“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm” Nightingale F (1863)
With this statement in mind, identify the major problems for hospitalised patients in acute wards, in the twenty first century. For each problem identified discuss the role of nurses in maintaining the safety, health and well-being of patients.
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Hospitals of today are indeed a far cry from the hospitals of the era of Florence Nightingale in very many respects, but the guiding principles of aspiring to be a safe and healing haven for the sick clearly have not changed over the years. One of Nightingale’s major crusades was the constant battle against infection which was rife in the wards of her day.
To that extent, her mantra continues with the problems that iatrogenic infections cause in today’s hospitals. It is worthy of note in passing, that Nightingale is credited with popularising the statistical analysis of problems. Her famous chart (Playfair 1847) that correlated the decimation of Napoleon’s army by disease as it advanced and then retreated from Moscow, was a milestone in the arguments that she was advancing in the dangers of potential of communicable diseases in crowded environments.
The title of this essay refers to Florence Nightingale’s famous remark which implied that in her day there was a real possibility of hospitals “harming patients”. Her remark, albeit made to address a serious public health problem of the mid nineteenth century, has a resonance which is both deeper and more significant than would first appear on face value. Her comment is actually a paraphrase of a quote from Hippocrates some two millennia earlier in his exhortation to aspiring physicians, “If you are to become a physician, adopt the first rule that whatever else, you will do no harm”. (Carrick 2000)
The significance of this is that even two thousand years after the principle was first enunciated, it was still recognised that healthcare professionals, whilst employing their best endeavours to cure patients, were still able to inflict significant morbidity and even mortality on their patients.
The main thrust of this essay is to demonstrate that even with the passage of a further one hundred and fifty years, it is arguable that the same premise holds good today. It is undoubtedly true that the advances in medicine and technology generally have changed the perspectives and horizons far beyond those that Nightingale would have recognised, but this has done little more than to simply change the nature and type of problem that healthcare professionals have to deal with. Iatrogenic morbidity is still a significant fact of life in our modern healthcare practice. (Sugarman & Sulmasy 2001)
The original work by Semmelweis (at about the same time as Nightingale ) in the 1850s, (Semmelweis 1861) made major inroads into our knowledge of the transmission of pathogens around wards. This work was augmented by Lister and others with their work on asepsis and antisepsis. (Birte Twisselmann 2003). Over the intervening years this has been translated into Nursing practice on the wards by a multitude of protocols at both local and national levels.
Simple hand washing between patient contact, is still regarded as one of the most expedient ways of reducing cross contamination between patients, but is sadly still frequently overlooked as both a nuisance and even a hindrance when in a clinical situation. Some of the more recent National guidelines are encapsulated in the Government White Paper “New Guidelines to cleaner hospitals” published in 2004. This has been augmented by a statement to the House of Commons by John Reid who has announced targets of cutting MRSA infection by 50% of current levels by 2008 (Reid 2004)
One cannot work in the current healthcare setting and not be aware of the high profile that MRSA has attracted. Some may say that it’s profile is disproportionately large when compared to many of the other iatrogenic problems that would come under the umbrella of Nightingale’s original statement. The fact of the matter is that it is not only a matter of patient morbidity and mortality, but it is also a matter of economic sense as well.
A recent study commissioned by the Department of Health (Public Accounts Committee 2000) concluded that Healthcare Associated Infections (HCAI’s) are currently running in excess of 8% of all acute hospital admissions in the UK. The economic cost is further expanded by the fact that a HCAI has the ability to delay discharge dates and thereby increase inpatient costs.
The same study also concluded that “For the NHS in England this represents 3.6 million bed days lost, with a projected cost of £1 billion a year.” and then went on to observe that “Implementation of all the measures suggested by the NPSA would release £147 million and save about 450 lives once target compliance rates have been met.”
We have commented on local initiatives and quote as an example the Epic project that has been run at local level throughout the country which seeks to apply evidence-based guidelines locally for the reduction of various healthcare associated infections. (Pratt et al 2001)
When considering any significant healthcare issue, one should always reflect upon the evidence base that is available to assess one’s own position on the subject (Gibbs, G 1988). Publications in peer-reviewed journals are perhaps one major plank in this evidence base. One must always be alert to differentiate between the weight to be placed upon the evidence in this type of publication when compared to others such as Government pronouncements, bulletins and circulars, unless they are attributed – and most are not – and can therefore be verified.
On the issue of patient cross contamination and handwashing we would commend the excellent tour de force by Boyce & Pittet (2002)
In current nursing practice we can see the modern consequences of many initiatives aimed at reducing the cross-patient spread of infection. The abundance of near-patient handwashing facilities (Donowitz 1997) and antiseptic soap dispensers (Graham 1990) is a testament to this fact as are the modern trend to single use equipment, dressings and aprons etc.
The provision of such facilities are, by themselves, not totally effective as many studies have shown that there is an inherent resistance from some staff to measures as simple as handwashing (Teare 1999) and that additional measures such as poster campaigns and staff lectures produce only transient behaviour changes
(Kretzer et al. 1998)
Another area where there is the clear potential to do harm to patients is the whole area of patient identification. Patients in hospital have investigations and treatments that are potentially dangerous. One hopes that for each intervention a “balance sheet” has been drawn up, which weighs the potential hazards against the potential gains for each procedure. This is fine as long as the procedure is performed on the right patient. If the wrong patient is identified for the procedure then it can have disastrous implications. (Williamson et al.1999)
To give a specific example. Let us consider the case of blood transfusion. This is a very common procedure in our hospitals with many thousands of units of blood being transfused on a daily basis. Despite stringent protocols and guidelines in one typical year there were 197 serious adverse incidents resulting from incorrect patient identification, this included 42 cases of major morbidity and two deaths. (Mayor 1999)
To combat this specific problem (and to illustrate our argument) National guidelines for transfusion protocols have now been advised and should be implemented in all NHS hospitals:
- The patient’s identity should be verified by two members of staff together
- The identification should be carried out at the patient’s bedside
- The identity and quality of the blood pack and the prescription should be formally verified
- The patient’s identity should be confirmed verbally
- The patient’s identity band should be formally verified
- The patient’s blood pressure, pulse, and temperature should be taken before and at regular intervals during the transfusion (as detailed in the committee’s report)
(Clarke et al. 2001).
Many nurses reading this may think that this is already normal procedure and yet studies have shown that patient identification checks were carried out in only 63% of cases – 46% verbally and only 60% against their wrist bands. Even more worryingly, only 25% of transfusion cases had their vital signs recorded contemporaneously. (Clarke et al. 2001).
Although we have used this particular situation to illustrate the possible ramifications of patient mis-identification (or simply poor practice), there are clearly countless other situations where patients are at risk. A typical ward nurse will know the majority of the patients on her ward. The majority of the medical and surgical healthcare professionals will not. (Savulesuc et al. 1998). It follows therefore, that the ward nurse is ideally placed to verify if the patient who is being dispatched to the anaesthetic room is the right one for the operation or appropriate procedure. In this respect the concept of patient advocacy falls heavily on the nurse.
This argument can be broadened further. The majority of medical staff (by virtue of pressure of work and time), can only spend a short time discussing each case with each patient. The ward nurse will typically have longer to discuss wider issues with the patient and may therefore be able to elicit or discover relevant facts which have not been discovered of recorded by the medical staff. The nurse is therefore again ideally placed to act as an advocate for the patient to ensure that relevant facts are brought to the attention of those who need to know (Bryant 2005).
An example might be that a patient had not discussed particular religious beliefs or points of view with the doctor which the nurse may subsequently become aware of. (Kuhse & Singer 2001).
Here then, is the thrust of Nightingale’s message. Hospitals are places that are (generally) full of healthcare professionals who are intent on providing a good professional service for their patients. In the pursuit of that aim they have to employ technologies, medicines and techniques that have the ability to cause harm. This harm can occur through chance, calculated risk or just bad luck, but equally it can occur through bad practice lack of communication or sloppy procedure. It is the latter that the nurse is ideally placed to counter. Professionalism demands that the nurse should speak up whenever such eventualities are discovered. In doing so they can often save accidents, unfortunate events or even disasters from occurring. If all members of the healthcare team follow the same mantra then Nightingale’s edict will become less relevant. (Veitch 2002)
Having said that, it is not a situation where complacency can be allowed any room at all. The healthcare services are extremely complex organisations requiring the combined efforts of many thousands of individuals. The potential for mistakes is therefore enormous. One must always bear in mind that the nurse is generally familiar with the workings and procedures of the health service whereas the patient generally is not. The patient will typically accept on trust what he is asked to do and submit to, without the background knowledge of whether it is actually appropriate to his particular case. It is this basis that is often the scenario for avoidable incidents where harm is done to patients. The nurse must be constantly vigilant for the potential for mistakes in order to minimise the potential for harm coming to the patients in their charge.
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