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The Role of the Nurse (Scenario)

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Patients were left in soiled bedding, patients not given access to food and water, a culture where staff were encouraged to keep their concerns to themselves.
People died due to these failings.

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Most of the UK media has reported on the Francis inquiry into significant failures in care at the Mid Staffordshire NHS Foundation Trust.

The report suggests a raft of radical changes to help improve patient safety. These include proposals to make serious but avoidable medical mistakes a criminal offence.

The Healthcare Commission (the hospital regulator at the time) first raised concerns about the trust in 2007, after determining it had unusually high death rates.

These concerns led to a series of reports, undertaken by different bodies, which all found widespread evidence of significant failures in care, including:

patients being left in soiled bedding

patients not given ready access to food and water

chronic staff shortages

failure in the leadership of the hospital

a culture in which staff members who had concerns about failures in care were discouraged from speaking out

This current inquiry was commissioned in 2010 to investigate wider issues that may have contributed towards these serious problems. The inquiry, carried out by the barrister Robert Francis QC, was asked to come up with recommendations which could help prevent similar failings from happening in the future.

The findings of the inquiry have now been published.

What were the main findings of the inquiry?

The findings of the inquiry can fairly be described as damning. It highlights what amounts to a 'perfect storm' of systematic failures of care at multiple levels, including:

a 'Somebody Else's Problem' attitude among hospital staff - perceived problems were too often assumed to be the responsibility of others

an institutional culture that cared more about the needs of the hospital staff than the patients

an unacceptable willingness to tolerate poor standards of patient care

a failure to accept and respond to legitimate complaints

a failure of different teams within the hospital, as well as in the wider community, to communicate and share their concerns

a failure of leadership - in particular, financial changes needed to achieve Foundation Trust status were seen, by the inquiry, to take precedence over patient care

Mr Francis concludes that, 'The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require a root and branch reorganisation - the system has had many of those - but it requires changes which can largely be implemented within the system that has now been created by the new reforms.'

What recommendations does the inquiry make?

The inquiry makes a total of 290 individual recommendations. These include:

causing harm or death to a patient due to avoidable failures in care should be a dealt with as a criminal offence (rather than a regulatory or civil matter)

NHS staff, including doctors and nurses, should have a legal 'duty of candour' - so they are obliged to be honest, open and truthful in all their dealings with patients and the public

a single regulator of both quality of care and financial matters should be created

non-disclosure agreements ('gagging orders') - where NHS staff agree not to discuss certain matters - should be banned

there should be a 'fit and proper' test for hospital directors, similar to those set for football club directors

a clear line of leadership needs to be established, so it is always clear who is ultimately 'in charge' when it comes to a particular patient

uniforms and titles of healthcare support workers should be clearly distinguished from those of registered nurses

What happens next?

The final report of the public inquiry has now been published, and the government has said it will respond to the recommendations of the inquiry in March 2013. Changes required by earlier reports into the failings at Mid Staffs are already underway.

The Prime Minister David Cameron has said that "quality of care" should be on a par with "quality of treatment".

He said: "We have set this out explicitly in the Mandate to the NHS Commissioning Board, together with a new vision for compassionate nursing.

"We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections.

"And we have demanded nursing rounds every hour, in every ward of every hospital."

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Mid Staffs inquiry calls care failings a 'disaster'

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Most of the UK media has reported on the Francis inquiry into significant failures in care at the Mid Staffordshire NHS Foundation Trust. The report suggests a raft of radical changes to help improve patient safety. These include proposals to make serious but avoidable medical mistakes a criminal offence.

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Being a volunteer or 'Good Samaritan'

There are two aspects that need to be considered:

Legal duty

There is no legal duty to volunteer help in an emergency situation. The legal duty of care generally only arises when a practitioner has assumed some responsibility for the care of the patient concerned (see above). Accordingly, if a nurse is at a road traffic accident, they do not have a legal duty of care to offer aid to any person injured in the accident. Many people mistakenly assume that nurses have first aid training which would assist the injured person. This is not always the case.

Professional duty

However, registered nurses, midwives and nursing associates should be aware that the NMC Code places a professional duty on them to provide appropriate assistance, within their sphere of knowledge and competence.

Paragraph 15 of the Code states:

"Always offer help if an emergency arises in your practice setting or anywhere else

To achieve this, you must:

15.1 only act in an emergency within the limits of your knowledge and competence

15.2 arrange, wherever possible, for emergency care to be accessed and provided promptly

15.3 take account of your own safety, the safety of others and the availability of other options for providing care"

Wherever possible, a registrant should arrange for emergency care to be accessed and provided promptly. They should always take account of their own safety, the safety of others and the availability of other options for providing care. This professional duty may vary in practice, depending on the circumstances and the expertise of the nurse concerned, from simply providing some psychological comfort to the injured person, through to offering more hands-on care.

This is illustrated in the following examples:

if a nurse has an understanding of the impact of moving a person with spinal injuries, then they may be expected to volunteer that knowledge at the scene of the accident

if a registered nurse with no midwifery training or knowledge came across a woman in labour their professional duty of care may be limited to reassuring the woman, making her comfortable and then calling an ambulance, acting within their competence.

As employer indemnity would not apply to an emergency situation outside the workplace, the RCN indemnity scheme does cover you for Good Samaritan acts subject to conditions and exclusions.

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Duty of care | Advice guides | Royal College of Nursing

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An advice guide for nursing staff on the duty of care covering definitions, emergency situations and conflict with employer's instructions.

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The Eight Principles create a guideline for how nurses should act in their profession. Though they are not mandatory to abide by, unlike the NMC Code, they do provide a clear outline for how a nurse should act.
Relating to the scenario, the principles can show that the way the nurse went about "helping" the patient is not met with what the guidelines suggest the standard should be. an example of this can be seen with Principle A, "nurses treat everyone in their care with dignity and humanity". This can show that the way the nurse stated how, she would give him a bowl of water to clean himself, can be seen as inhumane as he may not be able to do so. As well as this, Principle B, where it makes a statement that nurses should be accountable for their judgements and actions. This nurses actions are not caring and their judgements on how to take action on the situation could have been better assessed; e.g. allocating a fellow colleague with the correct competencies to take over.

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Principles of Nursing Practice

The Principles of Nursing Practice tell us what all people can expect from nursing practice, whether they are colleagues, patients, or the families or carers of patients. Nursing is provided by nursing staff, including ward managers (in hospitals) or team members (in the community), specialist nurses, community nurses, health visitors, health care assistants and student nurses.

The Principles are applicable across the UK. The same core values are also described in different ways in documents and strategies in the four countries, such as 'the 6Cs' (nursing care that is about Care, Compassion, Commitment, Communication, Courage and Competence) in England. You need to be mindful of how you personally contribute to the patient's experience of care and be confident that you demonstrate these core values in action. Reflecting on this is an important step in maintaining high-quality nursing care.

Nursing teams can use the Principles to drive quality improvement, continuing professional development (CPD) and sharing with patients and carers. They enable everyone to know what quality nursing looks like.

Some nurses are linking their CPD activities to the Principles to demonstrate how they're keeping their knowledge and skills up to date. This information is useful during performance appraisals to show how quality care is being delivered against set objectives or a job/role description. The Principles can also be used to support challenges to good practice, such as being a person's advocate (Principle D) or influencing changes to promote dignified care (Principle A).

You can find out more about the Principles of Nursing Practice on the RCN website.

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The Principles of Nursing Practice tell us what all people can expect from nursing practice, whether they are colleagues, patients, or the families or carers of patients. Nursing is provided by nursing staff, including ward managers (in hospitals) or team members (in the community), specialist nurses, community nurses, health visitors, health care assistants and student nurses.

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Medical negligence = duty of care owed by defendant + Breach of duty of care + Claimant's injury caused by breach (Samanta and Samanta, 2016).

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The code states that nurses should be "accountable for their decisions to delegate tasks and duties to other people" and to "only delegate tasks and duties that are within the other person’s scope of competence" (The Code, 2015). For the nurse to expect the patient and his family to understand these risks, as well as assuming that they could effectively clean the area is potentially putting their patient at risk of harm.

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Surgical site infections (SSIs) are the second most common hospital-acquired infections which contribute to high levels of  morbidity and mortality in patients (Sattar et al, 2019). Therefore, good hygiene is essential in keeping the stoma area clean and prevent from infection.

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High quality, person-centred nursing care is essential in effective stoma care (Bonill-de-las-Nieves et al, 2014). Informing and teaching the patient of stoma care and hygiene and paying attention to stool leakages is effective care that should be provided by the nurse (Bonill-de-las-Nieves et al, 2014).

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Many parts of the NMC code can be applied here.

"...the needs of those receiving care or services first." (NMC, 2018)