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"Essential Nursing Care - Heart of the Matter" (29.11.2006)

Address by Ms Emily O'Reilly, Ombudsman and Information Commissioner at the Sligo General Hospital Conference

Good morning everybody.

I would like to thank you for the invitation to your beautiful county and I would particularly like to thank Mr Michael Shannon, Director of Nursing, for inviting me here today to launch this Conference. I won't deny that I was initially rather surprised to receive his invitation given the publication of my critical report about the events surrounding the death of a patient in Sligo General Hospital some years ago. However, any concerns which I may have had were quickly allayed by Michael who was quick to reassure me that all of the recommendations which I had made in my report had been taken on board, and that I would be welcome at this conference.

Could I say that as a result of that, I have the utmost regard and appreciation for the manner in which Sligo has dealt with the fallout of that report. The wholehearted way in which the hospital went about implementing the recommendations is a testament not just to those involved but also exemplifies the good that can emerge when the Office of the Ombudsman and a public body, such as Sligo General Hospital, work together with just one agenda, to make life - and sometimes death - a much better experience for those that come seeking our help. I intend to use this example in the coming months and years to illustrate all the positives that can flow from that type of engagement.

As Ombudsman, I often highlight shortcomings in service provision and, despite what many may think, I am conscious of the effect these remarks can have on staff morale. No one is immune from criticism, not me personally, not my Office and it takes a certain kind of courage but also a commitment to the overall public good to take those complaints and embrace them as an opportunity to improve the work that you do.

It is inevitable that my Office will be at odds with public bodies when things go wrong, but I am obliged to highlight what I perceive to be certain shortcomings. That, after all, is my job spec. It gives me great pleasure today, however, to acknowledge the tremendous effort which you have made to learn from past experiences and to implement best practice protocols covering a range of areas.

There is nobody at this Conference, including myself, who can say that nothing has ever gone wrong in their office, surgery, ward or hospital. Everyone makes mistakes. The crucial issue is how we react when we make such errors and how we deal with things when they go wrong.

Many complainants who cross my path do so because they want to ensure that service providers learn from their mistakes and that other people do not go through what they did. How often do we hear people saying that. Before I became Ombudsman I thought it amounted to little more than a platitude, a cliché, yet time and time again I am struck by how often people express it and how sincerely they want it to happen.

Financial compensation may or may not be involved. It is my experience that the vast majority of people who complain are seeking an acknowledgement that things did, in fact, go wrong, that they had been unfairly treated, and an assurance that practices will change as a result of their complaint. They need to have the itch of frustration that they feel scratched, they need the more powerful body that did them harm or wrong to own up and say that yes it was wrong and that furthermore they are sorry. Only then can people relax and get on with their lives, satisfied that an injustice has been put right, no matter how small.

Some complaints can, unfortunately, be difficult if not impossible to resolve. I am referring to situations where conflicting evidence has been presented between what happened on the one hand, according to the complainant, and on the other, according to the public body. This is why good record keeping is so vital. It is critical that patient records are written with utmost care - my own view is that if it hasn't been written down then it wasn't done! Good record keeping makes life easier for all hospital personnel using the records - for the hospital administrator in dealing with any complaint and ultimately, for myself if I have reason to include such records in the examination of a complaint. Staff from my Office are always available to assist agencies in the public health sector in developing quality decision-making practices and complaint resolution procedures. Such interactions are usually very positive since we all have a desire to see improvements implemented and a better appreciation of the situation from the complainant's perspective.

Most of you will be aware of the new National Programme " Towards 2016" which sets out an ambitious agenda for modernisation and change in all of our public services, including the health sector. It is crucial for improved health service performance that there is an active willingness on the part of all staff to participate in the examination of current service delivery arrangements. Co-operation with such changes go without saying if improved operational performance is to be achieved.

The establishment of the Health Service Executive has brought about concrete opportunities for a more integrated and cohesive approach to the way our health services are delivered. Earlier this year, I had an opportunity to meet with Professor Drumm and the new senior management team in the HSE. At that meeting, I presented a review of cases which I had compiled relating to the public health and social services sector since I took up office. I suggested that my role could be viewed as that of a critical friend. My vision is that we can achieve a health system that is fair and one which supports and empowers the individual to achieve full health potential.

"Towards 2016" allows us to critically evaluate how services are currently provided, and calls for the creation of an organisational climate that is receptive to change, and open to learning based on past experiences. Change is never easy – it means that we have to examine the manner in which we do business and be prepared to make appropriate alterations so that we can become more effective. It is much easier to bury our heads in the sand and resist new ideas but this is not in our best interests and certainly not good for the people we serve.

The Taoiseach in a recent address on the topic of the future of the public sector stated that society had become "more open, more culturally diverse and more outward looking". He said that we are "redefining our values – what we want for our children, our elders and our communities". In this context, the Taoiseach went on to point out that public service organisations are not passively observing these changes but are actively involved in responding to the additional complexities of modern Irish society and the impact this changing environment has on the delivery of front line services.

I would like to compliment your nursing team for the whole hearted approach you have taken to implementing change in Sligo Hospital. Your efforts in this regard mirror the Taoiseach’s view as to how public sector organisations need to respond to our changing environment.

I have read the Philosophy of Care which was drawn up by the staff working in consultation with the multidisciplinary team. I am heartily encouraged by the concepts behind the philosophy which I understand have been embraced by all members of staff. The words "working in partnership with the patient" and "individuality of care" are music to my ears and are key to ensuring that the patient remains the primary focus in the provision of a quality service. I am sure you will concur with the view that nursing care is delivered to a person, an individual human being, and as such, we all have different needs and expectations. It is how those needs and expectations are met that determines whether a quality service has been provided.

Close to my heart is the issue of dying with dignity and that is why I recommended in my report that protocols should be developed for all staff in relation to treating recently bereaved people with compassion and understanding. I accept that it can be difficult to know how to console a relative who has lost a loved one, and words of comfort can often seem so empty and meaningless. Nevertheless, it is expected that service providers should know how to deliver practical and emotional support and advice to families in the bereavement stage. This is why I recommended in my report that the protocols to be developed could be informed by the features of hospice care which offers sound advice and support to such families.

The Irish Hospice Foundation, through its National Programme - Care of the People Dying in Hospitals - provides an excellent support and constancy service to Irish hospitals seeking to improve the standards of care to all patients. I understand that the nursing team sought and obtained the assistance of the Irish Hospice Foundation under this Programme because your key priority was to change the culture of care in respect of dying, death and bereavement in Sligo General Hospital.

This has now led to the development of standards and policies in the area of death, dying and bereavement and I understand that the North West Hospice has also assisted you in your efforts to bring the ethos of hospice care into Sligo General. The Irish Hospice Foundation has done remarkable work with many of our Irish hospitals through the Care of People Dying in Hospitals Project, and indeed staff from my Office have attended some of the excellent workshops hosted by the Foundation on this subject.

A national survey in 2004 initiated by the Irish Hospice Foundation found that the vast majority of Irish people believe that hospital care for terminally ill patients needs improvement with over 40% believing that hospital care needs urgent and considerable improvement. Two thirds of the survey found that Irish people want to die at home however, the reality is that most Irish people die in hospitals or other care settings. The limitations of the physical environment within the hospital, the shortage of private space, the work pressures on staff at all levels and difficulties with recognising the dying state as a legitimate diagnosis in the acute hospital setting are regarded as significant challenges. There is an urgent need to transform the culture of care and organisation around death and dying in our hospitals, and appropriate policies and practices need to be agreed and developed despite scarcity of facilities and resources.

I am aware that the existing facilities and the physical environment in Sligo Hospital are currently under review in an effort to provide rooms and facilities for breaking bad news to patients and their relatives, and rooms for dying patients. Such facilities are necessary to ensure that patients are treated with the dignity to which they are entitled. By engaging with the Hospice Foundation's national programme, you the staff at Sligo Hospital have helped to ensure that you have in place systems, policies and practices which will enable you to provide the best care possible to meet the individual needs of patients and their families.

Last week I attended and spoke at a meeting of the Irish Palliative Care Association. Much of the discussion that to be with issues around the complex world of palliative medicine and the need to broaden its scope and reach throughout the health system. As part of my contribution however I brought things down to a more basic, yet no less important level, standard end of life care particularly in our acute hospitals. I instanced stories that had been told to me by medical personnel, nurses and directors of nursing mainly, of people dying in noisy wards, of people dying with people on bed pans in the beds beside them, of relatives with no place to go at dead of night for a cup of tea and countless other instances of deaths without dignity.

I am well aware of the resource, infrastructure and other issues involved, yet I have an absolute belief that if the system, at the very top, was seized of the belief, of the absolute imperative that every patient dying in a public hospital was entitled to a dignified death, that that in itself would be transformative. Because if you believe that it is inexcusable that anyone should die without dignity then you will move heaven and earth to ensure that whatever is needed to make that happen will be done.

I am delighted to learn that a Steering Committee has been established which will drive new initiatives in relation to patient autonomy, integrated care, communication skills and dignity and design. Perhaps more importantly, this Committee will ensure that these initiatives are acted upon, and are continuously evaluated within the Hospital itself.

On the subject of communication, I am extremely encouraged to see that all members of staff who have significant contact with dying patients or bereaved families, are currently availing of training opportunities which will enable them to develop good communication skills. My understanding is that this training covers:-

• Breaking Bad News both in person and over the phone;
• Communicating with the dying patient;
• Communicating with families before and after death;
• Communicating with different ethnic groups;
• Handling complaints and awareness of best practice; and
• Organ and Tissue Donation.

These programmes are to be developed and run on an on-going basis, and this will, of course, ensure that new members of staff will receive appropriate training in addition to the ongoing training which is available to existing staff.

A communications protocol has also been developed which highlights best practice in relation to the provision of information to patients and their families, and there is an onus on the Line Manager in each speciality to ensure that all staff working in their area have read and understand the policy and guidelines in operation. In this context, I note that the protocol provides that nursing staff must actively engage with the patient and their families and be pro-active in the communication process. The point had been made to me by the family of the patient who died that they had to instigate contact with the nursing staff, and this lack of communication can often heighten the level of distrust and uncertainty experienced by relatives. The question had also arisen as to why a young medical intern had advised the family regarding their father's medical condition. I am encouraged to note that this area has been addressed in the protocol which states that Senior House Officers and Medical Interns should not be involved in giving information to relatives.

Other important nursing issues which arose in the course of the complaint such as the placing of a fluid restriction notice sign over the patient's bed, and the provision of oxygen to patients have been comprehensively addressed. In addition, I note that a Committee has been established to focus on 11 essential nursing care standards which will be the subject of discussion later today at the Conference.

At this point, I am keen to mention the importance of facilitating health care staff who report lapses in standards or possible risks to patients to their superiors or their peers.

A blame-free, non punitive culture encourages individuals to report errors and truly learn from their mistakes. It also supports organisations in their efforts to better understand how those errors occurred and to take the necessary steps to prevent a reoccurrence. A just working environment assumes that staff providing a high level of care are concerned about patient safety. In this context, could I put before you some observations recently made by Ms Maureen Harding Clarke who led the enquiry at Our Lady of Lourdes Hospital in Drogheda. Speaking recently to a group of Directors of Nursing she exhorted them to accept the responsibility of dealing with issues which they believed to be detrimental to the health and welfare of their patients. She encouraged them to rely on their own inner sense of intuition when they considered that unacceptable lapses in the standard of patient care had occurred. In such situations, she advised them to discuss the matter with trusted colleagues who understood the issue involved, to then commit their thoughts to writing and to again consult with trusted colleagues. Finally, she advised that once the written note was crystal clear it should be submitted to the relevant manager. In this way, the concerns of staff will have been committed to paper and must be dealt with. Clearly, for such a system to work effectively senior managers must show leadership by being willing to address any concerns that are brought to their attention. The recent court case involving a nurse from Naas General Hospital who was convicted of harming two of her patients highlights the importance of staff taking responsibility for their own actions and being alert to those of their colleagues. I believe that people want a hospital service in which they can have confidence, and one which is responsive to them and inclusive of them.

Mrs Justice Harding Clarke, when told by one Director of Nursing of the difficulties in standing up to a consultant, noted, that if a Director of Nursing was afraid to take on a consultant, then there no hope for the health system. Remember those words as you go about your work.

The problem of adverse events in healthcare in not new. The past decade has witnessed a range of publications in leading medical journals documenting serious shortcomings in relation to the safety of patients. The Hospitals for Europe's Working Party on Quality Care in hospitals estimated back in the year 2000 that every tenth patient in European hospitals suffers from preventable harm and adverse effects related to his or her care. There are no comparable studies in relation to Irish public healthcare, but should we expect things to be any better or worse than other European counties? While errors may be more easily detected in hospitals, they afflict every healthcare setting including our nursing homes. As you know, the control of MRSA is one of the biggest challenges facing our acute hospitals and nursing homes today, and hand hygiene is known to be the most effective method of preventing the spread of MRSA. I feel that it is incumbent, therefore, on all staff dealing with patients to ensure that they are familiar with the infection control policies and procedures which are in place in their work area.

Finally, I think it is important that the best practice policies and procedures which you, the staff at Sligo General Hospital have adopted and implemented should be extended to other service providers throughout the HSE who might not have such protocols already in place. There is no need to re-invent the wheel every month. Your efforts will, I am certain, provide considerable comfort to the family of the gentleman whose care was the subject of my report. Currently, there is considerable negativity in the national media about the health service, and I want to publicly acknowledge the comprehensive steps which have been taken in Sligo to rectify past failings in the provision of patient care.

And lastly on a personal note, drawing on my own personal experiences of hospitals, giving birth, watching my father die, visiting various friends and relatives at different times, could I say that there is such a thing as what I call, an unteachable nursing moment. What I mean is that moment of communication between a nurse and his or her patient that cannot be taught, that connot be incorporated into a protocol, but which is often the moment that gives most comfort to the patient, the moment that either they or their relatives will remember long after they have left the hospital. It is perhaps the offer of a cup of tea outside of the routine timetable, a bed bath before discomfort is even articulated, a hand held as the bed is passed by, pillows plumped, a quiet chat as the night starts to settle in. Nurses do what doctors often cannot, they enter that space where fear and pain reside and seek to banish or at least alleviate both. To some nurses perhaps, in their increasingly professional and academically demanding work, such tasks are not seen as core and perhaps that is the professional view. But for every fearful patient it is what they most yearn for, the gifting of a gesture that speaks from the humanity of the person giving it and to the humanity of he or she who gives it.

Thank you.

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