Plastic Surgery Fellowships in St Andrews Centre of Plastic Surgery and Burns. Contents

Plastic Surgery Fellowships in St Andrews Centre of Plastic Surgery and Burns Contents Pages Part One General Information Mid Essex NHS Trust 2 Terms and Conditions of Service 4 Infection Control 5 Safeguarding 5 Leave 5 Appraisal and Development 6 Equal Opportunities 6 Health and Safety 6 Personal Data 6 Part Two Specialty Information St Andrews Centre of Plastic Surgery & Burns 7 Staffing 8 Part Three Job Information Details of the Fellowships 10 Duties of the Post 11 Additional Information 12 Person Specification 12 1

Part One: General Information Mid Essex Hospital Services NHS Trust Mid Essex Hospital Services, which was established as an NHS Trust in 1992, has an annual turnover of 261m and employs approx 4,400 staff. It provides local elective and emergency services to 380,000 people living in and around the districts of Chelmsford, Maldon and Braintree (including Witham). The Trust also provides a regional wide plastics, head and neck and Upper GI surgical service to a population of 3.4 million and a supra regional burns service to a population of 9.8 million. Located in the City of Chelmsford, with all major road connections, frequent mainline rail services to and from London and a major airport at Stansted just 40 minutes away, the Trust is in an ideal location for commuting. In November 2010 the Trust opened a brand new PFI funded hospital wing which enabled the organisation to centralise the majority of its clinical services onto the Broomfield Hospital site. A committed and experienced clinically led management structure delivers the Trust s new vision and quality driven strategy of Care, Excel, Innovate and excellent progress has been made in delivering against the commitments set out in this strategy. Excellent Clinical Reputation Excellent progress has been made in respect of quality and performance improvement at Mid Essex Hospitals over the last 3 years, and these achievments have resulted in the Trust being recognised as one of the top performing District General Hospitals in the East of England and the Midlands. At MEHT we are proud to make patient safety the number one priority in all that we do. All staff commit to the following Patient Safety Charter: I am part of a healthcare team that is proud to put patient CARE first and whose reputation for EXCELLENCE and INNOVATION inspires our patients, staff and the population we serve. As a member of the MEHT team, I will always do my very best to ensure my patients are safe in our hospital: I will treat all patients with respect and dignity, ensure their basic needs are taken care of, involve them in decisions that affect them and check they have understood. I will clean my hands between every patient. I will always take the utmost care in the prescription, preparation, documentation and administration of medications. I will ensure all my patients have a VTE assessment on admission. I will ensure all my patients leave with a discharge summary. If I have a concern about one of my patients, I will immediately inform my senior colleagues and ensure prompt action is taken and recorded. If I witness an error, I will report it so we can all learn from it. 2

Our Clinical Activity Hospital activity for the last three years 2013/2014 activity 2014/2015 activity 2015/2016 activity Elective inpatients 11,615 11,341 11,877 Emergency inpatients 42,280 43,805 44,046 Day cases 32,086 34,036 36,254 Outpatient attendances 593,103 620,598 653,548 Accident and Emergency 81,619 87,291 91,082 Hospital acquired MRSA bacteraemia numbers for the last three years 2013/2014 2014/2015 2015/2016 MRSA 3 2 2 Hospital acquired Clostridium difficile numbers for the last three years 2013/2014 2014/2015 2015/2016 Clostridium difficile 13 16 20 Our Clinical Directorates The nine Clinical Directorates, which were established in May 2014, are each led by a Clinical Director (CD) and a Head of Nursing. The CD is supported in their role by Clinical Leads and Lead Nurse(s). Each directorate also has Finance, HR and IT support to manage the day to day service arrangements. The directorates are as follows:- ANAESTHETICS AND THEATRES DIRECTORATE Responsible for Pain Service, Pre op preparation and Theatres BURNS & PLASTICS DIRECTORATE Responsible for St Andrew s Therapy Services and St Andrew s Outpatient Nursing CRITICAL & EMERGENCY CARE DIRECTORATE Responsible for the Resuscitation Team, Emergency Department (ED or A&E), Clinical Operational Managers (Inc Discharge team) and Helipad Services SURGERY UROLOGY AND ENDOSCOPY DIRECTORATE Responsible for Lower GI (lower gastrointestinal), Upper GI (upper gastrointestinal), Vascular, Breast, Urology, Endoscopy Services SPECIALIST SURGERY Responsible for Max Fax (Oral and Maxillofacial Surgery), ENT (Ear, Nose, Throat), Ophthalmology and Cancer Services (incl. Chemotherapy Unit, Research & development nurses, Oncology CNS Team, Palliative Care, and MDT Team and Co-ordinators) 3

MEDICAL SPECIALTIES DIRECTORATE Responsible for the Dialysis Unit, Day Therapies Unit, Cardiology Angio and rehab, Elderly Assessment Team, Neurology, Haematology, Medical Photography MUSCULO SKELETAL SERVICES DIRECTORATE Responsible for Orthotics, Orthopaedic liaison and rehab team, Trauma co-ordinator, Rheumatology and Dexa Scanning THERAPIES/DIAGNOSTICS (Radiology & Pathology) Responsible for EEG (Electroencephalography) / EMG (Electromyography), Radiology and Pathology WOMEN, CHILDREN & SEXUAL HEALTH DIRECTORATE Responsible for Maternity Services including the birthing units, Delivery Suite and Labour ward, DSU (Day Stay Unit), Neonatal Unit, Gynaecology, Children s Services, Early Pregnancy Unit and Sexual Health Terms and Conditions of Service The post is subject to the Terms and Conditions of Service of Hospital Medical and Dental Staff (England and Wales) and to the NHS Pension Regulations. You will receive the nationally agreed remuneration for Specialty Registrars in Hospital employment and any changes to those rates that the Secretary of State for Health may authorise from time to time. The salary scale 2016/2017 for Specialty Registrars is 30,302-47,647 for full-time employees working a 40 hour week. A discretionary banding supplement determined by paragraph 21a of the Terms and Conditions of Service will be applicable. Part time staff will be paid pro rata to this scale. The current banding supplement for this post is 1B 40%. This is a fixed term post. The appointment can be terminated by giving three months notice on each side, unless application of the statutory minimum period would be more favourable to the Practitioner. Relocation expenses may be granted on the understanding that the new location meets the requirements of the Trust. Agreement regarding relocation expenses must be reached prior to expenses being incurred and before commencement of the post. As Mid Essex Hospitals is a multi-site Trust it is desirable for Trust Doctors to have their own transport. Mid Essex Hospital Services NHS Trust is a non-smoking Trust and smoking is not permitted on any Trust site. Mid Essex Hospital Services NHS Trust has an Equal Opportunities Policy. All employees are expected to observe this Policy in their behaviour to the public and fellow employees. Shortlisted candidates will be required to complete a health statement and the Trust may require an individual to pass a medical examination as a condition of appointment. Before commencing he/she will be required to furnish us with proof of their Hepatitis B immunity status and that you have not been exposed to Hepatitis C infection. Certification is only acceptable if it is taken by an Occupational Health Service within the UK, dated within 5 years of current date and shown to be an identified validated sample (i.e. proof such as a passport or driving licence was provided to the Occupational Health service at the time of providing the blood sample). Satisfactory CRB clearance and references will sought by the Trust prior to commencement in the post. 4

Due to the nature of the work in this post, it is exempt from the provision of section 4 (2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore not entitled to withhold information about convictions, including those, which, for other purposes are spent, under the provisions of the Act, and are required to disclose convictions, including those pending, to the Trust. Failure to disclose such information may result in dismissal or disciplinary action. Prevention and control of healthcare associated infections: The post holder; is accountable and responsible for the prevention and control of healthcare associated infections and must comply with the standards set by the Health Act 2006: Code of practice fro the prevention and control of Healthcare Associated infections (Revised January 2008) will ensure 100% compliance with hand hygiene and high impact intervention protocols. will demonstrate effective leadership by ensuring all clinical staff, whoever they may be, are aware of their responsibilities in relations to infection prevention and control. Safeguarding Children and Young People: All staff are responsible for ensuring that they are familiar with and adhere to Mid Essex Hospital Services Trust (MEHT) Safeguarding procedures and guidelines, in conjunction with the Essex Safeguarding Children policies and Southend, Essex and Thurrock (SET) procedures. All healthcare workers who come into contact with children, parents and carers in the course of their work have a responsibility to safeguard and promote the welfare of children and young people up to the age of 18 years as directed by the Children s Act 1989/2004. All Health professionals have a responsibility even when the health professional does not work directly with a child but may be seeing their parent, carer or other significant adult Safeguarding Adults: All staff are responsible for complying with MEHT Trust policies on adult safeguarding in conjunction with the guidelines established by the Essex Safeguarding Adult Board and SET (Southend, Essex and Thurrock) procedures. All staff are responsible for identifying potential abuse of adults and reporting it accordingly. All staff are required to attend Safeguarding awareness training for Children, Young People and Vulnerable Adults. Some staff groups will be required to attend additional safeguarding training relevant to their role. This is in line with the Guidance outlined in the Intercollegiate document (April 2006) Safeguarding Children and Young People: Roles and Competencies for Health Care Staff. Leave Annual leave entitlement is set out within the Terms and Conditions of Service for hospital medical staff. The Trust s annual leave year for Trust Doctors is 1 st April 31 st March. Study leave is available as provided for under the Terms and Conditions of Service for Hospital Medical and Dental staff, subject to the approval of the Supervising Consultant and Clinical Director. The General Manager has final overall approval of all leave (study leave, annual leave, compassionate leave and professional leave). 5

Appraisal and Development Annual Appraisal of all Trust Doctors has been introduced in the Trust. This is conducted by a trained, Trust-nominated appraiser. It is expected that you will comply with the process and engage with the software within the designated time-frame. Yearly appraisals are a key element to the Department of Health s Revalidation cycle for all medical staff in the NHS. Equal Opportunities The post holder must at all times carry out responsibilities and duties with due regard to the Trust s Equal Opportunities Policy. Health and Safety The postholder is expected to undertake the appropriate management responsibilities and be aware of individual responsibilities in accordance with the Trust s Health and Safety Policy and report, as necessary, any untoward accident, incident or potentially hazardous environment. The postholder will promote and implement the Health and Safety Policy. Personal Data All Person s Identifiable Information (PII) must be held in the strictest confidence and should be disclosed only to authorised people in accordance with NHS Confidentiality Guidelines (Caldecott) and the Data Protection Act 1998 unless explicit written consent has been given by the person identified; or where information sharing protocols exist. The postholder is responsible for meeting the requirements of the Data Protection Act 1998 to ensure that PII is up to date, that data is timely and that information is securely stored and safely disposed of when there is no continuing requirement for its retention. All clinicians are responsible for ensuring that clinical information extracts or reports are accurate prior to distribution. 6

Part Two : Specialty information St Andrew's Centre For Plastic Surgery And Burns, Including Satellite Hospitals Throughout Essex The Regional Plastic Surgery & Burns Centre was established at St Andrew's Hospital Billericay, in 1973. The Centre was relocated to a new purpose built development on the Broomfield Hospital site in Chelmsford in 1998. Management Arrangements The unit was incorporated into the Mid Essex Hospitals Trust in April 1995. The St Andrew s Centre has a Clinical Director and Head of Nursing. They operate with a small Management Board. This board is responsible for management of all clinical activity in the St Andrew s Centre and is one of several Clinical Groups within the Mid Essex Hospitals Trust. The Clinical Director, currently Mr Professor Dziewulski, sits on the executive board of the Trust. The St Andrew's Centre also holds contracts for Plastic Surgical services at a number of satellite hospitals. Geographical location The ST ANDREW'S Centre is situated in BROOMFIELD HOSPITAL, about 3 miles north east of Chelmsford, the expanding county town of Essex, which is central within the county. There are excellent road and rail links with all parts of the Region. The journey time to Liverpool Street Station from Chelmsford BR station is approximately 30 minutes. There are many pleasant residential areas, fine houses, good schools and attractive and unspoilt countryside within easy reach of the hospital. Local shopping facilities are good and there are opportunities for a variety of sporting activities, including sailing, golf and flying. The state grammar schools for both boys and girls in Chelmsford are regularly in the top echelon of the government league tables. Catchment area Patients are referred to the St Andrew's Centre and the satellite hospitals from all parts of North Thames (East) Region and most Purchasing Authorities have contracts with the hospital, although the majority of patients come from nearby districts. The population served is about 4 million. Description Of The Hospital I) St Andrew's Centre The St Andrew's Centre has been a Regional Centre since 1973. It comprises 3 plastic surgery wards and one paediatric surgical ward, shared with other disciplines in Broomfield Hospital. There are designated plastic surgery theatres, including an emergency theatre, in the main operating theatre block of Broomfield Hospital. These theatres, the reception area and the recovery are all fully equipped with high quality equipment. Although adjacent to the Broomfield Hospital operating theatres, the plastic surgery theatres are staffed and managed as a separate concern. The purpose built Burns Unit was opened in 1998. There are 20 beds, comprising 4 large ITU rooms and 4 HDU rooms with a low dependency area, which incorporates rooms specifically designed for children. Patients are not transferred to other plastic surgery wards for rehabilitation. There is a dedicated burns operating theatre with anaesthetic room and recovery area, a purpose-built admissions room, support areas and laboratories for clinical investigation and research purposes, including skin culture, and laboratory and support areas. The unit is fully equipped to the highest standard for the Critical Care management of burned patients of all types and ages. Adjacent to the burns unit is a specialist burns outpatient facility, where small burns are assessed and treated and where outpatient burns are dressed. Also on the site is an extensive Out Patient Department with an Operating Theatre for patients under local anaesthesia and a Laser Room. Adjacent to this facility are large physiotherapy and occupational therapy 7

departments, which specialise in hand and burn surgery, and a department of Speech Therapy. A Prosthetics department, a large Medical Illustration department and the Broomfield Hospital Pharmacy are sited close to the St Andrew s Centre. There is also access to all other services in Broomfield Hospital, which is the site of the District Postgraduate Medical Centre and the main District Medical Library service. ii) Broomfield Hospital Broomfield Hospital is the main District General Hospital for Mid Essex Hospital Services Trust. The building incorporates a relocated general ITU and a new HDU for the whole hospital, with a number of these beds dedicated to specialised nursing of plastic surgical patients. iii) Services Provided At The St Andrew's Centre The St Andrew s Centre provides a service to the population of North East London, Essex, and adjacent areas on a hub and spoke principle. The consultant plastic surgeons all hold appointments at the Centre and at other hospitals in the region, providing out patient care and variable operating facilities. Much of the routine general plastic surgery is carried out in the satellite services. Consequently, much of the case mix admitted to the Centre includes the more complex and sub specialist cases. A full range of plastic surgical procedures are performed in the Centre, including surgery for congenital defects such as repair of cleft lip and palate and hypospadias; reconstructive surgery after major tissue loss including free flap tissue transfer; reconstructive surgery for head and neck cancer; breast reconstruction after mastectomy; surgery for benign and malignant skin conditions; early surgical treatment of major leg trauma; and specialist hand surgery for treatment of trauma including the replantation of limbs or digits, and for degenerative diseases of the hand. Burned patients are referred from A and E departments all over the Region and beyond. Patients are admitted for assessment, resuscitation, intensive care and early surgical treatment of their burns. A review body of the Burns services in the Thames region has advised that there should be 2 major Burns Centres to which the most complex patients will be transferred, with supporting facilities provided in other plastic surgery units. The Burns Service at the St Andrew s Centre, Broomfield Hospital, is one of the 2 major centres. Supporting services at the St Andrew s Centre include highly developed departments and services in Anaesthesia, Acute Pain Service, and Chronic Pain Service for Peripheral Nerve Pain, Physiotherapy, Occupational Therapy, Radiology, Medical Illustration, and Prosthetics. Staffing The service consists of the following medical staff: Mr M Banwell ** Mr D Barnes **** Mr P Dziewulski **** - Clinical Director, Burns & Plastics Mr N El-Muttardi **** Mr D Elliot * Mr M Griffiths ** Mr F Iwuagwu * Mr L Kangesu ***** Mr B Mathur *** Mr P Morris ***** Mr N S Niranjan ** Mr B Philp **** 8

Mr V Ramakrishnan ** Miss A Shaw ** Mr O Shelley **** Mr A Sierakowski * Mrs M Sirotakova * Mr M K Sood * Mr M Tare * Mr G Thorburn ***** Miss K Tzafetta *** Miss C Zweifel * Miss Mary Morgan (Locum) ** Mr Fateh Ahmad (Locum) *** * Surgeons with a major interest in Hand Surgery ** Surgeons with a major interest in Breast Reconstruction *** Surgeons with a major interest in Head & Neck Reconstruction **** Surgeons with a major interest in Burns ***** Surgeons with a major interest in Cleft Lip and Palate Reconstruction 9

Part Three: Job Information St Andrews Fellowships Persons appointed to these Clinical Fellowships will be attached to various Consultant Plastic Surgeons for six month periods in order to gain further training in the particular expertise of those consultants. These are not recognised training posts. However, senior trainees from both home and abroad are invited to apply. Any successful applicant would be expected to work as an integral part of a surgical team and would take on considerable responsibility for patients under the care of the Consultant for whom he or she is working. The successful applicant would also be involved in research and would be encouraged to present and publish papers. 1. Skin Cancer with advanced management and Sentinel Lymph Node dissection These posts provide the opportunity for plastic surgical trainees to gain further experience in Skin Cancer. In supporting Mr Dziewulski, Mr El-Muttardi, and Mr Barnes in elective skin cancer. The fellows will be involved in the treatment of a large number of patients, with particular emphasis on the management of skin cancer, parotidectomies, lymph-node dissections, sentinel lymph-node dissection. In the event of annual and study leave, Fellows will provide prospective cover for other sub-specialities. 2. Breast Microsurgery and Lymphoedema Surgery This post provides the opportunity for plastic surgical trainees to gain further experience in Breast Micro and Plastic Surgery in supporting the Breast Plastic Surgeon Consultants in elective plastic, breast and microsurgical activities, and also the other consultant plastic surgeons in emergency activities. The Fellow will be involved in the treatment of a large number of patients, with particular emphasis on the management of breast reconstruction and other microsurgical activities. The Fellows will be allocated to work with Mr Ramakrishnan, or Mr Griffiths, Mr Banwell and Miss Morgan (Locum Consultant). In the event of annual and study leave, Fellows will provide prospective cover for other sub-specialities. 3. Head & Neck and Facial Palsy Microsurgery The post provides the opportunity for plastic surgical trainees to gain further experience in Head and Neck Reconstruction, Micro and Plastic Surgery. In supporting Ms Tzafetta, Mr Mathur and Mr Ahmad (Locum Consultant) in elective plastic head and neck microsurgical activities, in emergency activities, these fellows will be involved in the treatment of a large number of patients. Every year there is above 70 patients who undergo Head and Neck Reconstruction with free flaps for Cancer, Facial Paralysis and Trauma patients. The successful candidate will be expected to also attend the Head and Neck MDT meetings and clinics, and the specialist facial palsy clinics. In the event of annual and study leave, Fellows will provide prospective cover for other sub-specialities. 4. Trauma Hand Surgery This post provides an excellent opportunity to manage over 3000 cases of hand and lower limb trauma under the direct supervision of above Consultants. The department has a dedicated trauma theatre which is fully staffed round the year exclusively for trauma cases. Trauma Fellow will be responsible for running the trauma service under supervision. This post is appropriate for a year three/four trainee with previous experience in hand trauma Surgery. This job will offer an opportunity to participate in managing complex hand and lower limb trauma cases with microsurgical reconstruction under supervision. The Fellow will be working with Miss Zweifel, Mr Tare, Mr Sierakowski, and other hand Consultants. The weekly timetable will involve few general plastic surgery commitments. 5. Elective Hand This post offers an excellent opportunity for plastic surgical trainees to gain further experience in elective hand surgery and secondary trauma surgery. The post is appropriate for a post FRCS (Plast) trainee who is keen to pursue his/her career as hand surgeon in future. The successful 10

candidate will rotate among the hand consultants, Mr Elliot, Mr Sood, Miss Sirotakova, Mr Iwuagwu, Mr Tare. He /she will also have some general plastic surgery commitments every week. Every year over 1500 cases of elective hand surgery are performed in the department. In the event of annual and study leave. Fellows will provide prospective cover for other sub-specialities. 6. Post-traumatic Hand Surgery, Skin Cancer and Abdominal Wall reconstruction The successful candidate will be exposed to the management of skin cancer, abdominal wall reconstruction and post trauma hand management depending on the consultant they will be working with (Mr Tare, Mr Barnes, Mr El Muttardi). Fellows will provide prospective cover for other sub-specialities. 7. General Plastic Surgery The successful candidate will be exposed to the broad spectrum of plastic surgery, covering breast, skin cancer, perforator flap reconstruction, and perineal reconstruction. She/he will be working with Mr Niranjan. Fellows will provide prospective cover for other sub-specialities. Responsibilities and Duties of the Post The successful applicant will provide a specialist Plastic Surgery Service at the St Andrew s Centre, Broomfield Hospital. This will involve the management of patients with responsibility for providing emergency and ongoing expertise for patients, and services regarding patients referred to him/her. the total clinical care of the patients referred to him/her, including all administrative duties associated with patient care, proper record keeping and good communications maintained with patients and their general practitioners. positive collaboration with colleagues to provide the effective clinical leadership for all the staff in the Plastic Surgery Service. Multidisciplinary teamwork is envisaged as a key component of this. He/she will participate in out of hours consultant cover and in the cover arrangements during colleagues annual/study leave. undertaking regular ward rounds. participate in clinical audit and in continuing professional education. supervision, teaching, training and professional development of the junior medical staff working in the service. Consultants are fully involved in developing a high standard of teaching of junior medical staff, nurses, and medical students and in designing and contributing to the process for establishment and approval of training posts for junior medical staff. maintaining standards of care for his/her service to the Medical Director, the Chief Executive and Chairman and the Board of the Mid Essex Hospital Services NHS Trust. The successful applicant is expected to be involved in the development of the Plastic Surgery Service at the St. Andrews Centre, Mid Essex Hospital Services NHS Trust and will lead on the implementation of service improvements and ongoing monitoring of the Service and performance. The successful applicant will have access to a wealth of clinical material in Plastic Surgery for research and will be encouraged to develop links with academic departments in the region. The successful applicant will undertake to update their knowledge and skills and to demonstrate Continuing Professional Development at the Annual Appraisal. 11

Additional Information The above is an outline only; it is not exhaustive and may be altered in line with the needs of the service. The post holder will be required to be co-operative and flexible in accordance with the needs of the service. For further information about the posts or to arrange a visit, please speak to Miss Kallirroi Tzafetta (kallirroi.tzafetta@meht.nhs.uk, 01245 516119). Person Specification REQUIREMENTS ESSENTIAL DESIRABLE Qualifications Professional Experience/Training Communication Audit and Clinical Governance Standards MBBS or equivalent Pt 1 of Higher qualification Extensive experience in plastic surgery training in hospitals recognised by the Royal College for training Previous experience at SpR or equivalent level Ability to communicate effectively with all levels of staff, patients and relatives. Ability to work as part of a multi-disciplinary team with appropriate inter-personal skills for effective team working. Ability to gain the trust and confidence of colleagues and patients IT skills. Interest in, and knowledge of, medical audit and understands the principles of evidence based audit. An understanding of the principles of Clinical Governance. High ethical/professional standards FRCS, FRCS (Plast) or equivalent Ability to develop and maintain a subspecialty interest Evidence of audit participation Transport Ability to travel between Trust sites. Own transport Leadership Skills Registration Ability to motivate and develop junior medical and other staff Full GMC Registration with licence to practice. 12

Kind Safe Excellent Attending hospital is a stressful and anxious time for patients, carers and relatives. We will show empathy, sensitivity, compassion and understanding at all times. Behaviour we expect Behaviour we will not accept Treat everyone in a friendly, courteous manner; smile & make eye contact Help anyone who appears lost Listen to the wishes and preferences of patients Treat patients & colleagues with dignity & respect Understand people come from varied backgrounds; challenge bias, prejudice & intolerance Follow the Trust procedures for hand hygiene Maintain privacy and ensure confidential information is kept safe and secure Learn from mistakes & ask for support where necessary Respond promptly to call bells, telephones & other requests for help Ensure appearance is professional & name badge visible Keep work area clean, tidy & pick up litter when you see it Use plain language & speak in English when carrying out duties Provide consistently high quality care & service Look for better ways of working to achieve improvements Respect patients time; apologise & explain if we keep people waiting Question poor practice process & behaviour Access opportunities for learning & development Uphold the values and be proud to be part of the Trust Care, Excel and Innovate Forgetting we are here to provide a service to patients Criticising colleagues/disagreeing with them in front of patients, visitors and other staff Appearing unapproachable or moody Imposing personal beliefs and opinions on patients Blaming others/other departments for mistakes Wearing inappropriate dress/or having an unprofessional appearance Being unsupportive of change/of new ideas for improvement Moaning and demoralising others without making an attempt to change things 13