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Tensions rise on maintenance of safe practice in face of severe staff shortages

Niall Hunter reports from INMO national seminar on safe practice

Over 300 INMO members attended the Organisation’s major national seminar for clinical nurse and midwife managers on safe care and safe practice last month.

The day provided a comprehensive overview from key figures on the main factors involved in ensuring quality of care. The debate also highlighted the tension between the need to maintain safe standards against a background of rising healthcare demands and greatly diminished staffing resources.

Siobhan O’Halloran, chief nursing officer (CNO) with the Department of Health, told the seminar that the role of nursing and midwifery was critical to the future growth of the health service. She acknowledged that, with all the public and media attention on the health service and investigations, it was very difficult to manage, change and develop the health service.

However, Dr O’Halloran said that despite the often negative media attention on the health service, it had been shown that the general public trusts nurses and midwives and felt very positively about them.

She stressed the importance of the roles of nurses and midwives in the modern health service, set against all the negative attention and service pressures in recent years.

She described the recent creation of the CNO role as very positive as it gave nursing and midwifery a key role in health policy planning. Dr O’Halloran specifically identified the need to strengthen the role of the CNM 2, and stressed the need to develop quality assurance.

Clinical nurse and midwife managers turned up in large numbers for the INMO’s safe practice seminar last month

Quality and safety
Dr Philip Crowley, national director of the HSE Quality and Safety Directorate, dealt with the current actions being taken by the HSE in terms of improving quality and safety. He stressed the need for the Irish health service to learn from the Mid-Staffordshire scandal and the Francis Report which investigated it.

He said the message he took from the report was that every hospital manager should be asked about their knowledge of what level of care was being provided on every ward in every hospital. The only way they could be assured of that, said Dr Crowley, was knowing who was in charge on every ward.

In this context, he stressed the role of the CNM/CMM, who, he said, played a pivotal part in respecting the dignity of patients and in advocating for and on behalf of patients.

Dr Crowley pointed out that the key factor in job satisfaction for health professionals was not ultimately the amount of salary paid, but in being able to look after patients properly. When that does not happen, frustrations obviously increase.

He acknowledged that in terms of personnel, nursing and midwifery numbers had been ‘hammered’ in recent years and many senior staff had left the service, but “you are still the driving force of care in the health system.”

He said: “We need a radical rethink on how we view our staff in the health system.” The HSE is trying to ‘up its game’ in terms of the level of staff engagement, he said, and there was a need for a culture change, with an emphasis on quality and safety. This culture, should also be one of managers listening to staff and patients.

“We are only at the starting block in terms of listening to staff. However, there is no point in listening and then just going away,” Dr Crowley said.

He stressed the importance of managers engaging in ‘safety walk-rounds’ which can help generate a culture of listening to staff and patients.

He pointed to the necessity of initiatives such as the safety pause and safe surgery checklists – unfortunately, he said, there were still surgeons out there who did not use these checklists.

Dr Crowley also emphasised the need to abandon blame as a tool for maintaining quality and safety “because it simply does not work.”

In relation to the recent controversy over perinatal deaths at Portlaoise Hospital, he believed a major theme was how the health service reacts when things go wrong. Part of the HSE’s response to this crisis, which predated it, was to produce a policy on open disclosure. He asked for INMO members to champion this policy, where everybody drives for a new approach to engage with people immediately when things go wrong – to say ‘sorry, this is what happened, this is what we are doing about it and we apologise’.

The first thing that is said to a patient after something goes wrong often sets the tone for everything that happens afterwards. Dr Crowley said if you are satisfied with your work and you are happy that you did a good job, you are in a good place to work and you felt the workplace was safe, there is a relationship between you feeling that way, and patients will be satisfied as well.

There is also a direct relationship between employee satisfaction and a series of positive quality outcomes. “If our staff were happier at work, were more fulfilled, more enabled, more listened to, more empowered, we would have higher quality care.”

Mid-Staffordshire impact
Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing in the UK, addressed the meeting on the impact of the report into the Mid-Staffordshire scandal and what was learned from it.

The Mid-Staffordshire Hospital Trust controversy centred on poor care and high patient mortality rates at Stafford Hospital and was the subject of an inquiry headed by Robert Francis QC. This led to a number of subsequent safety inquiries into the NHS.

He said the RCN had stressed that it could not condone the wilful neglect of patients where it occurred. However, as well as focusing on actions of individuals in these cases, it is equally important to focus on the decisions that employers make about staffing levels. Dr Carter said in the various recent safety inquiries a common denominator had been a shortage of nursing staff and the fact that nursing work was being done by non-nursing staff.

While there was a legitimate role for healthcare assistants, he said there had been an over-reliance on them to perform tasks that had previously been the responsibility of nurses, without being provided with adequate training.

Dr Carter pointed out that prior to the scandal being uncovered, Mid-Staffordshire had actually passed muster in a test to check whether the hospital was fit to move to foundation status.

Dr Carter said the RCN was saddened by the Mid-Staffordshire report and the finding that the care provided was sub-standard, but staffing levels were a key issue. He said it is planned to publish the staffing levels of every ward in every hospital on the NHS safety website.

He stressed that in spite of the controversies in the NHS, 92% of patients in hospitals still expressed high degrees of satisfaction with their nursing care. However, many nurses were complaining that they were being left in situations where they cannot provide the level of care they wish to.

In the Mid-Staffordshire case, Dr Carter said the only people really held accountable were nurses. Senior managers escaped lightly, some with big retirement packages.

Pictured at the national education day on safe practice were (l-r): Liam Doran, INMO general secretary, and Dr Peter Carter, chief executive and general secretary of the RCN

Legal obligations
Olwyn McWeeney, barristerat- law and a qualified doctor, dealt with the legal obligations of frontline managers in the health service. She emphasised that the law was dispassionate and if a healthcare professional is asked to account for their actions on a particular day, she would challenge anyone to do that with the degree of specificity that the law requires.

She said it was important to raise awareness of the gap between what the law demands and the standards it imposes, and understanding and being sympathetic to clinical realities. Bridging this gap could be complex but it could be addressed by initiatives like quality management systems. When healthcare workers saw a fully integrated quality management system in operation its benefits would become clear, not just in terms of making patients safer but in terms of empowering staff.

Ms McWeeney emphasised the need for keeping good clinical records where an adverse event takes place and may be subject to a subsequent legal action or inquiry.

She felt that IT could be utilised more to make it faster and easier to record what is happening in real time in a healthcare setting. She queried why pen and paper was still relied on so much.

In defending healthcare workers in negligence cases, the currency of the legal profession was information and documentation, she said. A good clinical record, she said, should be legible, clear, concise and accurate. Retrospective entries in records should be avoided. Proper communications between staff, she stressed, was an important factor in avoiding adverse events and negligence claims.

Ms McWeeney said in actions resulting from an adverse event, what happened in the event will be compared to ‘general and approved practice’. If it was found that a similarly qualified nurse or midwife would have done the same thing, then it is unlikely to be deemed negligence.

She pointed out that when things go wrong, administrative health staff are accountable, but unlike healthcare professionals, are not subject to regulation.

Regulator’s role
Dr Maura Pidgeon, CEO of the Nursing and Midwifery Board of Ireland (NMBI), gave the regulator’s perspective at the meeting. She stressed the well-worn, but still relevant advice given by Florence Nightingale – ‘the first thing a hospital should do is do the sick no harm’.

Dr Pidgeon said while the objective of ‘putting the patient first’ was frequently quoted, she asked whether the patient was really at the heart of the health system. She said the focus on the patient could get lost amid all the complexities of the system.

She outlined the ever increasing emphasis on governance and regulation, not just in healthcare, but in other spheres such as the banking sector.

She said the NMBI, along with other health professional regulatory bodies, was studying the recent reports from the UK on patient safety and how they affect the regulatory environment in Ireland.

Dr Pidgeon said the NMBI was endeavouring to build up its credibility with its registered nurses and midwives and was endeavouring to develop the regulatory process.

Panel discussion
A lively panel discussion, which fol lowed the main speakers’ addresses, focused on the tension between implementing efficient governance and regulation and the reality of trying to maintain quality patient care in the face of diminishing resources and growing demands on services.

Contributions from the floor included queries on how nurses are supposed to meet regulatory and governance standards when, for example faced with up to 40 patients in an emergency department with severe nurse staff shortages. In that context, it was asked if the nursing regulatory body could credibly claim to be protecting the public?

Another speaker from the floor, referring to educational requirements, pointed out that it was difficult for nurses and midwives to attend mandatory study days.

Former INMO president, Madeline Spiers, a member of the NMBI, called for legislation to ensure safe nurse-patient ratios were implemented.

Tensions rise on maintenance of safe practice in face of severe staff shortages


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