OPINION

Stop passing the buck – patient safety is nurses' problem too

8 August, 2010 | By Suzette Woodward

Director of patient safety at the NPSA Suzette Woodward on the abolition of the NPSA and what this means for nurses.

It has recently been announced that the NPSA, along with several other arm’s length bodies, are being abolished and that the functions of the patient safety division of the agency will be moved to the NHS Commissioning Board.

This announcement, made in the Report of the Arm’s Length Bodies Review, follows on from the NHS reforms made in the recent white paper Liberating the NHS.

What is clear is that the size and scale of the changes being made are going to impact greatly on how health services are provided. No one is untouched by this reform, from the Department of Health, to primary care trusts, strategic health authorities, foundation trusts, non-foundation trusts, general practice - all are affected.

There has been a steady stream of consultation papers since the white paper. In addition to the arm’s length body review there has also been a recent one on outcomes - Transparency in Outcomes: A Framework for the NHS. For those who want to influence the current agenda, this is the time to have your say. Studies undertaken in the US, Canada, England, Switzerland and New Zealand, all show that the adequacy of nurse staffing and the quality of the nurse working environment are associated with the quality of patient care.

‘What is clear is that the size and scale of the changes being made are going to impact greatly on how health services are provided. No one is untouched by this’

In those hospitals that have poor work environments for nurses, patients tend to be at an increased risk of adverse outcomes - including mortality. If the NHS wants to improve outcomes, we need to address the following essential ingredients: adequate nurse staffing; a high proportion of registered nurses; a well educated nurse workforce; positive nurse-doctor-manager relations; and responsiveness of leadership and management when it comes to addressing problems in patient care that are identified by nurses at the bedside.

In the past 10-15 years patient safety has come to the fore and been recognised as an important source of preventable patient morbidity and mortality. It is a core agenda that unites us all, whether we are clinicians, managers or policy makers. Now is the time to shine a light on the link between nursing and patient safety. Rather than simply focusing the attention on preventing errors, we need to work towards reducing those latent conditions that actually increase the risk of error. Latent conditions that include nurse understaffing, tiredness and fatigue, distractions and poor communication, stress and burnout, inadequate education and a poor practice environment - all are classic examples that predispose individuals to make mistakes, and make it difficult for others in the environment to identify a mistake before the consequences are serious.

To date, these latent conditions have received less attention than the factors directly connected to the errors themselves. Reducing nursing numbers is not the way forward. So much more can be achieved, in terms of reducing errors and poor patient outcomes, by investing resources in work environments. We can improve the productivity of nurses by improving the environment at the bedside, thus making it possible to achieve more with the resources in hand.

Reducing latent errors requires a change which is hard to capture in any policy document; we need to change the culture. Nurses need to stop blaming and start learning. Stop pointing fingers at each other or at other professions and start working together. Demand a commitment from leaders and managers alike for a different style of decision making with a greater devolution of authority to nurses at the bedside. This authority should be proportionate to these nurses’ high level of responsibility for the welfare and safety of their patients.

Nurses must be developed in their roles. They must also be listened to and supported in their decision making and in the management of nursing services. They have the ability to transform the way in which care is delivered, to improve safety and reliability in healthcare, and are an untapped resource. Over the next few years we need to see significant advances in the way nurses are involved in patient safety improvement.

The continued need for strong and committed nursing leadership at all levels of the NHS is apparent. Authority and resources must be invested in nursing leaders, both at the frontline of organisations and at the executive level. In addition, meaningful and positive interdisciplinary relations must be cultivated. Without such leadership, the patient safety movement cannot succeed.

Improving patient safety has to underpin all decisions that nurses make about their work. They need to be trained for the future, not for the past and they need to master a whole new set of skills that are crucial when it comes to patient safety - skills such as continual improvement, teamwork, measurement, change management and so on.
Over the next few years as the NHS puts into place the changes set out by Liberating the NHS, and the National Patient Safety Agency moves some of its functions to the NHS Commissioning Board, it is more important than ever to ensure that patient safety is firmly at the heart of a 21st century NHS. Nurses can be the first to step up and lead this new agenda.

Suzette Woodward is director of patient safety, National Patient Safety Agency

Readers' comments (15)

Anna Lincoln | 8-Aug-2010 8:25 am
"Studies undertaken in the US, Canada, England, Switzerland and New Zealand, all show that the adequacy of nurse staffing and the quality of the nurse working environment are associated with the quality of patient care.

‘What is clear is that the size and scale of the changes being made are going to impact greatly on how health services are provided. No one is untouched by this’
In those hospitals that have poor work environments for nurses, patients tend to be at an increased risk of adverse outcomes - including mortality. If the NHS wants to improve outcomes, we need to address the following essential ingredients: adequate nurse staffing; a high proportion of registered nurses; a well educated nurse workforce; positive nurse-doctor-manager relations; and responsiveness of leadership and management when it comes to addressing problems in patient care that are identified by nurses at the bedside."

I am going to print this article out and give it to our hospital chiefs who say that 1 RN to 28 patients with 3 untrained auxilliaries and no ward clerk on a Monday morning is "adequate staffing".

That is the entire number of staff for the shift. The chiefs have refused to have any further dialogue with us so we have started sending them research and articles like this.

You have the frontline RN's and the few ward sisters that are left on board. It's the matrons, chief nurses, medical managers, finance guys, etc that find the idea of good RN staffing pointless and funny. They require further education and it doesn't seem as if they can distinguish between an RN and an auxillary anyway.

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Anonymous | 8-Aug-2010 9:09 am
Good for you Anna!!!! I would also do an incidet form for every shift you work like this and a risk assessment - until you do this you will carry the can - I know these take time and add to the pressure - but nless you do they will nottake you seriously.
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mike | 8-Aug-2010 10:39 am
Again I absolutely agree Anna! Outstanding!

This has been going on for far far longer than the new cuts have been proposed!

For far too long patient safety has been compromised NOT by Nurses, but by the moronic managers and trust executives and the government.

Inadequate staffing levels that have been PROVEN to be unsafe for patients.

Replacing registered and qualified Nurses with HCA's and AP's who are not qualified, registered or accountable and have a poorer level of education, qualification and understanding of the tasks they are being told they can now perform.

Too many cuts in training and updates for qualified staff.

A demoralised and exhausted workforce due to all of the above, plus crap pay, long hours and too many sacrifices being made for little or no reward.

Patient safety IS a Nurses responsibility, that is why we should speak out now and strike to change all of this!

It is not Nurses who are the CAUSE of the poor level of patient safety in the NHS, in fact we are the dam that is stopping the tidal wave, but we are on the whole failing in our responsibility to speak out about it and protect our patients!
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Anonymous | 8-Aug-2010 1:33 pm
The best way to ensure safety is by having enough nurses and health care assistants on the wards at all times. You cannot blame nurses when already we have too much to do and not enough hands.
The NLRS arm of the NSPA has tried with guidelines and alerts on things like infection control and safe medication practice but if the government think it should be abolished then, they shuold go ahead but a regulatory body as to be in place.
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Anonymous | 9-Aug-2010 11:51 am
It seems that the non clinical level of management are trying to prove their worth at the expense of front line staff. Surely at this time of getting rid of top down approaches and putting patients at the center it is the clinical leaders who are most needed and should be developed. This will help morale in terms of career development as well as ensuring that managers remain in touch with the front line.
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Janice Kite | 9-Aug-2010 3:36 pm
Excellent article.

In relation to my professional focus:

"They need to be trained for the future, not for the past and they need to master a whole new set of skills that are crucial when it comes to patient safety - skills such as continual improvement, teamwork, measurement, change management and so on."

Agreed and whilst I don't believe panceas exist in any sphere there are tools, techniques and processes that can be implemented to help improve patient safety. For example, implementing and using barcode technology at the bedside.

Refer: http://www.journalism.co.uk/66/articles/539998.php
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mike | 9-Aug-2010 3:54 pm
Janice, whilst I do not disagree that examples such as the one you give could improve patient safety, quite simply they are pointless unless staff numbers are increased. All the initiatives in the world will not make a damn bit of difference unless there are enough qualified staff there to implement them.

And for that reason it is the managers and moronic executives that are endangering patient safety, not us.
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Yvonne Bates | 13-Aug-2010 7:32 am
At the end of the day the RN is " Accountable"....if she is working alone with 2-3 HCA's I believe she is the one that will be held liable for whatever reason....end of.
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Anna Lincoln | 13-Aug-2010 5:39 pm
Thats right Yvonne that is why we are all getting the hell out of this country. Management short staffs the wards, the government and the unions and the department of health refuse to get involved and BOOM the RN gets her ass nailed to a wall.
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mike | 13-Aug-2010 10:57 pm
Exactly Anna and Yvonne, Melbourne here I come!!!
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Marjorie Lloyd | 16-Aug-2010 8:42 am
"nurse understaffing, tiredness and fatigue, distractions and poor communication, stress and burnout, inadequate education and a poor practice environment - all are classic examples that predispose individuals to make mistakes, and make it difficult for others in the environment to identify a mistake before the consequences are serious".

latent conditions - an interesting term that needs addressing urgently by everyone in the NHS. Playing the blame game does not help however and tends to get people's backs up. What is needed is a genuine approach to addressing some of these issues as professionals.

Nurses are not very good at caring for themselves which is perhaps where we need to start?
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susan mcconnell | 16-Aug-2010 4:14 pm
This is a good article and has generated some interesting responses but the title worries me. Nurses are not 'passing the buck' rather it's the other way around! Everyone is responsible for patient safety and nurses are the ones most aware of this, being on the shop floor with the patients 24//7. A little more help from 'above' and recognition of this problem would be welcome. If there is not enough staff to look after the patients then falls are more likely to occur. We cannot be everywhere at the same time. It's obvious really. Instead of doing yet another study on something we already know, why not address the real problem?
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mike | 16-Aug-2010 10:27 pm
Exactly Susan. it is usually Nurses who are getting blamed, not the ones doing the blaming. But in answer to your question, the real problem is not adressed because those in charge know the blame and responsibility would fall squarely on them, and that is never acceptable is it??!!
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Mohammed Albaadani | 18-Aug-2010 1:03 am
Medical errors typically result from a series of small breakdowns in complex systems, not simply from the mistakes or incompetence of one nurse or doctor,
Create blame less culture to report the errors and allow people to communicate confidentially without punished.
2-Establish fair and effect reporting system of medication errors also is the indicator of quality of improvement
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dino-nurse | 18-Aug-2010 3:52 pm
We have been saying for years that the sinlge most important thing for a patients well-being is an adequate number of trained RNs on the floor. This means no more than 6 patients per RN on an acute ward ( ideally no more than 4 but 6 would be a start). This means that you have to physically have that number of RNs available on every given ward 24/7. ED and ICU obviously have more RNs needed. Its not rocket science. Hospitals fudge the figures when they give out nurse to bed ratios as they include anyone with a PIN regardless of whether they are clinically active or not. In most trusts ths will be at least 80 RNs that are not actually bedside nurses as per their job description but also they would not be able to "fill in" if needed as they are too out of date. The NMC needs to re-consider what the PIN number actually means. What is the point in having a PIN if you are no longer competent to practice? Surely this is a no-brainer? This should also apply to nurse-tutors and those teaching in the universities- medics who are on teaching fellowships/lectureships most definitely have to be clinically active. Why should a so-called hands-on profession not follow the same rules?
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