Mid Staffordshire: heeding the lessons

An inquiry into a UK health service scandal has released its findings. Could such a tragedy happen here? 

The Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, recently released in the UK, examines how hundreds of people died due to substandard care at two UK hospitals between 2005 and 2009. It contains a number of lessons that nursing as a profession and the broader health community would do well to note.

The report highlights a number of failings that led to patient care standards that many would say were not possible. But looking at our own health systems, are we sure that we do not already have some of the early warning signs?

Robert Francis, who chaired the inquiry, talks in the Executive Summary about the number of incidents and issues that were occurring, but that the system failed to consider in full or see as representative of a larger problem. The answer, he argues, does not lie in "top-down" pronouncements or reorganisation of the system but in "engagement of every single person serving patients in contributing to a safer, committed and compassionate and caring service" (p18).

He further says that patient safety and requirements are obligations that "need to transcend particular policies and permeate all consideration within the system of fundamental standards" (p38).

Francis did not find that there were one or two poor managers or clinicians, but rather a combination of factors and deficiencies within a complex health system (p36).

In several places in the report, Francis refers to the focus on financial outcomes and targets. While he does not argue that having such requirements is inappropriate, it is the concentration on them to the detriment of care that is questioned.

Measurement is critical for the feedback it provides on how our system is operating, and in identifying opportunities to make the delivery of care more efficient and effective. There is, though, a need for balance and for a number of the measures to be seen to connect directly to care and patient outcomes. The measures that we use need to have meaning for clinicians and managers and provide feedback that supports and enables them to truly improve care. Margaret Wheatley, in a 1999 article with Myron Kellner-Rogers on measurement, noted: "But in too many organisations, just the reverse happens. The measures define what is meaningful rather than letting the greater meaning of the work define the measures. As the focus narrows, people disconnect from any larger purpose, and only do what is required of them. They become focused on meeting the petty requirements of measurement, and eventually, they die on the job. They have been cut off from the deep wellsprings of purpose which are the source of the motivation to do good work."

A number of the comments in the report seem to reflect this potential disconnection. Specifically for nursing, Francis notes the issues of poor leadership and staffing policies and the delay in addressing the shortage of skilled nursing staff (p45). A number of other recommendations are specific to nursing and are encapsulated in the need to have a culture that is one of "compassion and caring" - and that goes through the recruitment, training and education of nurses. He highlights the need for the ward nurse managers to not be office-bound but to be out on the floor and aware of the plans and care of patients (p76).

Francis argues that there is no need to "radically reorganise", but to emphasise what is truly important: that the patient should be the centre of care and that there should be no tolerance for poor or substandard care. He lists eight items that he sees as being important (p66):

• Emphasis on and commitment to common values throughout the system by all within it
• Readily accessible fundamental standards and means of compliance
• No tolerance of non-compliance and the rigorous policing of fundamental standards
• Openness, transparency and candour in all the system's business
• Strong leadership in nursing and other professional values
• Strong support for leadership roles
• A level playing field of accountability
• Information accessible and useable by allowing effective comparison of performance by individuals, services and organisations.

Some people reading the report may think the situation would never happen in Australia, that we do not have these issues - but is that really the case? Can we really be confident that some of the problems of Mid Staffordshire could not be found in our health system? Ours, too, is increasingly focused on meeting targets and financial outcomes, and it is not unusual to hear clinicians commenting that the interest in the patient seems to be at times overridden by the need to meet a target.

Nurses talk about the frustrations they feel at the emphasis on the targets to the exclusion of other important care issues. In thinking about this further, I would argue that they are, in Wheatley's words, in danger of becoming "cut off from the deep wellsprings of purpose" that not only motivates but sustains people in what are increasingly challenging and complex systems.

We also hear of the workload of ward nurse managers; that they find it difficult to get out of their offices and spend time on the ward, not only knowing what is happening with patients and their care but also providing the support and mentoring needed to nurses and contribute to longer-term staff retention.

All is not lost, though! Several health services in Australia have either undertaken or are undertaking work to both build the skills and capabilities of those in the critical role of ward nurse manager and also to ensure that they are not bound in offices.

A number of programs around Australia are seeking to shift the balance back to a focus on care; a number of these have transformational practice development as a foundation and they are having some success. Critically important in these programs is the examination of values that underpin the care that staff seek to provide, to enable them to implement strategies to deliver that care. I understand a system developed in the USA, known there as Transforming Care at the Bedside, is also being trialled in Australia. These more humanistic approaches to care contrast with the more mechanistic systems prevalent in recent years. They do not bring about fast changes or improvements, because they seek to bring about true cultural change, and that takes time.

However, as Francis says, it is critical that the culture and values that underpin our health systems are focused on compassionate care for patients.

I would suggest that all nurses take the time to read the Executive Summary (see www.midstaffspublicinquiry.com/report), reflect on their own work and practice, and identify what can be learnt both from an individual and system point of view. Ask ourselves: Are we satisfied that compassionate care is the overriding driver of our work each and every day, or are we only doing something because it is to meet a target?

Adjunct Professor Debra Thoms is chief executive of the Australian College of Nursing.

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