in it. So my temptation would be to say that it's a because I think that's the right answer. Ok. Brilliant. Thank you, Jolie. The rest, the rest. Kill me the next time you see me. Um OK, brilliant. Thank you, Jelly. We'll see you at two o'clock. Um Right. Thank you. Cheers. Bye. OK. So Jelly also thinks it's a and she actually gave good reason for it to be carbon heavy. Who knew. Um So let's see if some of you and Jelly were right. And so there's such a delay here, we press it and then like 56 seconds later it turns green. Um OK. And the other, so Jelly's right, but see is Propofol uh and B is actually Fitton and D is noradrenaline. So they all common drugs that we use. Um And we just thought we'd make it harder for the million point question because there were some easy questions in there and some that we actually thought were difficult and you all knew. Um So well done guys. I hope that was like a little bit light hearted fun, but hopefully you'll learn something or if you didn't, then at least maybe hopefully got like a link to some papers or websites or whatever that will be useful for prescribing in the future. Um We've got what we got just over 20 minutes until July does her. She's going to talk about critical care recovery. So she's lead for the critical care recovery service and Lothian, um, and not every health board has one. So she's going to talk about what we do here and how you could maybe become involved as an A CCP. And if you don't have a service, how you could maybe help or start thinking about setting one up. Um And then Callum Arthur uh is so he, so Callum Arthur who's gonna speak at three, he is a chap who worked in Lothian. Well, it still does just for now as an organizational development consultant. So he works with like quite senior managers on management and leadership stuff, but he actually does that part time. He's about to work, start working for the University of Edinburgh and give up his NHS job in a, in a similar capacity. But he also has his own business as a leadership consultant and he works with premier league football, um English, premier league football, Scottish rugby, lots of sports stuff. He's ex military and he does a lot of leadership. So he's going to talk to us about how we tease out our own personal leadership styles and stuff at three o'clock. So the other thing that while we've just got some time um I was gonna mention is um so Rachel and I put our heads together about another conference. Um We were gonna have one last year when we had the 2023 1. We, we're gonna try and aim to have one this year, but to do it to the same standard every year was probably not that realistic because it took quite a lot of money and effort. So we decided we will aim for every second year, um, and hope that we can do it to the same standard of the year. So, um, try to try to just get like a bit of a bit of a more sort of, um hands on organizing committee and Rachel has very kindly agreed to co chair the network with me. Um, and we have finally got drag our back on board as sponsors. I need to speak to S IC to see if they'll also sponsor us and give us some money again this year, but because they are back on board and because from last year, we had some money to pay a deposit for a venue again. Um We've secured a date for next year's conference. Um So it'll be the same venue. We've looked at some other options if we were going to be organizing it, it kind of had to be Edinburgh, unfortunately, because i it's just impossible to organize one in another city and it didn't seem like there were, there was much scope for like, there wasn't much, um, what we're trying to say, there wasn't many options or many people came forward who wanted to like co or anything like that. So we're going to go for the same venue. They got loads of positive feedback, that venue. Um, we did look at a few others which were a bit cheaper in Edinburgh. But, well, I just think we thought, I think if we did that, then I think the feedback would be why did you change the venue? Because none of them were anywhere near that nice. So, same venue. It's going to be on November the 20th next year. So, uh, drag are, are going to sponsor us again. They've got quite a busy September, which is when we were going to do it. So we've said we'll aim for November. We thought Edinburgh will be nice. And Christmas see the Christmas market and that'll be open by the 20th of November next year. So it'd be a nice place for folk to come and visit from all over the UK. So keep it in your diaries, November 20th, 2025 same venue. And then, and in the new Year, we'll reach out to you all and see if you've got like speakers you can recommend um from your areas like we did last year, we got loads of different people on board. Some of the feedback was that it would be nice to have some more A ccps. So if anybody feels like they have something they would be willing to talk about or present or whatever, then just drop me an email, get in touch me or Rachel, just drop us an email, get in touch. Um, and we'll try and get another like a couple of a ccps on the sort of main agenda as well this time. Anyway, I'm waffling, go grab a coffee and uh and we'll, we'll see you at two o'clock. Is that right? Yes, sounds good to me. Ok. Ok. That finish link. I need to stop shedding. Clar up. Great, thanks. Yeah. Hi, Jilly. We finished a wee bit early. Um, so everybody's just grabbing a quick cup and we'll come back for two. Is that all right? Perfect. Can you hear me? Ok, perfect. Great, great. All good. Ok. A dog sitting on top of me. Yeah, we're like sitting here. Uh Hi everybody. Um So welcome back. Um We have got jelly doctor Jelly Fleming. Uh who most of you know, I think or um have met at the conference. Um Who's gonna, she's going to talk to us about critical care recovery. She's the NHS lot lead for quick care recovery. Um and some of you may have a recovery service and some of you may not. So, um it would be interesting for those particularly who haven't. Um And how you could potentially set up a recovery service in your area. So I will hand over I'll, I'll mute myself and switch off my camera and hand over to jelly. Hi. Everybody can someone just give me a thumbs up? They can hear me? Ok. Yeah. Good stuff. Perfect. So, thank you Elana for asking me along today to chat to you all. I think I've met many of you before. It's nice to see everybody again and it's great to see that this network is continuing to put on really high quality education events for those of you that work in the AC throughout Scotland, which is great. Um Now disappointingly, this is not a particularly interactive talk. Um but um it is something that I care very much about and so I will try and make it interesting as we go along. Um So critical care recovery and Lothian is relatively new, we're about three years into our service. Um And there'd been, there's been attempts to do recovery for a long time. And what I thought I would do is try and use a model throughout this talk the next 35 40 minutes, something like that where I'd use a kind of how do we get here? What's led us to this point where why is critical care recovery important? Where are we now and then where do we want to go in the future in terms of critical care recovery? Not only I guess, an anxious Lothian but broadly across Scotland and across the UK. We want to be the gold standard in terms of a recovery for our patients. So um I think that probably until about 10 years ago, these those of you that are long in the tooth might remember the kind of attitude maybe that you saw where patients would leave critical care. And we did a lot of kind of like patting ourselves on the back, congratulating ourselves um that patients have survived. And I think some of my colleagues still a little bit have this opinion. Um But um until maybe about 10 years ago, really slightly more than 10 years ago, the focus really wasn't, was on survival. Survival was really the only important outcome for patients. And then what I thought I would do this first part of the talk is talk about some of the literature that's really led us to thinking, oh, maybe we're not actually doing as good as we could for patients in terms of their recovery after critical illness. The end of the day, um survival is not the only outcome for patients. There is um there are other outcomes, particularly good quality survival. And there's a good quote. Um where um somebody says that critical care shouldn't be measured by survival but should be measured by the quality of life restored, which is something that I really believe in. So the first paper at the top is a lady called Margaret Head and she really is the kind of um uh the lead, one of the leaders in critical care recovery. And she published this paper about just under 10 years ago or just over 10 years ago in New, in the Journal of Medicine. And she took, um, survivors of A RD. Right. We all after A R DS, one was common presentations to our care units and she looked at them to find out how they were doing a year later. Now, these were really, really young patients. The average age in this cohort was about 45 and she found that they really weren't doing well. Ok. When she looked at them, they've lost about 20% of their body weight. These were not patients who had a large BMI to start with. So they've lost 20% of their body weight, massive amounts of weight. And when she looked at them, she said, ok, well, maybe this is all just fibrotic change. Maybe you've now got chronic lung disease and that's why you're not doing so well. But they checked spirometry and lung volumes and they found that spirometry and lung volumes and resolution of those, they've completely resolved by six months. So almost all the patients had normal actual pulmonary function. But when you got them to walk a distance, they were walking considerably, a less distance than age match controls. And when you ask them about how they were doing, you, they were really, really weak and when you tested their grip strength, they were really, really weak. And when you looked at their health related quality of life. How are they getting on? How are they, um, uh managing with, with some questionnaires? They weren't doing particularly well. So that started to, to raise alarm bells that maybe actually these patients that survive critical illness do have some problems afterwards. And she subsequently followed that cohort up through five years, which found at five years they still had problems, they still couldn't walk as far as their um age adjusted controls, who had not been critically ill, they still had a lower related quality health related quality of life than their um their cohort equivalent and they still had detectable muscle weakness five years on after their critical illness. Um and they were still struggling and then just there and um in uh October at the SI M, they presented their 10 year data and they still found that those patients had difficulty. So we, what we know is that functional disability after critical illness is pretty severe, it can happen to really young patients and for a decade after their critical illness. And that is really quite frightening. And this is this sort of data started to really focus the attention on um what can we do for these patients after they leave critical care? Clearly, they're not doing as well as we thought we were, we aren't solving all their problems at the point of discharge. And then you can look at that as an even more extreme way this is another paper where they look specifically at older patients. So this is an a patients over the age of 65 who came to critical care and they looked um a year later to find out how they were getting on. Ok. Now a year later, remember these were patients who were good enough, functionally, good enough to be admitted to critical care. They were thought to be amongst the best and fittest of their cohort for their age. 45% of those patients were dead a year later on. Um And they had really poor health related quality of life and massive rates of depression. The rates of suicide were 4.5 times that of their age adjusted controls. Um So really, really this seems to be a particular, the problem of of critical care survival burden seems to be accelerated um in an older population as well. You can say, well, you've told us loads about physical disability. Well, this is AAA really interesting trial um called the Brain IC trial that was published a few years ago now. And what they were interested in was looking specifically at cognitive dysfunction after a critical illness and they took patients and the so these were patients who did not have cognitive disability baseline, they all had normal cognitive function. Ok. Um And about 75% of them were said to be delirious during their ICU stay. It's about in keeping with what we know from published literature and what they did was they looked at patients three months, six months and 12 months later and they did some formal cognitive testing on them at a year down the line, 40% of patients had cognitive impairment in keeping with the diagnosis of Alzheimer's disease. Ok. And the most frightening thing about this paper is that it wasn't just older patients, but that was seen across all age groups. So, if you could imagine if you are a 35 year old who has a, you know, a strep pneumonia gets ventilated for four or five days, has a bit of a delirium but gets out pretty quickly. There's a 40% chance that a year down the line, you have an equivalent cognitive function to someone who has Alzheimer's disease. Now, if you are someone who runs their own business, that means you probably can't return to work. Um, because you aren't going to be able to, to, to manage, to function, you may be dependent on others. And that is a really think a really frightening thing. So, physically patients do well, cognitively, you know, they definitely don't do well. Well, we're in a sit, what about in terms of resource allocation? Well, we're in a situation where everybody knows the NHS is at breaking point. There is absolutely no money for anyone. Um, and if you look at patients who have been in critical, in critical care and then you look at the resources they use afterwards, the resource up and um and health economic burden massively increases. About a third of them are readmitted to hospital pretty soon after their um their ICU stay, they use up loads of resource and loads of money. They're very expensive patients to look after and remember these are survivors and these are good patients that have done really well. And then again, finally, the literature focused on um we, we think we know these patients are doing badly. But what about their, their families? And when they looked at symptoms of anxiety and depression amongst family members of people who'd been in critical care. Um it was well recognized that their rates were massively above the baseline population level. So it's not only patients that are suffering here but but families. So that's kind of where the literature read led us to. And then what happened was, oh gosh, it's hopefully gonna click forward uh in 2009. Um This is Dale Needham who is again one of the sort of drivers of critical care recovery. They brought a whole load of important what the people they thought had important opinions on this topic together at a stakeholders conference. OK. And they said you've all published this data that says um patients are struggling physically, they're cognitively struggling, they have mental health issues, the families are struggling. And what happened at that consensus stakeholders conference is that the, the the diagnosis of post intensive care syndrome. The consent was a consensus agreement for the diagnosis of post intensive care syndrome and post intensive care syndrome is a syndrome. It's a, it's an umbrella term that covers physical impairment, cognitive impairment, mental health issues for the patient, but then also has a family arm as well and it covers all sorts of things from, you know, the things that are that we see commonly, which is muscle fatigue, muscle weakness, physical functioning, lots of rates of chronic pain problems with um uh you know, um uh with breathlessness on exertion, cognitive issues around attention processing, executive dysfunction, and then mental health issues, anxiety, depression, posttraumatic stress disorder, sleep problems, and then massive caregiver burden and, and emotional distress amongst families. So this was the where the definition came from and really this is super slow. The um this is a nice um this paper that uh Margaret Herridge and a Az who's again, another person put together a couple of years ago that illustrates all of the sort of sequelae of critical illness that um exist for patients. So things that you just often don't think about things like um patients who uh develop um problems with dentition or oral sores or pressure injuries or peripheral nerve injuries are really common. Um caregiver issues that we've spoken about increase. The other thing that is pretty frightening about caregivers is that caregivers have an increase in their mortality independently associated with their loved ones, critical care stay, which I think is pretty frightening, right? And then this recognizes also the burden to Children which has reduced, you know, the increased risk of um of trauma, particularly to those patients ptsd anxiety. But also that they tend to have um be less likely to attend school, often have time out of school, have education, educational attainment gaps, et cetera. And then finally, I like this little paper because it also talks about the the the risk of um of long term burdens to critical care professionals, particularly in the risk of moral distress and um and in burnout anxiety and physician fatigue as well. Um So we know that this is a big problem and it's been addressed, it's been a thing um for many years now. So, oh sorry, this is a um this is a nice slide here that illustrates the kind of patients that we all are all familiar with. So you've got patient a who is your 35 year old totally fit and well, Jim Gore with community acquired pneumonia, obviously that patient has a significant illness and then they tend to have functional recovery. But the important thing to say is that patients in critical care, we should never really be promising patients recovery to to baseline because for what we know is for even for the well patient groups, they do not recover to baseline, they recover to below baseline. Um So my phrase turn of phrase that I like to give to these patients I like to use is that I like to say to them. The best case scenario here is a protracted recovery into many weeks to months because we know that's true with a reduced level of function at the end of it. And that is a kind of even my best patients. That is my baseline going in. I'm going in to speak to the family. That is what I am saying. We've got a patient who um already is frail. Um They, you see that they are much, much more likely to have a far uh when you compare to their, to your, to your totally functionally well, low clinical frailty score peers, their, their level of degree of dependency will be increased relative to um the severity of the illness that they have. So and then patients c obviously is a patient who dies during their stay, but this also mirrors how the caregivers of those patients do as well because a patient who does pretty well and gets to near functional baseline, their caregivers are probably also gonna do pretty well for most of the time. But if you have a patient who like patient b who isn't doing that well, that caregiver is probably also not gonna do well, they might have to give up work. They're gonna have to take on a cure burden. You're giving them symptoms of anxiety and depression. So it's all pretty closely linked together. Ok. So we've, we've been here for a long time. So um in 2009, nice came out with a statement saying um a a clinic guideline saying patients should be rehabilitated after, after illness. And then it's actually rehab services after critical care have been a quality indicator within six ag since 2015. But actually, for many, many years, critical care recovery was not really streamlined or organized, particularly within Scotland. And there was a number of reasons for that. And some of the main reasons are that we had pretty different models and literature looks at different things. So my question is with critical care recovery. When, when's the right time to do it? Do you do it early when the patients are already, are still in critical care? Do you do it as an inpatient as a post discharge, inpatient rehabilitation or are we looking at outpatient rehabilitation here? We're looking at getting patients home, discharged from the hospital and then bringing them back to a clinic environment in terms of our critical care recovery services, how should they be organized? How should they be, what who are the key staff members that should be involved in them? Um And then what sorts of components of critical care do you want? Do you just want this to be a nurse led service? Do you want this to include therapies? Do you want it to be a very medical model? Where there's a, a medical thing, a medical lead because all those things are different and the difficulty. And I think the reason that there wasn't cohesion there is because loads of people were doing loads of different things. And when loads of people are doing loads of different things, it is almost impossible to show benefit to these things in terms of literature. OK. Um So it's meta analyses of all the different critical care recovery interventions. When you look at them, it's almost impossible to pick them apart because there's so many people doing so many different things in Edinburgh, though, our experience that's led us to the point we're at now came from a few places. So at the top, this is Tim Walsh's study from um from several years ago now called the recover trial. It was a randomized controlled trial. And what Tim did was he um got a funding for a generic rehabilitation assistant sort of part physio, part occupational therapist. Um And the patients were randomized after ICU discharge into getting inpatient rehabilitation, either from the generic rehabilitation assistant or just standard care as we would normally do. And as you would expect, um it's really hard to show these things would benefit, right? So what he did find is that patients really like this model, the patients were satisfied, there was good patient satisfaction, there wasn't any change in health related quality of life, but patients really did like the model and then that moved on. So we were saying that it's probably important that the patients have inpatient, they like inpatient rehabilitation. But what about when they go home to the community? And how are they getting on at home that then led on to this project, which is called the Scarf projects, which is the healthcare improvement Scotland projects, which looked at community based rehabilitation using lots and lots of engagement with third sector resources. And the goal of this program was to reduce um remission rates to hospital, which they managed to do. OK. So the Edinburgh data has told us some things patients value in patient rehabilitation, but there's something really important about what after they go home as well. And then uh I know that many of us worked through the COVID pandemic. There, there are not many um silver linings to be found in the COVID pandemic. Um but critical care recovery was one of them and this is how our own critical care recovery service ended up getting funded. Um Two seconds. I'm just on call. I'm just checking. That's nothing big. No, it's fine. Um uh So I can put in a position statement saying patients after um a with after COVID pneumonitis need rehabilitation. The middle report was the cassette report who will come on to talk about the cassette is our recovery psychiatrist. She looked at the mental health needs of those recovering from COVID-19 and identified there were significant needs and then finally um published this life after critical illness document that looked at as a guide to delivering aftercare services for critically ill patients. And then on the back of the COVID pandemic, we managed to get pilot funding for six months of a critical care recovery program. And that pilot program ended in February of 2021 with us showing that the service had been beneficial and the service was funded um in a long term way from that. So I wouldn't like to do a global respiratory pandemic again. But um this is the one really good thing that has come out of it for us in terms of critical care recovery in NHS Lothian and the benefit of um the global respiratory pandemic and being given money to um to try and form your own service is that you have the ability to go back to the drawing board. So this is what happened with us in Edinburgh and we went back to the drawing board and we looked at what we thought the ideal critical care recovery set up would be if we had, you know, what would the gold standard be looking at the literature, looking at what we know and looking at our experience in Edinburgh, what sorts of things were important? Well, it was clear to us that the critical care recovery needed to cover transition points, we all know that patients really feel anxious about step down to the ward, feel anxious about going home. And um there needed to be really seamless care transitions where we they would be picked up after leaving critical care and that would continue through and will involve discharge planning. So transition points we knew was really important. We knew it needed to be patient centered, right? With individualized patient treatment plans and patient involvement in their care. That was really key. We knew we needed to be integrated in terms of continuity of care. We wanted there to be the same team looking after people after discharge and then out into the community and then maybe back to clinic as well. And we knew we needed to engage our colleagues in the community. We know that after we go home, we sort of lose contact a little bit when the ability to provide therapies. But our colleagues in the community are really, really useful. It clearly needed to be a multidisciplinary approach. There needs to be collaboration and we needed a format in which we could have that through regular team meetings. And we wanted an approach that was both holistic, so physical rehabilitation, psychological support, nutritional support um but targeted. So the patients had specific goals that were set for them. And really importantly, as with all services in the NHS, we knew that we would need to sing for our supper through um using reliable outcome measures. So that was where we were at. So that kind of led to the design of the service which led us here now. So what happens with us in NHS Lothian is that we provide a comprehensive coordinated recovery and rehabilitation pathway. Ok. So that means that regardless of we've got three critical care units with NHS Lothian, got the royal, the western and ST John's, whatever, whatever hospital you present to the critical care recovery pathway that you follow will be almost identical. Ok. The service is really, really keen on continuity. So it it commences at the point of ICU discharge, it takes the patient right through the rest of their hospital journey, including discharge planning and then extends out into the community. OK. So and then again, the patients then come back to us. So the idea of that is that the same multidisciplinary staff are providing continuity right throughout the patient journey and a key transition points of care. OK. So I don't like the slide just mainly because it is the most heinous photo of me that has ever been taken. But this is our critical care recovery team. OK. We are a large group, it's complex group to coordinate. But um we think we have the right balance of the people we need there. So um we have a service lead that's Joe Thompson. Um she's here and she leads the kind of logistic and management part of the service. We have a critical care recovery nurse, that's Betsy, our critical career recovery nurse at the royal here. Um and she um largely coordinates triages and um and uh delivers patient care. Um We have two consultant intensivist. Uh It's me and Les Wilson um who's soon to retire. Um And then we have a consultant in rehabilitation medicine, Alistair Fitzgerald here who um helps look after patients who may need in longer term inpatient rehabilitation. We know that mental health recovery is really important. So we have both a consultant psychiatrist and a mental health nurse who work embedded as part of our team. And then we have a full array of therapists. So physiotherapists, occupational therapists, speech and language therapists, dieticians all embedded within the service. And then most importantly, or some of what I say, most importantly, we found the most important recently, we have integrated a pharmacist into our um our team and that's been really beneficial in terms of patient safety. So there's looks like a lot on this side, but I mean, basically just going to, to use it to try and explain to you how we manage to work out what patients might benefit. So we know that patients are most likely to have um uh post intensive care syndrome if they are ventilated for probably about four days or more. So for any patients who um who come through critical care at any point through their stay, we screen them and we then allocate those patients into a number of different pathways. Your low risk patients are like your overdoses, vent for 12 hours. And people that um you know, are a bit drunk and fall over and get you to go home. Those patients generally do reach their functional baseline. So they get a packet that explains a critical care state and they get some telephone um uh updates about 7 to 10 days later. Just to find out how they're getting on our pathway. Patients are patients who have established rehabilitation pathways that things like stroke, eyes, et cetera. We don't really get involved with those patients. We have a mental health group which is patients who specifically require mental health output. And then obviously, those patients that are diverted towards NADI or a psychiatrist or Tom or a mental health nurse for them to see specifically. And then the two groups that are most common is are high risk patients who are patients who have complex comorbidity. For example, that might be patients who have head and neck cancer at ST John's who are undergoing major cases or who have um our rehab patients who are patients who we classically think of. These are patients with complex icu um rehab requirements. They're weak, they've got delirium, they have got complex polypharmacy need to sort out those patients go through a process where they get an MDT discussion every single week. They are cared for by the consultants and therapists who are part of that team at discharge. There is um engagement with the GP and community services. Um and they then after they go home, they get a telephone call and they're brought back to clinic about three months later on to find out how they're getting on. So where, where are we now? So we um in uh in the last year, um the service is busy. We've had 850 patients come through our service in the 12 months between April and March of this year. Um And that excludes about 100 patients who are referred into our service. That might be, for example, um uh patients who maybe it comes to light after they've gone into the community that they have complex needs, they might be pathway patients. So transplant patients, for example, who have really complex needs that get referred in. So it's about 850 plus another 100. So, right, almost 1000 patients a year are coming through the service and about 75% of that caseload is, is held within the Royal Infirmary of Edinburgh, which is our big unit. Um And the rest is split between ST John's and the Western. OK. And so we're finding out how we're getting on. Well, if you look, since COVID numbers have actually decreased, we're getting about 26% fewer patients through. So you're like, oh, well, maybe you're, that's great, right? Your needs are reducing that on like most services, the demand of most services is increasing, but actually we just don't have a global respiratory pandemic through. So going on. So we just don't have quite the same volume of critical care patients as we did in 2021 when we sent this service up. But actually the really complex thing about these is although our overall numbers have reduced, the patients are getting sicker. Um and this is probably something that you recognize within your own units. So in the past year or since service has been set up our rehab ie that's the patients of really complex rehabilitation needs weakness, complex delirium, complex polypharmacy, they have doubled. Um And overall, that's just the overall throughout NHS Lothian, they've increased by a third. So these are really, really really sick patients and you'll recognize that, you know, you've got patients who are coming in for high risk operations who are staying for longer. You know, you've got loads of patients who are having not just seven day stay, but 50 day stay, 60 day stay, 70 day stay in ICU and longer. And these are the patients that we're picking up. They require huge input from critical care recovery once they leave. So as an example of how hard our staff are working. So this is just a snapshot from the royal in for me. So 100 and 67 patients, um we got many, many phys physio sessions, like 2030 4050 physio sessions, but importantly, it's not just a single member of staff that's required to staff those sessions, two thirds of those sessions required at least two members of staff to deliver the sessions because patients were not mobile, they needed Sara steadied, they needed hoisted. So most of our patients require multiple inputs from multiple members of staff. Now, speech and language, 875 discrete sessions of speech and language therapy delivered to our patients and 60% of them had in reaching to ICU. And the thing that I find most like astonishing about the hard work of these patients. So our critical care dietician works a 0.1 with the service. So I don't know what that is of a like of a um It's about 3.6 hours a week. OK, 1200 discrete dietetic contacts they delivered in a year to support the 90% of patients who are discharged from critical care still completely dependent on alternative sources of nutrition. Ok. So these staff are working unbelievably hard. Um We look at our mental health input. One single clinician delivered not only inpatient care for mental health, of which 50% of those 900 patients require mental health input, but also 300 individual mental health outpatient appointments drives me like it blows my mind. These figures. We also we're talking about the integration of our pharmacist. So our pharmacist came and joined us for um a pilot period where we got funding. She delivered an average of 11 interventions a week and she used something called the hospital pharmacy intervention scale which basically grades your pharmacy intervention from like, oh, I changed the time of something up to something was a threat to life. Almost 20% of the intervention she made were potential threats to life. And that really highlights just how complex the polypharmacy in this patient group is. And for example, interventions that she sort of made were, you know, patients who had Parkinson's disease, who were prescribed haloperidol and then were totally rigid on the ward. Patients who had um you know, traumatic subdurals or traumatic brain injuries that were receiving treatment dose delta par for sample patients with major allergy where it hadn't been picked up. So yes, we have pharmacists on our wards. But if you have one pharmacist covering three or four medical wards, it makes sense that maybe these things just go under the radar and it really, really highlights the need, you know, for intervention in these patients. Now, a lot of our colleagues think about clinic as being the as the, as the main part of this. Um But actually I think clinic is a nice wee um carry on the top of our critical care recovery service. The majority of the work is done in the inpatient component of it. It is the MDT every week, it is being seen by clinicians and by therapists every week to get them to a point of discharge. But our clinic runs every month and um, uh, I made a joke when I last gave this presentation about it being a WWE tag in, tag out style which didn't really land well with the audience, but carousel style I think is probably the way that it could be described where the idea is the patients before they come back to, to clinic, get, um, a phone call where they get triaged. Basically. What, what are your needs at the minute? And they might say, you know, uh I've got a whole lot of physical problems. I've got some mental health problems, not sleeping very well. Um My voice actually, I can't sing karaoke anymore and they all get then. Um A so all of our MDT professionals go to clinic and the patients that need to be seen get swapped in and out. So the idea is it's a one stop shop for patients. Um Not that many of our patients end up coming back to clinic. Um And that's because most of them are doing too well to come back to clinic, which is quite nice, but we saw 50 patients last year. We made lots of ongoing referrals. So that would be for things like um uh chronic pain. So patients who maybe came back to clinic three months later, who were still on a, who are now in a, a phase where they were on long term opiates. Those patients need to be referred onto a service that can help them manage those chronic pain issues, they're like to persist. Um We made lots of referrals to our colleagues in ent for voice problems, lots of referrals to the hand clinic, um or to our orthopedic colleagues for peripheral nerve injuries, really, really common, but a third of patients will have a peripheral nerve injury. Um uh all sorts of things. Um uh and we did just check recently that the patients that were doing, we were worrying are we missing a group of patients that really need to come? But actually, the most common reason that they didn't come back is that they were doing pretty well importantly, every single patient that came back to clinic found it beneficial. And we do take a variety of outcome measures. We use something called the EQ five D 5 L which is a health related quality of life measure. Um And the idea is that can allow our service to from a quality improvement point of view, ensure that we're doing what we want, which is improving patients, health related quality of life. But then where do we want to go next? So that 2009 was that consensus statement? We've come a long way since then, but we know that we're probably that this is on, this is a uh an aspect of critical care that will only develop. Um And so we need to be smart about the way that we expand things. So, um this is our driver diagram those of you that are familiar with Q I methodology will have seen these before. But um, our goal is to make sure that all patients who've been ventilated and for more than 24 hours receive critical care in a pan lot way and the ways that we need to do that, we have primary drivers, secondary drivers and change ideas and we've got a whole load of, um, of things that we are doing in our um in our er service. But the things that are really, really important to us within the next year or so is uh around ensuring consistent uh outcome measures. And I'll come on to talk about those in a wee second uh talking about um Q I and research, which we've got a research, a bit of research going on at the minute looking at why patients don't come back to clinic Q I around things like rehabilitation, prescriptions, rehabilitation boards um and ensuring the quality of the service that we're delivering is as close to kind of what is set out in the life after a critical illness document. And then education is a big part of it. So our critical care recovery team are setting up a uh course with the MSC in Critical Care and the University of Edinburgh, which is a recovery based module. The idea for that is that will be the gold standard um educational um module for critical care recovery anywhere in the world. Um and that staff from throughout anywhere in the world who want um PPD opportunities can join that um to ensure that they can also learn from it. So I don't want to lose you all with this. But um when we're talking about outcome measures, we need to aim to think about how we measure data consistently. And I already have alluded to this. But the problem with some of the literature and critical care recovery, everyone's doing different things and everyone's measuring different things. So when you look at the core outcome set, so Dale Needham, the guy that I talked about that did that stakeholders conference. He published what we call core outcome set of all the different outcome data sets that had been used in recovery. And there's something like 29 of them on the list. Now when you're trying to work out whether your service is any good, if you're using one of any one of like 30 measures, it's, it's it's not going to be consistent. You can't compare one thing against another if you're using two different ways of measuring it. And so we're trying to move consistently towards one approach. OK. So the approach that we have taken is the UK Recovery Outcomes Collaborative, which is a large database of recovery patients, uses one single or recommends one single outcome measure as its primary measure. And that is called FFA. Now FFA is um a really, really good outcome measure because not, it's not just like testing a physical thing like grip strength, it's not just cognitive testing and it's not just to do with people's health related quality of life. What it does is integrate all of those things, which is a much more holistic outcome measure. So this is what you get when you have a fam, this is an actual patients. This is the lady who was in hospital with community acquired pneumonia and you get a visual representation of their outcomes and how they're doing. Now, it's got 30 domains and that covers physical things. That's things like, can they get dressed? Can they, are they managing their bladder and bowel? It covers um uh cognitive things like reading, writing expression, comprehension and then it covers psychosocial things that's like, am I getting out and about and doing the things I enjoy? Am I adjusting to my illness? Am I able to interact with others socially? Ok. So it's a nice holistic measure. It's on a scale between I require complete assistance with all those things up to. I am completely independent. OK. So the first, the purple line here is when this lady was admitted to critical care. OK. So when she was admitted, this lady was already ventilated when she was admitted. And so she was completely dependent on us for all of the aspects of care. OK. This lady had a relatively short stay. She was in the in critical care for about a week and she was ventilated for four or five days. So she's, you know, she's not a very, very ill patient by our standards. But you can see the blue line is when she is discharged from critical care to the ward, she's still requiring a lot of support with many of the aspects of daily living from a physical cognitive and emotional point of view. Ok. And then the red line is when we have rehabil her to the point of hospital discharge, she's much, much more functionally independent. What this flat lax is her three month fa she's actually coming back to clinic next week, which is will be another line which hopefully for her will be now back to her being completely independent. And the reason that FF is really nice is that it's not a single measure, you can measure it over multiple different times points and you can get a really nice visual representation of progress for your patient, you can see how patients are doing. Um And so we think this is the right sort of data set for us to use holistic being recommended by large rehabilitation collaborative. We think it's the way to go. And then I thought finally, I would just, it's really abstract talking about a lot of this stuff, right? But um uh I thought it would be useful to illustrate it with a case study. Um And this those that were kind of you, this is a a patient that you may be familiar with. Um but she, this lady was a, a middle aged patient um who had a protracted critical care stay. I think she was in critical care for about 50 or 60 days. Ok. She was a lady who was entirely well at Baseline. Um She worked as a teacher. Um and uh she didn't have any significant past medical history. She was admitted to a hospital not in NHS living and was transferred here because she was an acute liver failure patient. Um So with pin and hepatic failure, no, we didn't actually get to the bottom of what caused this lady's pulmon hepatic failure. But she was so ill in the 1st 24 hours or so that she was listed for a liver transplant and she got that liver um a couple of days after that, that liver transplant was complicated and ultimately, that first liver transplant failed. She was relied for another liver transplant and she had a second liver transplant during her stay here. And she had all of the complications of acute hepatic failure that we know um happened. So she had severe vasoplegic shock and was on very, very high dose vasoactive drugs. Um She had acute renal failure. She was managed with plaque to try and manage her. Um you know, her very high a uh um very high vs of pressure requirements. And as a consequence of just the sheer volume of v pressures are shown she developed significant digital ischemia of her hands and her feet. And not surprisingly because of how ill she had been, she needed a percutaneous tracheostomy for respiratory weaning. And really her issues were this lady had severe critical illness, polyneuropathy, she could not um even control her head. Um At the point when you know, she was starting to rehabilitate from her illness, she had very significant nutrition issues. She had a big operation on her tummy and she had a prolonged ileus. That meant she had lost a vast proportion of her body weight. About 30%. She had digital ischemia and her hands and feet became demarcated in terms of necrosis and she subsequently down the line has had terminalization of her fingers and, and feet. And um uh but functionally, that wasn't great for her while she was recovering because she couldn't really use her hands and she couldn't really um you know, start to mobilize effectively because she had necrotic feet. She had the problem that all critical care patients have, which was she was massively boggy and fluid overloaded. She had innumerable infective complications during her stay. And so she had major critical care recovery input. So she stayed in our um hospital for about another four weeks before she was repatriated back to her base hospital. And in that time, she got 70 physio sessions delivered to her on the ward initially, that was just chest as she was. So her cough was so poor that she needed chest video to keep her back from coming back to critical care. Like I said, she had very severe critical care polyneuropathy with no head control and she had to be maxi hoisted to her wheelchair. And we just gradually built up on that. So she started the tilt table sessions very early on. We got her upright, we got used to that progressed gradually over a number of weeks and then Sarah steadied and then she made significant progress. And to the point that she was actually mobile with a zimmer frame um and managed a flight of stairs with some supervision by the time she went back to that. So in about four weeks, you had taken her from being unable to control her head with 70 physio sessions to mobilizing with a zimmer frame, which I think is pretty amazing. Our occupational therapist, this is my, I talk about, I really don't think I understood what an occupational therapist did before I became interested in critical care recovery. I thought it was just kitchen assessment really. But actually our critical care recovery, occupational therapists have a significant increase in I was going for an interest in functional upper limb rehabilitation and in cognitive rehabilitation of the two things they focus on. This lady in four weeks have 50 occupational therapy sessions. She had a very intensive upper limb therapy using something called the SBO mechanical arm. So if you have critical illness, poly, and you can't lift your arms against gravity. You're not going to rehabilitate very well. The SBO mechanical arm takes gravity out of the equation. And a good example is this lady, she was not really gaining weight all that well, because she couldn't lift a fork to her hands. And with a Sable mechanical arm that became an antigravity movement or a sort of took out the role of gravity in bringing a fork to her face. And she, she suddenly was able to start eating and drinking and gaining weight. Um She couldn't press her call button obviously, because she had digital ischemia. So they got her a large call button so she could ask the nursing staff for help. They moved on to do lots and lots of toileting and washing and dressing, practice lots of cognitive rehabilitation because this lady had quite a severe delirium. Um And we wanted to try and optimize her cognitive recovery here. Remember she's a teacher, you don't want her to be in that group of the 40% that can't recover to the point where they can go back to work, speech and language therapies. Initially, she was aphonic. They worked on her same way that critical poopy causes muscle weakness in big groups. You get weakness of your laryngeal muscles and patients can't, can't phonate very well, basically get physio through um S LT. And by the time that she went discharge a month later, she was eating and drinking normally and her voice was pretty much back to normal. She had 40 dietetic contacts to support her transition from energy feeding back to normal diet through fortification et cetera. And the pharmacists were involved in terms of adjusting her gabapentin dosing. This lady has lost all her hair, which for a young woman is after severe, this is not unusual but is particularly distressing. So we gave advice about starting something called Betnovate, which is a scalp steroid ointment, which can help with hair loss. And you'd be surprised how often the medications we start in triple care do not get stopped. And so we reduced and stopped benzodiazepines. So I that's just a case which I hope demonstrates um how we got here. So really the literature, the critical care recovery is not a soft topic. The literature on this is really very clear. Patients really struggle after critical illness. And if we take the approach where when they leave the unit, we think everything's dandy. Um We're really not doing the best in serving our patients. Well, critical care recovery is about reestablishing quality of life where we can, it's taken a long time to get here. But we're now at a point where we're able to deliver seamless and pretty coordinated multidisciplinary care. And it will be exciting to see where this goes over the next little while. Um I do wonder as a group of a ccps, whether you're so embedded within the unit culture now. And um uh you're such drivers of innovation where that I, I have no doubt that for those of you that may be interested in this sort of thing, there's a role for you within recovery services. And really what we're trying to do is always go back to what is our gold standard here for patients, what can we provide for them? And I hope that I'll be uh for those of you that don't have organ organized recovery services within your area. I hope this has been a bit of an inspiration for you in terms of hoping to set things up and I'm happy to answer any questions. I'm sorry, that wasn't very interactive. Um er, but I hope you have found it useful and interesting. Thanks, Julie. That was really good, really interesting. Um I've got a couple of questions just while we wait to see if there's any pops up in the chat, if that's all right. Yeah, of course. Um The so multidisciplinary team members are pretty extensive and like I've obviously do them recently because I'm sort of involved in the MSC course that jelly mentioned. Um who funds them? Is there like a care recovery service that funds them or is it like the dietetic service that funds the 0.1 on the pharmacy funds the pharmacist, et cetera? How's that? How's that work? That's so that's a good question. So yes. So the there's no doubt that the model we have chosen, which is like a very much a full on model of lots of staff, everybody we thought we'd need gold standard reaching for that, that's really expensive model. Um And you could probably do much more pay back things for, for far less. So the budget for our critical care recovery service in is about 500,000 lbs a year we spend on it. Um Predominantly the funding for that comes through our critical care budget. You know, bearing in mind that we spend an NHS Lothian 100 and 80,000 lbs on like 18 doses of IV IG that does very little evidence base. I think that this is actually a service that is pretty lean in terms of the what it delivers for the cost. Um Having said that there's some reciprocal arrangements that we have with physio and things where they pay for a little bit of our time. But predominantly this is funded out of our critical care budgets. Um It is hard. I know if you are someone who's trying to set up a service at the minute, there's no money for anything. The way to set up your service is to demonstrate needs and to demonstrate benefits. So, um uh you know, if you are working in a place where you don't have um uh um a service um and you're looking to demonstrate needs um then um collecting some data on your ICU outcomes might be a good place to start and then approaching your management here. But um yeah, there's no doubt it's not a very, it's not a very, it is a very expensive way of doing things and um it's difficult and takes years to set up a service. Yeah. Um Jack's asking how did you manage to sort the funding? We have started an outreach. So, Jack and Dumfries, we started an outreach in the last two years. But our service is only a critical care nurse and consultant. The critical care nurse is having to annually submit renewal for her funding for the job. I suppose that's about getting by in. And yeah, so we started with a pilot, a pilot a which was largely driven off the back of money that came for rehab from, from COVID. So that funded it to start with. And then at the end of that six months, when you present data saying that actually patients are rehabilitating, getting home pretty quickly, they're all finding it beneficial that you're, you know, you're um that you are um uh taking robust outcome measures. Um that is the way to get by. And so people can, can argue with data. I think it's probably a good way of putting it forward. So data that shows either quality improvement data that shows the importance of your service. Um outcome measures really important. Um Quality feedback is really important. So what do patients feel about your service? But also what the staff feel about your service. And that can be useful to ask not only your critical care, colleagues, patients and families, but also um other teams within the hospital. So say you have um you're you're discharging commonly to general surgery and they just don't have the staff or um the, you know, the the funding to sort of rehabilitate these patients if you then have a pilot and then suddenly get data from your general surgeon saying, thank you so much for all that you're doing for these patients finding big, big improvements in their outcomes. That's really important as well. And that was a big part of securing our permanent funding was just day to day to day. So you need to sing for your supper. So I think uh if I could give advice, Jack and I know it's not easy if you work in a smaller system, which they're the relatively the pot for funding is so scaled down that you um looking at really robust outcome measures is really important and getting data in terms of both quantitative data, in terms of outcome measures, but qualitative data in terms of feedback from others can be really important too. Thanks. Great, thanks, July. Um If anyone else has got any questions, feel free to put them in the chat, we've got maybe five minutes. Um Still um can I ask another question? A CCP? So at the moment, I don't think there's an A CCP involved in the care recovery services. There is scope for that and how like what, how would, what would that look like? Um Yeah, I undoubtedly, I think is a, is my answer to that question. Now, um now I almost say very, very biased about the a you know, that um uh that I value all of you as colleagues and I see your exceptional skill set, you know that um but in the same way that there is a, there is a role for a CCPS within most of the systems that we have in critical care, right? Whether that be you have procedural interested a CCPS who want to start, I don't know a pic line service, you have um uh you know, AACPS who have specific skill sets as we do locally where we have those people attached to pain team and preassessment clinic, all those things, I don't see why that this is, you know, this is just a different skill set, right? So if you have someone who is interested, so particularly I think for an A CPAC P that might be interested in longer term patients. For example, the longer term patients we have on the ward who are really, you know, you know, those those amongst the group that are really motivated to get folk out of bed, to get them weaned from a ventilator or to get them outside. These are I think the kind of people that might fit really well and into a, a kind of critical care recovery. I would see that flesh out as you would almost certainly be a part of the MDT. You would almost certainly be a part of assessing patients. I don't see why those, why they couldn't see clinic patients independently because I'm not doing anything at clinic that, um, that you guys can't deliver as well. So, um, you would fit into the medical model, I think predominantly of that as part of the MDT working with the therapist as part of the team. Yeah, brilliant thanks. And one more final question. Sorry thing, I really like it. I really ii can get my simple brain around how that works on the different colored lines. Do you share that with the patients to show their progress? Does that help from a psychological point of view can be really powerful? Right? Because um so the big problem we sometimes see psychologically with patients is they just are like I'm not the same as I used to be, right? And that is that can be uh just this um per um persisting um really negative thing that just means that they just don't get on with it. But if you can say to them, right? Let me show you where you were when you left critical care, right? You were completely dependent on other people for toileting and these things. Look at how you're getting on now in each of those domains. You can show measurable progress. And I think that is reaffirming for patients in terms of their journey we incorporate. So we do ff at different transition points, not only because it's important for outcomes, but it's useful for patients to see as well. We also have like um just revamped our critical care recovery pack, which basically it's made it much more patient centered and much more goal focused for the patients. So they get a pack when they leave, that incorporates what happened to them in critical care, but also lets them set some goals. So that is things like they can set physical goals, they can set social goals, they can set long term goals. Um And then the reality is that can be really useful in terms of more motivating people as well. If they want to get to, you know, out for Christmas, out for their son or daughter's wedding, you can, you can help them work towards that. And I think it just lends to a model of a much more patient centered approach to care. Um Michelle saying or Forth Valley, I've got a similar model and seems to work well and they have a funded psychologist. Um Yeah, I mean, so um our mental health team are um are a key component of our, of our critical care recovery service. What I would say is that we've started to come up against things that I don't have a lot, you know, there are new things that pop up because you're, you're not just looking after people when they're on ventilators anymore. But increasingly we find as a service as we expand, we come up against new issues and new problems and that's useful to have a, a team when you're responding to them. So recently at a clinic example of, you know, for a clinic, for example, we had a disclosure of a domestic violence situation that was occurring in one of our patients. And it's knowing how to respond to that because actually, I don't have a lot of training and looking after and how to respond there. So it's just seeing that drafting an op. So if it comes up again, you'll be able to respond to it. Yeah. And um we keep seeing these unusual things and we got a kind of growing receptor of, of things and team members who are contributing to those kind of approaches to it. So, yeah, our um our mental health team are are um are key and I think of it very much as like uh the recovery is blended. If you do not have mental health recovery, you cannot have physical recovery. If you don't have physical recovery, you can't have mental health recovery. It's all kind of in there together. You need to address all of those problems, I think. Excellent. Um Well, it doesn't look like there's many more questions and I don't have any more. So, thank you. Jelly. That was really useful for everybody. Um And it's actually quite interesting to know that A CPS could potentially get more involved with quick care recovery in the future. Certainly will. Um, so thanks for your time. I know you're clinical. Um, so thank you for your time. Thank you for being our phone, a friend. Your answer was. Oh, good. I'm glad I'll see you soon. Bye. Yeah, nice to see everybody. Have a good one. Uh Hi guys. Um, so it's a couple of minutes to three. our next speaker is Callum Arthur and I think he, yeah, I can see he's in the chat. Um, so the speaker invite didn't work unfortunately. So what we will do is get Callum, I'll, I'll screen share. Um, Callum. Can you hear me? I don't think you. Oh, no, I don't know if you've got a mic cause you're a guest. Oh, goodness me. Let me see if I can change your invite to stage. Hold on, Callum. If I've invited you to the stage, does that give you camera and mic access? You can type in the chat if you can't speak to me. Oh, no, you're here. There you go. Bear with us guys. We'll just figure this out. But I think I might need to screen share and then Callum can just nudge me when he wants the slide to move on, but bear with us for two seconds. Hold up. Can you hear me? Yes, I can hear you. Lovely. Oh, I wasn't expecting my background not to be blurred. It's normally automatic, but there we go. Happy days. There's no way. Hang up there. We've never used metal before. So there's a few teething problems and it wouldn't, I think it's because I'm on a Macbook. It wouldn't let me upload anything. So I need to troubleshoot that for the next time. So I think the best thing to do is if I just share my screen with your slides because you sent me them. Unless you can screen share, you actually you could probably screen share now that I've invited you to the stage. Yeah, I'm just looking for the tab now. I've never hold on present present. No. Happy days that we could be. You should have a wee arrow in a box. Yeah, present now and it should let you share your screen if you share the whole screen and it'll apparently if you share just one window, it get stuck on one slide. But if you share the whole screen and you can OK, try that, share entire screen screen two. She there's a wee bit of a delay so just wait on it coming up but I can see it but we we're logged in as me on another. Yeah, I can see that. Um So you should be able to just move your slide and speak um as you need to then. So I will very quickly introduce you, but then I'll let you introduce yourself properly because afterwards, so um everyone, Callum Arthur is our third and last speaker of the afternoon. Um I met Callum a couple of months ago now because I was creating a leadership course for the master's in critical care that I work on. And he very kindly did a lot of leadership stuff and facilitated chats and live tutorials and things. And his life show that he did for our MSC students who are all qualified health professionals was really good and just making you think about your own leadership styles and theories. Um So, Callum currently for the now works in NHS Lothian as an racial development consultant. Um and I will hand over to him and he can introduce himself further. Amazing. Thank you Elana, really absolute privilege to be here. Um Yeah. No, and thank you for the invite, Alana. Really excited. Can you hear me? OK. Is everything everything looking? OK. Will I just crash? Can hear you? Perfect. OK. So this is a totally new system for me, but it seems to be working well. So here we go. Um Yeah, listen, real, real, a real privilege to come in. Um Sort of have a wee chat with you guys about leadership and sort of encourage a bit of self reflection. And uh yeah, just sort of look at leadership from maybe some different angles um as we go through this. So we've got approximately an hour. Um I'm not sure if your microphones will work, but you know, encourage, please do pop stuff in the chat or come on at different points. I will pause throughout, but please, this is interactive. Please do um pause me if you want me to go into detail at any point um in, in, in this presentation. Um So, so as I want to say, this is a real introduction to, to sort of leadership styles and theories. Um um And, and it's just to really give a flavor for some of the history of leadership and maybe how it might relate to how we might think about leadership today. And then we'll focus on a sort of modern theory of leadership that has a bit of a substantial um um um um research behind it. So just firstly, oh, there we go. I took that yesterday. I was down. I, I've just got a whole new respect for, for all the folks on the call because I know you have all done night shift and it'll just be part of your thing that you do. It's not part of my thing that I do. I'm not medically trained. Um But I was down in the Belfry last night and I had to drive back at 330 this morning or set off there. So I am feeling a bit of that. So I've just got a whole new respect for those of you that do night shift So, um there we go. Um Yeah. OK. So a little bit about me, a little bit about background, a little bit about what I sort of feed into this talk today. So I've sort of spent my career really trying to work out, you know, what is good leadership? What, what makes the difference between average to great, let's see. And in lots of different environments, um I've got a phd in it. Not, not that, that means a huge amount. It just means I can write a lot and study some bits and, and maybe understand some data. So, but this phd was in the military and um um it was really trying to look at um what the best leaders in that organization did and then try and train other leaders to be more like that. Um But the, the, the unique bit or, or one of the really interesting bits about this research was we began it sort of 2004, 2005 and really, we flipped the leadership hierarchy. So all of our um understanding of leadership came from the people at the bottom of the organization to the soldiers, the recruits, we actually asked them what they thought excellent leadership is and when they experience it and what differentiates it. And we based our models from the bottom up which, which actually was quite a challenge to the military, very hierarchical organization. Um um But, but they were very um courageous, I think, to allow us to do that. And we ended up with some really excellent models and we did some, some really, really pretty cool work there. I think so. That was this chap P Sergeant Major Fitz was in the parachute regiment. Um He now he's an amazing character. He now has a phd in, in, in leadership, in psychology and mental toughness. He left school with no qualifications. I met him back in 2005. And you know, and then he, he, he got really into the research uh and then ended up with a phd and subsequent publication. So I worked in the military for maybe 1010 years or so. Then um I worked up at Sterling as well as an academic when I ran the M SE sports psychology program up there for a number of years. Then UK Sport approached me so to work in the Olympic system um that was between Rio and Tokyo Cycles and, and really that was to try and help sports. Uh we got very good at winning medals. Um And, and Olympics still are uh to an extent and, and uh but some of the cultures in sports may not have been what they wanted them to be. Um And, and so my, they recruited me to work with the senior leaders in the sports to try and understand what a culture for being the best in the world is. But also looking after people's wellbeing and, and emotional needs. So we weren't winning medals at all costs. It wasn't the sacrifice of the individual in there. I absolutely loved that work and then I joined the NHS. Um but almost four years ago. Um and again, just absolutely love such a privilege to work within this organization to help support people the best we can who are doing really, really tough jobs uh in that environment. So, yeah, I absolutely love that. Basilan says that I'm leaving in January, I'm going to Edinburgh University um to become a senior leadership and surgical performance. So that's all about performance under pressure, how cognitive load might impact decision making and find motor controls. I also do some business work um in business psychology, uh those sorts of things and I work in the premier League. I was just there yesterday and it was quite a highlight for me to stand next to uh the, the, the, the premier league, er trophy there. That was quite a cool thing. I wasn't allowed to touch it, but I could stand next to it. So, so I guess, you know, what, what I'm gonna try and do is I'm just going to try and bring in a whole range of experiences to your world. But really your challenge today and what, what, what I'd like you to do is to everything I'm talking about is just to take it and think about what does that look like in your wards in your situation on a good day, on a bad day and really translate it. So it's meaningful to you because you'll have your own style, your own individual differences. There'll be unique challenges in your systems, in the wards in which you work in. And really, you know, the, the challenge is to try and not just take everything verbatim. Um And, and, and, and as a talk about things but to really transfer that into your context. So, what does it look like for you? Oh, actually forgot about the triplets. So, uh they'll be upset with me about that. So, so the triplets um so really what started and, and really ignited my passion for leadership and psychology and people overcoming trauma and those sorts of things. These are the three boys, uh Ro Ro Ro Fergus and you can tell him a bit lack of sleep. I'm not used to that like you guys will be Fergus Roddy and Dermoid. Um the triplets and they were offering their, their mom died at five and their dad at 13, I caught them when they were 16 and I was sort of looked after them sort of thing until they were 21 sort of responsible sort of living guardian, so to speak. And, and really, that's what, what fired my passion for psychology, really just to try and understand how we overcome things, how we can deal with stuff and how we approach life and those sorts of things. So that was a real pivotal moment. Really. I just wanted to share with you there. OK. So moving on what we're going to do today, so we're going to talk about defining leadership. That's a bit of my research in me. We need to really be clear about what we're talking about, what approach we might do. Um We're going to talk about the major approaches to understanding leadership and then we're going to just pick up one influential theory of leadership called transformational leadership. Oh, actually, I can see some of these, maybe there's a message here. Oh, it was Elana there. So that, that's fine. Um OK, so everybody can use their microphone. So please do uh if you have examples or you want to challenge or understand anything more ple please do. Uh unlike and come in and, and have a chat about that. Um And, and again, one of the other bits that, that, that, that, that, that I really want us to focus on is, is I'm not an expert in leadership. I've studied it. I've, I've sort of experienced it. I've done it, you know, those sorts of things, but actually, I know everybody on the call will have is a leader or will have been a leader in, in, in, in different environments and will have also have received leadership. So the place I want us to start really is to just start reflecting on um what makes a great, great leader for you. Yeah. Maybe think about the best leader that you've ever had. Why, why have they popped into mind? Has somebody popped into mind? Has a couple people popped in? Has nobody popped in? Yeah. And just reflecting on that, you know, and, and then, and then if you can start to identify one person, what we want to start thinking about is what you, what was it that made them special? Why is this person popped into your mind? It could be a parent, it could be a teacher, it could be a sport coach. It may be something in your professional environment, all those sorts of things. And really, when I think when I say that everybody knows what great leadership is. Everybody on the call, everybody in this room knows what really good leadership is because you've experienced it. You'll also know what not so good leadership is because you'll probably experience that too. Um So, so I guess to start in place when we're starting to think about you as leaders, what your leadership style is and ultimately developing your leadership style is to really start thinking about your experiences, making sense of that, jotting some things down so I can encourage you after this session or even during it, just write some little things down about to you. What are the most important characteristics of leadership that you've experienced? What are the things that, that, that, that would be really impactful for you. And then I'll come on to the leadership model a bit and then we'll just expand that out just a little bit. OK. So hopefully I've just sort of set the scene a little bit about what to expect for the next sort of 50 minutes or so. Um OK. So defining leadership, OK. So really simply not house very, this is probably the most common definition that we'll find in the literature of leadership is a process. So it's some sort of actions that will, that will infl influence things in a, in an order uh where one individual influenced a group of people towards a common goal. Reasonable. I think I don't think there's anything massively controversial. The only bit of a challenge about this definition is whether it needs to be a group of people. II think it can be an individual. Um It doesn't need to be a group of people, but obviously, uh in that sort of space, I think that that's a reasonable definition. It's about influence. And this is the, the key bit here. Let me see if I can get my, my pen, my laser to work here and there we go. So this word here I think is really, really key. So what this definition implies that is that in the absence of influence, there is no leadership. Yeah. So in the absence of influence or the potential to influence leadership doesn't happen. Now, it doesn't say in what direction we can have a good influence or a bad influence on people, right? And, and, and it doesn't, it's not automatically a good thing. OK? But the very premise of leadership is that one person is influencing another. So then what that also implies is that there's a power differential between people now that could be hierarchically um um determined by the organization that we work in if we were of a higher rank or more experience. And, and we, we've got certain authorities that are bestowed upon us by the, by, by, by the organization that we're part of now now. So, so that gives us that sort of asymmetry, let's say of somebody can influence somebody else. Um So, so that leads us on to the, the, the portion of one cannot be a leader without power. Now, people sometimes get a little bit um um um concerned or, or, or the, or, or this word of the, the, the, the notion of power um of, of being a little bit uncomfortable and that's OK, but it's, I don't want to think of it as a negatively, a good or a bad thing for the session. It's just part of leadership. It, it is there. Um And, and it's about influencing or exerting one's will over others, right? So now we get into this sort of space about um and what's the difference between influence and coercion and all those sorts of things. So I think just to clarify that really quickly is important. So, so we think about coercion um and influence um the thing that they, they're the same thing at, at one level, the thing that differentiates them is who the beneficiary is of this influence. So coercion, the beneficiary is me the leader. OK. So I'm doing this to satisfy my own needs to get my own promotion to look good in front of my bosses. What whatever it is, the purpose of doing this behavior is, is for my benefit and it doesn't really matter the um the, the benefit of the people that I need it. It's obviously not a good thing and not something we'd encourage. Whereas influence, that's for the benefit of the people that we're leading, right? So, so it's who the beneficiary is. So if I'm doing things for the greater good, the good of my teams and all those sorts of things, now, if I'm doing stuff that's for the betterment of my teams and my people that I'm leading, then that's probably gonna indirectly benefit me as a leader because you will rise to the top and we'll all sort of get on it in a certain way. But I think that's a really crucial difference here because that's the game that we're in if we're thinking about leadership is that, is that there's a power differential. Now, I've just described a hierarchical differential, he's interested in this French and Raven back in the fifties talked about this and it's still relatively influential this theory today. Um And this is about the sources of power. So, OK, I've talked about hierarchical power, but we're gonna have social power, social influence. Remember, power of what we're talking about is a potential to influence. So we can think of our social groups in some situations, you know, when we're, who's making the decision of what bar we go to or what we do and, and who has in what situations might somebody influence the group more than others? And then we have informational power or, or, or, or tactical power or, or, or, or knowledge, you know, or skills, I might, I might know something so I might be helping people. So I'm influencing them to do a skill better, right? And, and all those sorts of things. But what we're going to focus on today is, is the, is the acceptance that actually there's a hierarchy, we're going to talk about leadership as a, as a hierarchy from, from somebody who's, who, who, who's, who's a higher ranking person, so to speak in the organization. But it can be addressed in just normal flat situations as well. And interestingly in this notion, there's, I think something to consider is, you know, even the very presence of a power holder or power bearer, so to speak, can change the behaviors of others. So I don't know about you, but I was driving back last night and a police car sort of spotted the police car quickly looked at my speedometer just to check and I never speed obviously that, but it'd only be an accident, of course, but it influenced my behavior. You know, if a police car pulls up behind you and we want to and, and the traffic lights, we, we, we might all of a sudden become a little bit more self aware of how we're going to pull away, even if we've done nothing wrong and there's nothing there just the very presence of a power holder may change our behaviors and may do things. So I guess that's important, you know, if you're a leader and have people that, that, that you're hierarchically more senior to, you know, you being present may or may not change people's perceptions in that, in that situation. So hopefully that's clear, please do uh because this sort of serves the basis of, of where we go on to next. So please do um pop in the chat or, or, or, or just pop your hand up if you have any questions on that. Ok. So following on for this. So I guess, you know, what we try and do is we just try to pick some things so that there's all sorts of demands that are placed on leaders and, and being a good leader and all those sorts of things. And, but there's, there's, there's often less direction on actually what it is we do as leaders, what can we do that, that brings these things about. So we want to be compassionate, compassionate leadership is really, really big and we'll touch on that today, great theories and Michael West and the King's Fund and absolutely fantastic stuff in there. Um But then it's actually, so how do we be compassionate? What, what do we do? And it's assumed that we all know, but actually, I think that assumption is maybe sometimes misplaced because what's compassionate for me might be different to somebody else, right? So we're all different and I might receive one leader's behavior as I might think, oh, that they'd be quite compassionate with somebody else. But I know they're really not. I like people to talk to me like this. So, so it becomes quite complicated in this. So what we're going to do, we're going to break down this leadership model to hopefully. Um And so it makes sense a little bit of it, I guess. Um So the leader of the place we start with is who you are. Your self-awareness, your personality, your life experiences, your levels of emotional intelligence. For example, we know that's important predictor of, of effective leadership. So that's the really start in place of, of your beliefs, of what good leadership is, your style is what you intentionally try to be. Not to say that, you know, because we intend something that's always going to be delivered or received in that way. But it starts with that intentional bit. So in any leadership model, in any place where we're starting to think about developing leaders and who you are, you might have done some personality inventories, you might have done NBT strength development, the compass brilliant stuff just to give you an indication of roughly where your preferences or your strengths might lie. Nobody go too much into the detail of that stuff. But, but you know, no self awareness and we can have some things that can help to sort of point us in directions against and then those things will lead into our behavior. So this is actually what we do, the choices we make, the decisions that we might make in a situation. Um So what you do, but the crucial bit is, and they're just sort of intubated to that a wee moment ago about OK, who you are and, and what, what our intentions are and how that's received isn't always one for an actually often it, it's not. Um so there's some classic bits of research in, in the sport literature. Um really coming from the mediational model, which is Smith and small out of Washington developed this sort of model of leadership and essentially, um and what, what they, they, they, they, they described is, is, is um I as a leader, I might intentionally want to do something. But actually, it's my team that are the ultimate arbiters of whether I've done that or not. Um And, and that's the sort of research that we did in the military, we flipped that hierarchy. Now, one of the classic bits of research in this space is where they asked maybe 100 different leaders, how often do you praise your teams and, and a scale of 1 to 5. Let's see. And they, let's say this. Yeah, II give out a lot of praise actually and they'll maybe mark four. And then we asked the very same people that they lead, how often do you receive praise from your leader? And almost always, it's lower. They're sort of probably answering around about a three. OK. There's lots of variation, but on average in this research and other research that demonstrate this consistent finding that what we think we do as leaders is, is invariably not what's received uh by the people we're leading. Um So, so that's something just to bear in mind. OK, when we're thinking about ourselves and, and, and how our behaviors are coming across and how we might check indeed what's going on here. So I'm using the word follower again, sometimes people can um um and have a little bit of a reaction to that word. And, and I'm not mean in the blind sense of a follower, it's just, it's just I could have used subordinates team members. It's just the word I'm using to differentiate. There's a hierarchical differentiation in this space. So that, that's the word I'm using um please, you know, um challenge that and feel free to do that, but it's just for ease of communication just now. Um OK, so then, so your cognition. So it's what you're thinking, right? So my leader maybe goes call amazing. Thank you. That was a brilliant job. Really appreciate that. I'm probably gonna think that's cool. They quite like me, they quite appreciate the effort and I think I'm quite good and that will affect my emotions. So I'm feeling quite confident, quite happy in that moment. Um, and then that'll influence my behavior. So I want to do more of that because I want more praise because it just makes us feel good when somebody says those things once we get over the awkwardness because it's always a little bit awkward, somebody praises us, but deep down, we're probably feeling quite nice or a little bit afterwards. It sort of sinks in, but we often don't know how to respond in that moment in that awkward awkward phase almost. It was great. I've got a five year old daughter and she was five just recently. And, um, and it just made me think of this a little bit about why we find it awkward sometimes when somebody says well done a great job and, and, and so so it was a birthday and, and we just going happy birthday, you know, and she say happy birthday back, which is quite funny for everybody else, but it's just she wanted to reciprocate, right? So it's that sort of modeling that emotional sort of thing. So she wanted to get into that sort of reciprocation. So I think there's something quite similar in that space. We're not going to get into that in any depth, but it's just to be aware of, ultimately, this is where we're at believers. We want to ultimately influence the behaviors and we want to influence the behaviors that are goal directed that are positive for other people in their teams and the outcomes and the patients and all those other sorts of things even on a difficult day. So I've just presented that up there. It's a bit of a straw man because there's lots of feedback loops, there's lots of different things in there. But I guess it's just to start in place to start, you know, if we think all sciences in some ways is, is about trying to categorize and make things simpler. So we understand them. That's the Darwin's original theories, right? Of, you know, of species and evolution was we need to put animals in different species in different boxes. So we understand and you know, and all those sorts of things. So this is in essence, what we're trying to do here, we're trying to just understand and create a framework by which we can hopefully um have have a slightly easier to understand. The construct is often quite tricky to understand. OK, so just gonna pause for a moment. Does anybody have any questions? Any challenges to, to, to what, what, what I've described here? Ple, please do come in anything you think? Oh, yeah, that makes sense. Or, or, or that, that's a bit different. I hadn't heard that before. Or, or actually Callum, you're, you're talking nonsense. It's like this, it's not really like how you're seeing it. Ple, please do come in because this is a conversation. right? This is, I'm not dealing in facts here. Um I don't think anything's coming up. Cool. No worries. All right. So um leadership's been a major and it's, it's the most widely studied construct in social psychology and social sciences. It's often the most important thing that people want to understand more and do better. It's also one of the hardest things to do better. Um But, but that's nonetheless, we've learned a lot over the years of, of, of, of, of, of leaders and how we develop them who emerges as leaders. Is it the right people that become the leaders and all, all those types of questions? So the original sort of attempt to, to look at leadership was a trait based approach. Then it sort of moved more into the skills based approach, then more of a behavioral based, then situational and contextual approaches. And then they sort of new leadership approaches are not really that new, they're sort of the nineties and two thousands. So knew when I was sort of studying the first studying this stuff. But, and really the new stuff was all about the emotions of, of leadership, about the emotions that we engender in others. And so I'm just gonna quickly go through those just to help us maybe understand some bits and, and actually, they're all still prevalent today. It's just just these, these, these were the major dominant approaches and then died down, but then they've all now sort of amalgamated into our, our general understanding of, of, of, of leadership. So trait based approaches. So, you know, the, the research very clearly shows that personality has a significant um um um um prediction of who emerges as leader. This is about good leadership. This is who becomes a leader. Height, taller men were, were um um um um more likely to be a leader. Um how good looking you are as a male and a female is, is determined your facial face, of your, the shape of your face. There's lots of research that looking at the, the, the, the, the, the facial shape, the square jaw and that sort of thing, those people usually emerge as leaders more more than different shapes. So there's lots of research in this um really fixed approaches not so popular nowadays. Um But gender obviously, um race, self-confidence, narcissism, we know I did a lot of research on narcissism. I'm not saying narcissism as the um um um um as the, the, the sort of mental health is all about narcissism as a uh distributed in the normal population. So everybody will have certain narcissistic tendencies and we can be in the NP narcissistic personality inventories like a 0 to 40 we'd all be somewhere on that scale. Some people would be higher, some people would be lower, you know, people who are higher on that scale in a normal population are more likely to emerge as leaders. Um So essentially what, what this was talking about is some people are born better leaders than others, right? So maybe you heard this, some people are natural, some people really um lean into that space more really heavily criticized by stil in the sort of the 19 forties and that sort of put an end, not, not an end, but paused that research a little bit a reemergence by anus. He's an AUS is one of the probably the most influential researchers in leadership research to this day. Um So, so he, he, he sort of brought a re emergence of actually we need to really think about and it makes sense the personality because that's what influence lots of things. Now, we can't really change it. So if you're a developer, we can't really change people's heights, we can't really do lots of stuff, you know, in that sort of space. But actually, it matters to who you are as a leader and how you're going to become more effective depending on your particular constellation of personality traits and experiences. Um So, so I'm not spent too long on these bits. Um Then, then it sort of research moved into more of a skills based approach to leadership and you might still see some things in the, in the literature or, or bits that, that sort of relate to this. So essentially they talked about there's some technical skills that, that are fundamental. You've got these, these technical bits, the human bits and the conceptual bits. So technical is about how good you are at doing the job, right? How good you are at, at, at whatever it is that you do and and those are really important at the bottom level, at the first line line management level, the supervisory level, because you're still doing that a lot and showing others to do it, you'll be passing on your skills to, to, to, to the next generation coming through and those sorts of things, the human bit is our social, emotional intelligence, that type of stuff about how we interact with others, how we communicate, the sort of relationships that we can build with people. Conceptual stuff is the more the bigger picture, that's more the um um and so the visionary the how everything fits together in a healthcare system, how the different parts of a hospital might be linked and the major complexities between the front door and patients sort of coming out at the other end and that sort of flow of patients and those sorts of things. So that's the bigger sort of picture. So as you'd expect really quite straightforward, nothing um controversial in here, technical remains relatively important. Conceptual becomes more, but the top level management, you'll be leading areas that you're not technically proficient at. So as you go up to a level, you'll now be at a certain level in an organization, you, that'll be when you go into a position where you're, you maybe have no idea how to do a particular technical aspect of the job of the people that you're leading or the functions that you're leading. So that becomes less important. This stuff here becomes more important, reasonably useful, I think, to conceptualize and think about um, relatively simple. I don't think there's anything controversial there and there might be elements in, in, in, in the leadership experiences that you've had there. Ok. Then they sort of moved into the behavioral approaches. So this sort of stuff, we've got the Ohio State and Michigan studies and then we've got the, the, the, um um um and, and they identified basically what is it that leaders do, you know, what, what, what, what behaviors do they exhibit? So sort of similar to the skills base because the skills will relate to your behaviors. But the skills were almost sort of, you know, a little bit before a behavior in some ways. Um So we're now getting into observable things that people might do that leaders might do in the environment in terms of how we're measuring those things. Um So the Ohio State and the University of Michigan were the most influential in, in these, in this sort of starting place. Lots of other um studies um came after those things and they essentially split leadership into two major categories, initiating structure and consideration in Ohio State Studies, University of Michigan production orientation and employee orientation. They were virtually the same thing. They just called them different names. Um They were sort of evolving in their own little pockets. There wasn't, this was back in the fifties and sixties, it wasn't the social media people didn't connect as much and these pockets were sort of emerging and it takes a long time from data collection to publication and all those sorts of things and especially in those days. So, so they were sort of emerging, but they came up with roughly the same answer uh that, that you could really split behaviors into those bits. It's thought of as being overly simplified. Now, I'm all about simplifying stuff and, and actually it sort of makes sense in some ways. So initiating structure, that's, that's about essentially this was a basis of management stuff, this is process, this is um hr type policies, procedures, you know, that that sort of thing in there. And then the consideration was how you delivered those policies and procedures. Um and how you connected with people from a behavioral point of view. OK, just really quickly in there. So this is about to find what leaders do and, and really, this was a sort of, you know, starting to understand leadership from the follower perspective rather than who the leader is or their personality. It was really defined in the follower. Now, the situational and contextual approaches really moved this on a little bit. Now, what, what they really focused on in, in their research was they, they identified that there was um different situations would require different types of leadership makes sense, you know, you know, like COVID gold command, stepping it up, command and control, then we're backing away from that hopefully and getting more into sort of participative or, or, or, or, or consultative leadership and all those sorts of things. But, but essentially what? But so, so they, so basically the argument was we cannot understand leadership if we do not understand the context and, or the situation. So the situation, what what we're talking about is, is when something happens. So that's a, is a major incident that's happened. Is there, has there been infection control or something like that in, in the environment and your normal daily stressors? Where are we in this and a game of football? Um It's, have you just won, have you just lost, have you just won the league? Have you just had the big disappointment, all those sorts of things? Um So that's your day to day variations. Now the context is, is your actual role, it's defined by a role. So everybody on the call all in healthier, right? So that's one big massive umbrella and that will include everybody from um you know, the nurses in, in ICU to A&E but also the, the medics, the surgeons, the, the health and social care partnerships, the the scientists, the porters, all that stuff comes under that, that, that context, this raises a reasonably interesting and very important question about your identity. So I think I don't apologies. I think we've all got nursing back. I've not got nursing back, but I think everything in the college has got a nursing background or a medical background. Um So that will define so at one level. So let's take the nurse example in ICU, I'm an ICU nurse, right? So that's your ident identity. It might be, I'm an ICU nurse in NHS Lothian or it might be I'm an ICU nurse onward in this particular bit and there might be some quite fixed identities through there. So you'll have lots of different levels of identity that that will go through that you might identify as a nursing profession. At some point, it may be your specialization, it might be your hierarchical level. It might be you're a charge nurse and when your other charge nurses from different parts of the hospital, then you identify at that level. So this is your context, these are things that are stable and not relatively, of course, you'll move and change and all those sorts of things. So, in sport, the example is it football, is it rugby? Is it gymnastics? You know, what age group are we working with? Is it professional? Is it premier division? Is it league four, all those sorts of things? So this is a context. So the the situation of contextual approaches really said that we need to work that out before we do anything. Um And those sorts of bits and, and obviously, with all the bits that we've talked about, there's an element of truth to them all. Now they suggested that there's four styles, you might have heard people talk about leadership styles. And really, this is where this word came from and it all gets used in different places now. But, but really this is the origin of the leadership styles in this context. So identified four styles that were suitable for different situations and context with what directive command and control, you know, in, in the military, we talk about this in operations that we can't, you know, if there's a, if there's a particular objective or something we need to achieve in this particular moment, we're not going to have a discussion, we need to act fast or the ma overrun us. So we're, we're not, we're not going to get into delegating coaching or even supportive, we're just going to stay in order that this needs to happen now. So there's some situations where that is entirely appropriate. There's lots of situations where it's entirely not the best thing to do as well. It can be an area where people fall back on when we get stressed, when we're under pressure ourselves. We feel as though we need to be directive. Um but actually, we may not have those time pressures, but sometimes this is if it's an emergency, this is what we need to do. We're not going to stop and start coaching somebody in that moment. But again, equally, there'll be moments where coaching is absolutely the best thing to do when we're trying to develop people, we're trying to encourage ownership of, of something. Coaching is the best way to do that. If we're delegate, if we're directing in a, in a, in a teaching moment, people aren't really learning and they're just learning to follow instructions or not learning to think for themselves. So if we are overly directive, overly controlling, we're actually creating our teams that are more dependent on our instructions and will be less empowered to do things and then delegating and supportive. Um Again, it'll be different situations where those, those the different contexts and situations where those would be more relevant. What time are we at? Um Yeah, I'll move on from that, but hopefully, that sort of makes sense a little bit. I'm really just throwing some stuff out there, the classic um situation that, that the the situation and contextual based researchers sort of call on to provide evidence for their approach to leadership is Second World War. Um So Winston Churchill, um often he's, you know, if you read the literature, um and, and understand what was going on in those times and he's often described as saving the, the, the, the, the, the, the, the, the, the UK and the, and the Western world was not in that moment and his leadership style was entirely appropriate entirely what the country needed entirely, all those other things. Uh So in wartime, absolutely phenomenal leader. However, very quickly afterwards, in peace time, it was very quickly recognized that he was incredibly um um um not well suited to lead a recovery in peacetime. So the, so the context created the situation in one situation. He was exactly what we needed another situation. He was exactly the opposite of what we needed, same person, probably the same people, different context. So that's the power of that. So they often use that example um to support their view of, of of the world. Now, I'm not in any particular camp, as you can probably imagine. I think they all have a relative contribution to help us understand this complex um situation. So um one of the theories I'm just going to introduce just now is is called transformational leadership theory. You may or may not have heard of this. Um This is still the most widely studied theory. And it has the largest peer reviewed base for its effectiveness. Now, as with any research, it has its criticisms and, and, and these are valid for most, regardless of that. It's still the most uh studied. It's got um um um significant, more uh randomized controlled trials with it than, than any other leadership theory still to date. Um um It's not perfect. There's lots of challenges with it, but I'm not going to get into that at the moment. There's lots of similarities with compassionate leadership as you'll see as we go through it, if you, if you, if you understand compassionate, so it's not to replace it, it's just a slightly different take on it, I guess in some ways. Um So, so it's embedded within the behavioral paradigm. So at its core, it's trying to understand what leaders do. Now, it, it, it, it, it evolved the behavioral paradigm um um to incorporate more behaviors um than just the initiating structure. Um um or the, the, the supportive type leadership from the Ohio State and the Michigan approaches. So to identify more behaviors, because of course, there is more behaviors and, and that differentiation there. What is transformational leadership theory? So basically, um it splits leadership into two higher, higher order concepts here. And again, you'll notice different, you'll notice similarities in the initiating structure from uh the Ohio Michigan studies. So you've got this thing called transactional leadership. Now, this up till about the eighties this is what the research was based on. So this is where bonuses come from in, in, in organizational psychology and business and businesses um and threats of punishment and being sacked and all those sorts of things are being made redundant or, or, or, or actually our business going out of business. Um So, transactional leadership is we enter into a transaction with the organization that we'll both honor. If I work, I'll get paid this amount of money. If I do this, this will happen. So it's a quid pro quo relationship. It's a transaction. It's a, it's a, a formality. It's, it's in stone and it's, it's, it's where, where we're at. Um And then it's all the management stuff that, that goes with that. So, so that, and, and what it says is that actually this is the foundation to exceptional leadership is you need to do that stuff really, really well and be really on it and be consistent, have the goals, really clear objectives, all the management things. It's not to say it's less or more important. It's the foundation, right? So if we're building a house, we're going to think about a massive big architecture of our house. This is how good are our foundations. That's what a transaction that builds trust. Because if we say what we're gonna, if we do what we say we're gonna do, that's how, that's one of the bases of a trusting relationship. However, when sort of bass and colleagues sort of tried to work out the same sort of question that we had in the military. Um um about what is it that differentiates the great leaders from the average leaders, the average leaders did this really well, right? The bad leaders did it badly, of course, but the average leaders did this really well. But nothing much more. What I noticed the great leaders did is he did something else. So that transaction was there, but they did this thing that they labeled transformational leadership. And this is a leadership that really elevates people's sense of worth, sense of belonging and sense of purpose to higher order ideals. So they'll relate what we're doing on a day to day basis to something bigger than us and, and, and something that's, that, that's a valuable contribution to, to, to, to what what we're trying to do. So talking about patient care, the population health, the importance of why we're doing things is that why question in there? And, and, and they really emphasize that. So one of the examples in the military. So, so we, we, we started trying to understand this in the military and one of the examples that was given or that no, that, that, that, that yeah, that when we're asking what this was was. So, so you've got all these, you know, infantry, it's all young men that in this particular example, 16, no, 17, I were at Catholic. So it was 1819, 18 to 26 I think was the intake at that point, mostly 18 to 20 year olds. And they all share a big barrack. Right. And you can imagine the toilets aren't the most pleasant environment to be in, but they're always really clean because hygiene was one of the most, um, um, um, um, important aspects in the early stages of training. So you can imagine that and they had to, you know, to clean the Barret, cleaning the toilets, putting their hands down the toilets, making sure it's absolutely spotless. Nobody is ever going to enjoy doing that work but nobody, I've ever met anybody that thinks, oh, this is great. It's my turn to clean the toilets after about 50 to 60 men have been using them. Um, but that has to get done on, on, on a daily basis and it, and it gets suspected and if it isn't done to a certain level, um, certain things will happen. So what, what the normal sergeants or what the average sergeants would do, they'd enforce that and they'd, you know, when somebody went there, the, the punishment would be insured. Now, what the really good sergeants did is they, they did something a bit different and they, they had described it to us. So they would not, they would, they would do the transactional bit, but they, they'd go, do you know why we do this in our toilets, you know why we do this because during the Second World War, there's more of our soldiers that were deemed that they were operationally inactive through dysentery and poor hygiene than were um by enemy fire. So being the the cleanliness hygiene is the building blocks of a strong, good professional fighting force. So they related this not pleasant job to something that was abso continually reinforced it, right. This is the but reminding people. So that's what it is relatively straightforward. There's other examples of it um in that sort of situation. So that that was a bit, they're tying the day to day tasks that don't have any inherent satisfaction in them to something that was really, really important. Whereas other ones, the ones that were just average, they wouldn't do that. And, and so that that was what we sort of spent really quite simple stuff talking about um in the literature, if you, if you read any of the transformational stuff, this is often called the augmentation hypothesis. So, so this is a bit, it's about actually the transformational leadership, augments the positive impact of transactional leadership. So it makes better, it builds on it, it does something on top of it, transformation on its own without that basic transactional agreement, strict clear rules, not necessarily strict but clear rules that are consistently applied. That's your transactional bit here. If you've got rules that are a bit ambiguous and are not consistently applied, you haven't really got a foundation to be inspirational on top of that because you're, you don't know what's going to happen next because things have been applied inconsistently. So, one day you might get it next day, you might not, you know, oh, they're in a bad mood today or we're all up for it today or whatever that is. That's, that's the stuff here. You don't know what you're getting. So, it's very hard to be transformational on top of that. So, but, but being a leader is really difficult to show up every day, you know, in, in, in a good place. So it's, it's just recognizing that, that it's a challenge. OK. So what is this thing? Transformational leadership. So basically, um what we talk about is six observable measurable, modifiable behaviors. So there's lots of research that we can do, we can measure the stuff we can modify it and it can have the, the, the, the um the, the outcomes that we're desiring there. So this is the most common measure of the Multifactor Leadership questionnaire. It's American um which is fine, but it's got language. It's not really the best for us. This is a measure that I developed in my phd. We had these, these behaviors, inspiration and motivation, intellectual stimulation, high performance expectations, individual consideration, role modeling, group goals, this is our belonging and contingent reward to that. That's essentially about praise. So this was the bit in our, in our leadership that that or, or, or how we operationalize leadership in the military. This is the stuff that we measured. Um and then this is the stuff that would help people to get high on this. So the idea is that all these are high. So one in here is this high performance expectations. So this is about, you know, what we have the best standards in here and we consistently apply them and we always expect you to show up and do your best. Recognizing that some days are quite challenging, but that bit here on its own would lead to burnout and would lead to, to, to short term high, high productivity. But, but what you really need is this individual consideration. So this is about the care support. It's like, listen, I know it's hard or, or, or actually, you know what, just take five minutes, get your feet up if it's possible and all those sorts of things, this is about finding ways to really support people to be really, really good at supporting people if it's not possible, just go, I know it's just a bit rubbish and really sorry, we can't do anything about it, but I really appreciate your efforts, tho those sorts of things. So whatever you can do in that space again, I'm not gonna go into that in a huge amount of detail. It's just a, a sort of an introduction to get sort of thinking and, and, and, and, and doing, but one bit here inspiration and motivation. So they'll come on to this, we talk about the vision support challenge. Uh No, I'll do that in the next slide. Actually, I won't do it here just a co of time. So what, what one of the theories or the model that I developed in my phd is called the vision support challenge model. This was back in 2008, it subsequently been used in, in different different places. Um So what we did is we want to make it simple. So we've got these sort of six behaviors that are transformational. So what, what, what we've sort of theorized is that these would load on these three contracts and we've got vision support and challenge and, and then so, so that was the core, that's the heart of what great effective leadership is. So what we mean by vision and how we'd find out if a leader was, was, was working to their best in this space, we ask their, their, their teams go when you think of your future in this organization, how excited are you by it? Or when you look at your leader, how much do you want to be like them or, or, or, or, or those sorts of things? So it's about and, and then when you think about how well do you feel that you belong, that you're part of a team that everybody's got each other's back, you know, what's your vision for yourself in this organization in the future? And are you excited by it? And that's the bit in here support is the extent to which I feel supported by my leader, the system, the, the management, the structures, how well supported do I feel given everything else and all the constraints that we have to operate and how well do I feel supported? Ultimately, when push comes to shove, does my leader genuinely care about me? And if they could, you know, would they support and help me in those situations? And then the third one is challenged. So when we talk about high performance and excelling and being really, really excellent in places, this is a bit, that's, that, that's really important. So this is the, the notion of, you know what that we in order to be part of our team, our award, our profession, we expect the best and, and, and that, that's it. We, we expect 100% effort, not outcomes, outcomes can sometimes be a bit tricky. But I want you to show up and I want you to show up with as positive an attitude as you can and, and that's really important to us. Yeah, and I want us even on a hard day, I want you to really try and be civil and understanding and all those sorts of things. So, so that's the sort of challenge bit about really high expectations. Now, if this is all we have, as I said earlier, we're not gonna end up in a good place. That's what we, so make the analogy here about putting rocket fuel in the carbonator, we'll get people spinning really fast, but it won't last long. It'll go out of control, it'll burn out. Right. That, that, that's if it's justice and it's really important to have this support. So however much challenge is in the environment, we up that support. If sometimes if we've got somebody who's really experienced in their jobs, they might be feeling quite supported. And, and actually we need to up the challenge, we need to give them some more responsibilities or challenge them in slightly different ways. So we won't need to present that, whereas somebody's quite new or there's somebody that's coming from another department because you're understaffed that, you know, they might not be feeling they might be quite high challenge just by doing that. So we need to support them and find ways to support them and help them. Vision is just always important. But what we know about these two constructs is they need to, they need to equal each other out. They need to be in balance. If I have too much support, we don't get a high performance. Ok. People will feel good, but standards will slip, ok? And then in the long run, that's not gonna lead to sort of good places. Ok. So hopefully that, and that's the real sort of sort of litmus test of this really about, ok, checking in our teams, what is their vision, how well supported? Do they feel, do they feel challenged? Is it optimal? Is it, you know, is it hard, but actually, you know, a achievable or is it too easy for them to be up the challenge a little bit? So, because we're in healthcare, I just wanted to, you know, there's tons of research in this area. So this is about, it's a randomized. Uh was it randomized? No, it was a controlled study um in three groups. So basically safety leadership, this was in Canada. Um And it was on in nursing healthcare teams in, in Canada and what they did, they had a control group that I think they, they played games or did something and a transformational leadership about general, you know, so, so their nurse leaders think it was equivalent to charge nurses were trained in this. And then there was one specific about health care. Um um sort of um um um um um behaviors, safety outcomes like needle pricks, injuries, those sorts of things. Um So it was a big drive to reduce those things in the environment by, by, by doing this intervention. Now, this is one of the graphs in here. So obviously, this is the the amount of injuries that were reported over. I think it was maybe a six month period in the training. It wasn't a huge amount of training. I think it was about 42 hour workshop, something like that. So as you can see here, the transformational specific group, they were significantly reduced while the, the, the control group and the transformational general group just really expect impacts in this bit because they didn't really talk about um um and safety behaviors, but they, they could have measured other variables in there, like satisfaction, confidence, those sorts of things. So, so, so this is some examples in a healthcare environment uh where transformational leadership has been shown to be um impactful. OK. So in summary, 5 55 minutes, we've got five minutes for questions. So really, please do pop something in the chat. Um um So we're represent in the leadership model. So hopefully to try and make sense of it and remember, great leadership starts with you and you're reflecting on, you've all received brilliant leadership, you've all done it. Um And you've all received leadership that's probably not so brilliant and, and actually, you already know the answers, you know, I'm just presenting some things here. Hopefully that's helped, made you think and reflect and, and, and again, your challenge is to try and bring that into your environment. What, what could you do a bit better or, or what do you continue doing? 11 of the bits in here that we often talk about and this can be quite a tricky thing. But, but we, we, you know, because in essence, we're trying to map our behaviors or adapt our behaviors for the betterment of our teams and, and all those sorts of things. So, one of the bits that we can do is just ask people, you know, this is one of the challenges I do this in organizations. I'm working with a business in Manchester just now and we're sort of developing a feedback, culture sort of thing. And, and one of the bits I'm sort of challenging the leaders to do is to ask the teams in the lead. OK? Give me one thing that you really like about my leadership. OK. What, what do you, what do you think I do really well and give me one thing that you think I could do even better. Now, that's a really difficult, it sounds easy, but it's a really difficult question to ask the people that you lead. Um But I think it's a really powerful question now it's really difficult for them to answer that as well. So it's a really, you know, you, you want to really sort of use that we, we, we care and, and, and think about it very carefully and tip people off that this is what you're doing. Um And maybe it might not be appropriate to do that as direct as that. Um But that, that's the sort of principle in there. OK. So, yeah, I'm just going to take my slides down here. There'll be a couple of references here, just some references at the end there and I'll stop sharing my screen. So we've got five minutes for questions. Uh Let me just stop sharing my screen if you can look at how to do that. Thank you, call. Um That was really good. Um We've got a couple of questions coming to the chat. Rachel is using my login, but she's asking how can you help draw the best out of your leader if you feel unsupported in a particular area, but perhaps really well supported in another area? Yeah, that, that's tricky. That's tricky. So it's a, so, so it's a leader that they're, they're, they're receiving it. So it's an upward influence. Um Yeah, that, that's, that's a different lecture but, but I guess, I guess send them on because it's a high, there's a hierarchical thing there isn't there. So I guess it's trying to open up conversations about feedback and, but, you know, one of the most powerful things we can do to for our leaders and when we're trying to influence upwards is is we start by praise and I know it doesn't feel like the most obvious place to start, but often if I'm talking about this isn't what the session is about. So this is just a really quick snippet and, and think about this carefully. But one of the bits is you often forget to praise people upwards. So our leaders and, and what we appreciate about them, uh we will focus on what they don't do so well and, and, and, and, but actually what I challenge you to do is think about something that they're doing really well and tell them that's usually a good place to start because a lot of people will act out of, um, low confidence or uncertainty or I'm not really sure. And, and then, and if we can help people to bring them along, we say, actually, you know what I think it's a really difficult job. You've got, you know, that something to that extent, but that's a whole another sort of place. But yeah, great, great question, great question. Um Thanks call um and Callum Parker has got a comment more than a question. So he's saying you can see transformational leadership and successful quality improvement projects to people are more likely to change their practice if they understand the effect that the change has. And I totally agree with that. Actually, I was going to say so the AC A ccps in Scotland, we're not, not many of us are managerial roles. I think, I think, I think there's three in the whole of Scotland. We've got one in Lothian who's like lead A CCP, who is our manager. And then a and a have got one and Aberdeen have got one but correct me if I'm wrong guys. But I don't think many other health boards have like a lead managerial A CCP. So like from a leadership point of view for the rest of us, it's more like your Q I lead or you're an education lead or something like that or even just leadership is one of our pillars of practice and you're just seen as like a role model um And to lead by example and things like that. So I totally agree with call's comment there about the QI project. I know that someone on the call is also like our Q I lead for, for care unit and Lothian and stuff. Um And I suppose I've got a question that follows, that follows on from that. So you spoke about vision support and challenge, right? And the vision was about your future as a leader. But actually, how do you get other people on board with a shared vision? Is it like, does that contribute to your success as a leader is to get for if you're leading quality improvement or education initiatives or even just a team and managing that team? How is the best way to get other people on board and get their buy in, I suppose for a shared vision, if it's a better team rather than just an individual? Yeah. No, I love that. Ala I think that's good. First of all, you call it, call great name and you spell it properly by the way. So I just want so just not really that one. I'm just buying some time, Elana to think about that question. No, it's a great question. I think it's tough. I think, I think, I think it's, it's always that way because you, if you've got 10 people on your team, you've got 10 individuals that'll have 10 different visions. But actually, as part of our team, we want to try and nurture and develop a shared vision or a shared mental model of what the team is. So, so I think that there's always a, a space for having an individual in one on one chats and, and helping people to identify their own vision. But then when it comes down to teams, so that's my door, but I'm not going to answer to it. That's my team. So then when you come into a team vision, you know, you, you know, you'll do this anyway, but you know, you need to, there's no shortcut here, you need to get your team together and talk about what do we want to achieve? What's important for us? How do you want to leave the service? So you maybe start in two years time or probably start with. If I'm doing a vision session, I'll go. Alright guys, let's get together. What are you doing? Really? Well, what, let's write down everything that we're brilliant at that you do. Well, that, that's in this place and, and then what's important to you as, as a team and as human beings, as individuals and just start sharing with each other and you'll probably notice some differences, some similarities there. Often there's some similarities there and you really sort of, uh, play on them a little bit and then emphasize them and share them, then you move them into. Ok. So what might that look like on a good day? What might that look like on a bad day? And then, and then you sort of start talking about stuff and then you maybe get some values or things that, that fall out of that or some, some sort of um things you can agree to and then you go, OK, so what, what are we not so good at or, or what are the barriers to be more effective? And then you start to share and all those sort and then you bring them together and they say, OK, so what might we do differently? And then, and then we get into that point where we hopefully get a collaborative shared vision of what our team is going to be like. Um But there isn't a short, well, there is a shortcut is we don't do that and we tell people what the vision is. That's not usually a good way to get them on board right now. Sometimes you have to do that because sometimes you just haven't got time. So then they have to work really hard and selling the vision, why it's important, what you get out of it and all those sorts of things. But yeah, great, great question. But that would be sort of take a specialized sort of moment to do that, I guess. Does that make, have I sort of answered that a little bit or? Well, thank you. And I think we've got time for one more question. Jack's popped one in the chat with the shared vision with a shared vision and trying to improve stuff clinically. How would you navigate around low morale? I suppose if you were in a leadership role or just as viewer, I suppose on a CCP and have that leadership qualities that you, that you needed to boost morale. How would you navigate that? Yeah. And Jack, great question. And again, it's, it's tough because if the teams a little low low morale, the leaders are probably feeling it as well and, and actually having to show up and have a positive attitude and, and on a daily basis, it's, it's just, it can be a hard thing to do, right? And leadership can be quite a lonely place. Um Now, now again, low morale is, is, is, is, is, you know, it can be tackled from lots of different places. But I think the start in place of any of this stuff is to because we're often told about what we're not good at or when we make a mistake or this is there. And we've got a very, you know, when we look at the neuroscience behind this, we've got our, our brain is positively offset to pick up more negative information and to attend to more negative information. So, so really, we want to try and short circuit that so what we want to start off with is going, let's just appreciate what we're good at. Right? Given all the situations, the circumstances, the staffing levels, the whatever, whatever that's causing that low morale in the environment, don't, don't go that direct. We go. All right. Let, let's just write down what you're proud of, what have you achieved. And it might be really as simple as, you know, what I turned up with a positive attitude and I'm just having an absolutely horrific time at home or, or there's been a really challenging in the workplace and, and really, I'm proud that I've turned up today, you know, and, and that, that's enough and that should be celebrated sometimes not every day. You know, if we're getting to the point where that's every day, then, then, then that's a different conversation. But I think we really appreciate yourself. First of all, being compassionate to yourself and then being passionate with others I think is something that, that, that, that's really can make a start there. But again, in groups, how do we support each other better? And sometimes just hearing other people's challenges go, actually, you're, you're doing the same thing. Oh, actually it's hard for you as well to help us to, to, to support each other better. But again, Jack, it's tough. Yeah. Brilliant. Thank you. Call. That was really excellent and hopefully has helped people just think about, like I say, we're not managers and our roles mostly. Um but we do have a leadership pillar of practice to achieve if you like. And we are like I say, role models or people that lead by example and do lead like things like quality improvement in education and things like that. So um hopefully that has helped people tease out what traits and styles will be useful for them moving forward in their practice. And so I think if there's no other questions, we will let Callum go. Thank you so much that I really appreciate your time. I know you're a busy man and no problem. Um I if everyone who hangs on for five minutes, so after calls finished, I'll just give you a quote, a couple of updates on the network and then you're free to all leave. But call, thank you guys. How I could make that better? One thing you like the one thing that I could do better for you, that that would be awesome. So just, just share the shot and I know I'm also trying to get better as well. So, you know, please do so all the best and then we'll see you soon. Cheers and thanks call. Um Right guys, just to finish really quickly. I've got a couple of things just wanted to update, I'll send them an email as well. I kind of, it's got dark in here, I can barely make money. So what to just reiterate the conference date for next year, there will be correspondence coming out and shortly, but 20th of November 2025 at the Royal College of Physicians in Edinburgh again. Um, we also, I spoke to a couple of folks from Forth Valley, um, a few months ago and we thought about maybe trying to organize some ACP drinks or some kind of activities centrally to see like a social rather than an actual educational thing. I don't know if many people would be up for that, but I don't know, maybe Glasgow or Sterling or somewhere like that. And either do, I don't know, like an escape room or just go for drinks or like, but get to see each other socially and network. But again, just an idea, um, this has worked quite well and I think it's been good. It's been ages since we last had one. So Rachel and I were thinking that maybe we could do something like this but for two hours every quarter, maybe every three months. I don't know. Again, this is, I'm just putting these out there, I'll put them in an email. You could tell me if you're not up for it, but we thought maybe three monthly CPD for two hours at a time, one afternoon and we can get people from all over the country to either volunteer speakers or we could, like, reflect on a prescribing scenario or a case scenario, an interesting case that you've been involved in for like 20 minutes or something and we can share our learning and we can get invite speakers and stuff as well and make it a more regular thing on this platform. Si CS do it monthly for an hour, one evening a month, but that's a bit much to take on, but maybe quarterly for two hours might be doable and, and we can make sure it aligns with the pillars and all that. Um We will, what we, what I might do is try and make a Google form or something where people can populate if they thought speakers might be able to say we had one and I don't know, like February and then May or something, you could prepopulate it with somebody or yourself. If you want to speak then and we can figure that out. So we'll, we'll come back to that. There's an SI CS event on tonight. If anybody can make it, I think it's about declaring death, which we obviously can't do in Scotland. But Julie just asked me to give that a wee prompt for tonight. Um And it's on me on the SI CS page and the last thing was just to remind you all that the Bursary is still open um until eighth of January. So if anybody, I know money is tight in health boards and we don't have masses of money, but we do have a bit to put back in a CCP education. So, if anybody wants to do like Fusa Car is 250 quid or I did a research course last year it was 200 quid. Or if there's a conference you desperately wanted to go to, you could apply for conference fees or if there's like a post grad course or whatever that you maybe wanted money towards. Then remember the bursaries there? And we're, we're hoping that we can maybe give a couple of small bursaries out. We've had one application so far. So, um, if anybody is thinking of a course coming up for next year, um, yeah, fill in the form, send it off and we'll get it anonymously marked and we'll just be basically copying the SI CS format. That's all. Thank you for being with us with the technical stuff on this platform and stuff. And, um, yeah, I hope that's been all right for you. Um, and we'll like I say, we'll fire an email off. Um, and we can plan the next one for next year and take it forward from there. So, thank you. See you. Ok. Yeah.