Thursday, 17 October 2019

Voluntary stopping of eating and drinking is a rare but nevertheless relevant phenomenon in long-term care

Sabrina Stängle*, MSc, RN
Wissenschaftliche Mitarbeiterin
ZHAW Zürcher Hochschule für Angewandte Wissenschaften Institut für Pflege, Departement Gesundheit Technikumstrasse 81, Postfach CH - 8401 Winterthur Tel. +41 58 934 4144

Voluntary stopping of eating and drinking (VSED) is a way to end life prematurely. People who choose this path are able to make decisions, are able to eat and drink and are neither cognitively impaired nor suffer from mental illness. They decide to follow this path in order to end unbearable suffering that cannot be alleviated despite medical progress. Aware of the phenomenon, VSED was included as a controversially discussed option in 2018, when the guideline of the Swiss Academy of Medical Sciences "Dealing with Dying and Death" was updated. The guideline is trend-setting for health professionals. However, it was unclear what relevance VSED has in Switzerland. For this reason, the objectives of this study were to assess the incidence of VSED in long-term care and to gain insights into the attitudes of long-term care nurses about the VSED. Heads of Swiss nursing homes (535; 34%) took part in an online survey on this subject. The results could show that almost every second institution among the participants has already accompanied a VSED case. Moreover, among all persons who died in Swiss nursing homes in 2016, 1.7% are due to VSED. Participants' overall views on the VSED are very positive, whereas it is assumed that it is a phenomenon of old age. Professionals still lack sufficient knowledge about this phenomenon, which could be clarified through training.

* Forthcoming article: Stängle S, Schnepp W, Büche D, Fringer A (2019) Long-term care nurses´ attitudes and the incidence of voluntary stopping of eating and drinking: a cross-sectional study Journal of Advanced Nursing (in press)

Saturday, 5 October 2019

The colour of your skin may influence your pain relief

Roger Watson, Editor-in-Chief

The colour of your skin may influence the extent to which you obtain pain relief from a health professional. This is reported in a systematic review by Aronowitz et al (2019) from the USA titled: 'Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients'.

The study aimed to: 'explore the factors that influence provider pain treatment decision making and the receipt of pain management by injured Black patients in the United States'. Twenty studies were found which met the criteria of the study and the main results were: 'that healthcare provider characteristics, racial myths about pain sensitization, and assumed criminality all impact provider treatment decision making and the receipt of pain treatment by injured Black patients'.

The authors concluded: 'Racial disparities in pain treatment are clearly unjust and can understandably sow mistrust in healthcare providers among individuals in communities harmed by these disparities, which can lead to an avoidance of care. The results of this review provide important areas for further study, including how intentionality of injury may impact provider-perceived patient trustworthiness and the receipt of pain treatment by injured patients. The assumed criminality of certain populations, particularly people of color, can negatively impact the way people are treated by law enforcement, potential employers, healthcare providers, and the general public. How the assumed criminality of certain patients by providers may impact the quality of care that these patients receive has not been thoroughly explored, but is vital to address healthcare disparities.

You can listen to this as a podcast


Aronowitz, S. V., Mcdonald, C. C., Stevens, R. C. and Richmond, T. S. (2019), Mixed Studies Review of Factors Influencing Receipt of Pain Treatment by Injured Black Patients. J Adv Nurs. doi:10.1111/jan.14215

Friday, 13 September 2019

Celebrating Women : Women and Ethical Employment

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board 

In contemporary society much is spoken about the travesty of unethical employment. In the destructive life of a mardi gras bead, David Redmon cites the hidden dangers associated with the colourful beads, mostly associated with mardi gras. Combined with the risks posed to human health, linked to poor working conditions, exposure to neurotoxic chemicals such as lead poisoning, as well as the impact on the global environment this trinket, has a lot to answer for. Many of these workers are children whose lives are controlled not by what time they need to get up for school, but by the number of beads they can make and the wages they can earn to feed their families.

Historically women and children have borne the brunt of patriarchal intentions made all the more intolerable by the cruel vagaries of Victorian England and the often-unendurable conditions in which women and children lived, worked and died. Such conditions such as those associated with the plight of the matchstick girls, the Cradley Heath Women Chain makers and the New Jersey radium girls are recorded in the annals of history as a stark reminder of the importance of ensuring ethical employment is high on the agenda of all governments.

Such accounts continue to tell the stories of the many actions undertaken by women that would see them challenge the paternalistic world in which they lived and worked and for many ultimately win. This is perhaps no more evident than the matchstick girls strike of 1888 when 141 women and girls came on strike following a resounding call to action. The narrative of those who worked in the Radium Industry a poison which significantly contributed to the early deaths of many women who worked within its walls, caused teeth to fall out, jaws to necrose and flesh to ulcerate. And to the Cradley Heath Chain makers whose miserable wages and impoverished lives led to the strike of 1910 when women downed tools as a result of the starvation wages and strict regimes imposed.

In Victorian England nursing was also considered sweated labour, but was it really necessary that ‘to help a million sick, you must kill a few nurses’? For nurses too were subject to the horrors of employment and with blood poisoning from sewer gas, TB and other infectious diseases, including cholera and typhoid, rife in the hospital setting, along with many others, nurses paid the ultimate price; they were dying as a result of caring for the sick.

Today, the World Health Organisation’s response to workplace wellbeing is clear, that the health of the worker should be protected, whilst the World Employment Confederation presents a strong business case for ethical employment.

In their quest to ensure fair work for all, the government of Wales has released a Code of Practice , which seeks to ensure good employment practices for the millions of workers at every stage of the supply chain. Although the Welsh Government has moved forward with a code of ethics, there is still much work to be done before this is enshrined in legislation

The NHS too is playing its part.  All healthcare practitioners have a role to play in ensuring ethical employment and reducing the risks associated with the environment. In 2018 Great Ormond Street Hospital launched ‘the gloves are off campaign’ the aim of which is to reduce the associated risks of dermatitis, due to overuse, improve hand hygiene compliance and improve the environmental impact as well as reduce the risk of hospital acquired infections.

Nursing continues to remain a gendered specific profession. We may no longer be killing nurses, with blood poisoning from sewer gas, TB and other infectious diseases but are we not killing their passion, spirit and willingness to nurse.

All of these scenarios have one thing in common; they are all associated with product development and service delivery. It is the responsibility of each and every organisation involved in the supply chain to ensure ethical employment practices are adhered to. We have a long way to go.

Different times, same issues

Aligning Safe Staffing with Patient Safety: Is this Two Sides of the Same Coin?

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the second of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

Research undertaken by Dr Linda Aiken and others has identified a strong link between, nursing skill mix and improved patient outcomes:

‘We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes’ (Aiken et al. 2016).

Nursing research has also identified an increased risk of patient mortality, during hospital admissions when nurse staffing levels are reduced and there is a reliance upon nursing support staff to cover the shortfall.

The Royal College of Nursing (RCN) report Nursing on the Brink makes their position clear:

‘Having the right number of registered nurses and nursing support staff with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for patients and clients’.

With Westminster demonstrating a lack of accountability in ensuring safe nurse staffing levels, many see this as a flagrant lack of commitment to a nursing workforce that is teetering on the edge. The RCN is calling on parliament, not only to ensure accountability for staffing becomes the domain of the Secretary of State for Health and Social Care but also that accountability for the health and care workforce is firmly enshrined in English law.

Encouragingly legislation has been passed in both Wales and Scotland, which goes some way to making safe staffing a reality, but What about England? What about Northern Ireland? Nurses who take the fight to the doorstep of Westminster, must be prepared to be in this for the long haul, for history demonstrates that what we do today, requires patience, resilience and a sense of determination to succeed. This understanding however, should not dampen the spirits of any nurse who finds themselves working in understaffed clinical areas, for every great achievement must begin by taking the very first step. In the meantime, while we campaign for safe staffing levels to be enshrined in English law, what can nurses do to reduce the significant challenge to maintaining patient safety?

Find your voice and speak up 
It is not simply the role of nurses to speak up, but all healthcare professionals. Freedom to speak up was introduced following a 2015 review into whistleblowing practices within the NHS, the aim of which was to create a culture shift in the way in which safety issues are addressed ultimately reducing the need to ‘whistle blow’.

Disappointingly the continued culture of blame in the NHS fails to consider the consequences of poor staffing levels, inadequate skill mix and continued lack of investment. With the RCN demonstrating the impact of the loss of the nursing bursary and the cumulative effect of 40,000 nursing vacancies in England alone, nurses are being increasingly challenged in their attempts to ensure the delivery of safe and effective care. And when mistakes do happen, the impact can be devastating, not only for patients, carers and families but also for those healthcare professionals involved. Creating a just culture in healthcare settings is as important as ensuring safe staffing is enshrined in legislation. Nurses should not fear the stigma of blame when things go wrong; instead they should be encouraged to speak up in order to reduce the associated impact and for valuable lessons to be learned. It is however important to note, that a just culture does not absolve nurses of their accountability to deliver safe and effective patient care, simply that a fair and honest approach is taken.

The significant shortage of nurses is now considered to be affecting patient care and threatening lives. One way in which nurses can find their voice is by contributing to the 100 voices campaign. By sharing experiences, reflections and actions, nurses can contribute not only to the educating of others but also in ensuring lessons learned are encased in policy and health care reform. 

Pursue Learning Opportunities When Jeremy Hunt the then Secretary of State for Health declared in the report Building a Knowledge enabled NHS for the Future that:

‘The world’s fifth largest organisation needs to become the world’s largest learning organisation’. 

he was absolutely right.

However, when crisis after crisis continues to plague the NHS, as evidenced in the recent Whorlton Hall abuse scandal it is a strong reminder of the polemic approach that governments take when responding to any crisis.

Improving patient safety through education and training is recognised as an essential requirement and in recent weeks the government has gone some way to improving funding for continuous professional development for nurses, but this is only skimming the surface. More commitment is needed to ensure the future of nursing is guaranteed, throughout all sectors and in all specialties. A lack of funding for pre-registration nurse education has been cited as a reason for the reduction in the number of students entering nurse training. If the government is to be congratulated for their commitment to ensuring high quality patient care, then investment in the nursing workforce is crucial.

Demonstrate Strong Leadership
Strong leadership in nursing is considered one of the most important aspects of ensuring safe and effective care. All nurses have the capacity to lead; crucially however nurses must also have the ability to reflect and act in dynamic situations, not only to ensure that patient safety is maintained but that risks are identified quickly and service delivery transformed.

Nurses have a unique role to play in encouraging other nurses to speak up when they have concerns. All nurses have both a duty of candour and a responsibility for ensuring continued patient care and this cannot be achieved by nurses who are afraid to speak up and act. Supporting individual nurses with a degree of compassion and understanding when things do go wrong can make the difference between someone returning to work or not, staying in the profession or leaving or in some severe cases even prevent nurses from taking their own life. Errors in general occur as a result of bad systems, not bad people. Whether you agree with this or not is a matter of personal belief, however what is clear is that mistakes occur as a result of a very complex chain of design, systems, inadequate training and human factors.

In today’s turbulent healthcare climate, the responsibilities placed on nurses, is overwhelming. Nurses are no longer able to guarantee the delivery of safe and effective care, perhaps we never could, but we can continue to raise awareness of the impact that poor staffing, poor levels of skill mix and a lack of appropriate education and training can have on patient care. To do this may instil a sense of hope that things can be different.

Wednesday, 11 September 2019

Promoting a safe and just culture in nursing: Aligning Human Factors with the Courage to Speak Up

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the first of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

The theme "Patient Safety: a global health priority", with the rather apt slogan “Speak up for patient safety” is a call to action for all healthcare workers across the world to help reduce the 134 million adverse events, which results in 2.6 million deaths each year globally.
Ensuring patient safety is an essential role of all healthcare organisations and arguably all health care professionals; this role, being enshrined within both the UK Nursing and Midwifery Council and General Medical Council Codes.

Human Factors
Within healthcare in recent years, the term human factors has been synonymous with patient safety. In an attempt to make sense of the causes, the facts and the myths associated with near misses, healthcare failings and individual responsibilities, the study of human factors has sought to identify problems and generate effective solutions in order to reduce the risks associated with maintaining patient safety.

In accordance with the World Health Organisation, human factors examines the correlation between humans and the processes and systems with which they interrelate, the aim of which is to improve efficiency, creativity, productivity and job satisfaction, whilst seeking to reduce the risk of errors. Investigating adverse incidents within the healthcare setting, often identifies a failure to apply these basic principles.

Contemporary organisations, particularly the aviation industry has recognised human factors as being an important element of safety; this recognition now evident within the NHS. The Clinical Human Factors Group (CHFG) highlights the seriousness of the iatrogenic consequences of accidents and incidents borne out through error. Disturbingly statistical data highlighted by the CHFG makes for stark reading; most of all the cost to human life insurmountable. But it doesn’t have to be this way? Improving safety through speaking up is both an ethical and financial imperative, and organisations should be responsible for encouraging employees to speak up and share their concerns.

For many healthcare professionals their first introduction to human factors may be as a result of an incident in which a patient was harmed, as a result of potential failings. It should not be this way. By gaining an insight into the complexity associated with human factors through educational tools including the well-publicised videos ‘Just a routine operation’ and ‘Gina’s Story’, many healthcare workers can learn about the devastating effect experienced by many. Many more stories, such as these no doubt exist.

These real-life events have in some way occurred as a result of clinical error and a lack of professional judgement, perhaps something that any one of us could be subject to, if exposed to the right situation. We just need to be in the wrong place at the wrong time, for catastrophe to happen.

The Swiss Cheese Model
One theory, of how such incidents occur was proposed by James reason in 1978; known as the Swiss Cheese Model. This model can help to identify potential hazards, demonstrate how incidents occur and help to illuminate or clarify potential causes in accident investigation. When all the holes line up, anything is possible. Inadequate staffing levels for example, could be a contributory factor in helping to align those holes, another perhaps inadequate skill mix. Agency staff can be a buffer to reducing the risk, or can be a mitigating factor, but buffers should no longer be acceptable. Other factors such as skill set and skill mix, attitude, beliefs and values, all play their part, the willingness to challenge senior staff and as nurses make your voice heard could be argued is a significant factor, and is particularly evident in the Elaine Bromiley tragedy as shared in the video ‘Just a routine operation’. Promoting a positive safety culture in which all staff feel able to speak up may also be a positive step in reducing risk.

Developing a safety culture
Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns is an essential element of any healthcare organisation seeking to reduce patient harm, and not simply the NHS. From domestic staff to consultant and all roles in-between, staff must be aware of the importance of raising the alarm, when they think something may be wrong or when it has gone wrong. Disappointingly staff working within healthcare settings continue to be overwhelmed by the challenge of speaking up, so eloquently discussed by Professor Mannion in his article ‘Speaking Up in Health Care: The Canary in the Mine?’ that they fail to do it. So, despite the introduction of Freedom to Speak up Guardians created as a response to the Francis report; a lack of confidence in speaking up remains evident.

The World Health Organisation has produced a multitude of technical reports, a link which can be found here. These reports describe the nature and impact of harm, and provide some potential solutions and rational steps to take in order to help improve patient safety.

Sunday, 18 August 2019

Which parents are more likely to call an ambulance unnecessarily for a sick child?

Roger Watson, Editor-in-Chief

Having a sick child is stressful for parents and there is always the issue of whether or not to summon help, sometimes from the ambulance service. Not every instance of parents calling an ambulance is necessary, but which parents are most likely to make unnecessary calls? This as the subject of a study by Ueki et al. (2019) from Japan titled: 'Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study' and published in JAN. The aim of the study was to: 'examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily' and over 170 parents who had visited the emergency department of a hospital were questioned.

The results showed that 'parents who did not use resources to obtain information regarding their child’s illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances. The authors concluded: 'Publicizing available resources regarding child health information, social health care activities to raise parents’ health literacy and explanations in accordance with parents’ uncertainty, especially when faced with new symptoms in their child, might reduce unnecessary ambulance use.'

You can listen to this as a podcast

Ueki, S. , Komai, K. , Ohashi, K. , Fujita, Y. , Kitao, M. and Fujiwara, C. (2019), Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross‐sectional study. J Adv Nurs. doi:10.1111/jan.14161