Conference Report
Warning: Safe care must always come first
Lessons must be learned from UK. Alison Moore reports from INMO conference
Ireland’s healthcare budget
over the past four years has suffered the largest pro-rata cuts
in the shortest space of time
of any OECD country to date,
according to Irish Nurses and
Midwives Organisation general
secretary Liam Doran.
Addressing the INMO conference on patient safety in Dublin
last month, he said: “Wards are
closing around us and nurses
and midwives are being placed
under increasing pressure to do
their jobs with fewer and fewer
resources”.
In a time of financial cutbacks, nurse and midwife
training can be seen as a soft
target but Mr Doran pointed
to the case of the Mid-Staffordshire Foundation NHS Trust
in the UK, where similar cuts
had a disastrous outcome for
patients. The purpose of the
conference was to help members to maintain safe practice,
protect patient care and recognise their accountability within
the current climate. In this environment, Mr Doran said that it
was “more important than ever”
that the patient came first.
The Mid Staffordshire Trust
in England was the subject of
a major statutory investigation
following allegations of high
mortality and morbidity rates
(see www.midstaffsinquiry.
com for more information).
Robert Frances QC, chairman
of the Independent Inquiry
into care provided by the MidStaffordshire NHS Foundation
Trust, concluded in his final
report that “patients were routinely neglected by a Trust
that was preoccupied with
cost cutting, targets and processes and which lost sight of its
fundamental responsibility to
provide safe care.”
18
WIN
Pictured at the INMO ‘Maintaining Safe Practice’ conference were (l-): Manjit Obhrai, medical director, Mid Staffordshire NHS Foundation
Trust; Colin Ovington, director of nursing and midwifery, Mid Staffordshire Trust; Prof Anne Scott, deputy president and registrar, DCU;
Annette Kennedy, director of professional development, INMO; and Mike Gill, associate director, Health RCM Tenon, former finance
director and deputy chief executive, Mid Staffordshire Trust
His final report is based on
evidence from more than 900
patients and families who contacted the Inquiry with their
views.
The Irish public health service has lost
nearly 3,100 nurses and midwives and
2,342 beds have been closed
Lessons
Referring to the Mid Staffordshire case, Mr Doran said
that standards of care fell dramatically as the focus shifted
from patient care to financial
accountability. He warned
that Ireland “must listen and
learn” from the experiences in
the NHS, be mindful that the
clinical needs of patients must
remain the priority and that
nurses and midwives must
continue to repor t unsafe
situations as they arise in Irish
hospitals.
“The Irish public health service has lost nearly 3,100 nurses
and midwives and 2,342 beds
have been closed. However
there is an ever-increasing
demand for healthcare – the
number of people attending
emergency departments has
increased again this year,
the number of out-patient
appointments has increased,
the number of admissions and
day cases has increased and
the number of home visits has
increased – yet demand cannot
be met and waiting lists continue to rise. The stark reality, to
patients and those working in
the frontline, is that our health
service is now under unbearable pressure, standards of care
are inevitably dropping and
patient outcomes are being
compromised arising from
shortage of staff, increased
patient dependency and delays
in accessing treatment,” said Mr
Doran.
…at all times a hospital and healthcare
worker’s priority must be the patient
Dire consequences
Mike Gill, the former finance
director and deputy CEO from
the NHS Trust concerned, told
the conference of the dire
consequences that the policy
of “being on the money at all
costs” had on the clinical outcomes at his hospital.
This focus led to changes in
nursing practice that diminished skill, undermined clinical
leadership and ultimately culminated in raising mortality
rates in the hospital, he said.
The lesson learned was that at
all times a hospital and healthcare worker’s priority must be
the patient and the “big picture
stuff”, and not to be distracted
from this, Mr Gill said.
He told delegates how the
hospital had suffered from a
stagnant nursing service with
very little staff turnover leading
to “institutionalised behaviour”.
The skill mix at the hospital
should have raised a red flag
but it did not: there were no
ward sisters or managers, only
floor managers who managed
many wards. There were no
matrons. In addition, the ratio
of staff was 40% registered
nurses to 60% unqualified
nurses – many of whom had no
Dec 2011/Jan 2012 Vol 19 Iss 10
Conference-Safe practice-AMTH.indd 1
08/12/2011 12:10:42
Conference Report
training to do the job expected
of them.
Due to cost cutting the clinical leaders had been stripped
out leaving the nursing service
rudderless. Another problem
was that known issues were
blamed on lack of record keeping, not a lack of training even
though evidence pointed to the
dearth in both systems management and training.
There was very weak governance, no accountability
arrangements and the hospital also had a culture of
non-reporting due to the pervasive attitude that nothing
would happen anyway, according to Mr Gill.
Colin Ovington, the new
director of nursing and midwifery at the Mid Staffordshire
Trust, was taken on to address
all problems identified by the
inquiry.
Recipe for disaster
“From a nursing point of
view there was a recipe for disaster. Systems of governance
were non-existent – finance
was centre stage at that time.
The line of sight from board to
ward was completely blind – no
one knew what was going on.
There is a lesson to be learned
from Mid Staffordshire,” he told
delegates.
Mr Ovington’s account of
nursing practices at the hospital was brutally honest: “The
staff was not held to account on
what was happening on a dayto-day basis and not just about
what happened in the past.
There was no organisational
learning and care delivered was
unstructured, unsympathetic
and poorly constructed. Standards of practice were undefined
and inconsistently delivered,”
he said.
He outlined some frankly
shocking scenarios of total
lapses in professional standards that he encountered in
his first few weeks at the hospital, illustrating his warning to
nurses and midwives in Ireland
to never accept poorer standards because of work pressures
as it was very easy to become
conditioned to accept lower
standards as being ‘normal’.
His philosophy was that
there is only one job for a nurse,
whatever their role, and that is
to ensure patients are safe and
well cared for at all times. “That
was my job the day I entered
nursing and that is still my job
today. I expect my staff nurses
On the podium at the conference were (l-r): INMO president Sheila Dickson; INMO general secretary, Liam Doran; and Mike Gill, associate
director, Health RCM Tenon, former finance director and deputy chief executive, Mid Staffordshire NHS Foundation Trust
Michael Shannon, nursing and midwifery services director, HSE; Manjit Obhrai, medical director and Colin Ovington, director of
nursing & midwifery, Mid Staffordshire NHS Foundation Trust
WIN
Conference-Safe practice-AMTH.indd 2
to know that this is their job.
I expect my ward sisters, the
matrons, all of the nurses to
know that this is their job. The
key thing to remember is that
without patients we don’t have
jobs,” he said.
Leadership
Leadership, or the lack of it,
was a major issue facing Mr
Ovington at the Trust, both in
causing the initial problems and
in attempts to address them.
Many of the leaders had been
lost due to the focus on finance
and when he arrived at the hospital Mr Ovington said that he
saw very little potential among
the existing staff. He spoke of
what were known as appliance
nurses – nurses who have little
interest in their job but “work to
buy appliances”.
Countering this ethos is one
of his major aims but he recognised that the nurses and
midwives in his hospital had
become very disillusioned and
downtrodden and a major
part of his job would also be to
build esteem and encourage
professionalism.
“For me, what motivates professional employees is going
to be crucial. Speaking with
them about the detail of what
is going on with patient care,
being present in their care
environment, going on their
wards, seeing what is going on
first hand is crucial. It’s how I do
my business. I operate an open
door policy, I expect people to
use that open door and they
do. It took them a while to get
used to that notion but they are
using it very strongly now,” said
Mr Ovington.
He hopes that the staff will
begin to feel more inspired by
what he is trying to achieve.
“Creating a new culture is going
to take a lot of trust and I have
to ask myself regularly, why
would they want to trust me?
They trusted a previous director
of nursing and look what she
did,” he said.
Communication is pivotal
Dec 2011/Jan 2012 Vol 19 Iss 10
19
07/12/2011 14:24:00
Conference Report
in achieving trust and getting
ideas and investment from the
staff about things they want to
do.
“Giving them permission to
try things out in a way that they
had been stopped from doing
in the past; to know that they
can try things out without fear,
safely and with my support and
not necessarily have to wait for
a new policy to be created is
crucial” stressed Mr Ovington.
“I created a professional
forum in the hospital for the
ward sisters. It only happens
once a quarter. We have a full
day out together as a group of
senior nurses in the hospital
with the matrons and some of
the practice development team
that we have in the trust. We
are using that forum to gather
their thoughts around a nursing strategy, to think about how
the vision of nursing should be
in the organisation, how we
can work together to drive that
vision forward.”
Regardless of the financial
pressures, everyone must heed the
findings of the inquiry in England
and we must all ensure that patient
care is never demoted to second
place
New legacy
Creating a new legacy for the
Trust is another aim: the existing
legacy is absolutely “atrocious”
and not one that Mr Ovington
plans to leave behind him.
“That’s why I am motivated. I
am motivated by good things,
I am motivated by things that
go wrong and I am motivated
to see patients get a good deal
out of the system and I have no
intention of leaving my career
with a legacy like Stafford and
its history.
“I am leaving my career
knowing that Stafford has been
fixed. By doing that it will create
confidence in the community
to realise that there is good
20
WIN
stuff going on in the hospital.
I don’t think you have to work
on reputation, you have to work
on giving good care to patients
and then the reputation will
begin to take care of itself,” Mr
Ovington said.
Compassion
Mr Ovington explained the
emphasis he places on compassion at the Trust.
“I need to see compassion.
What I could not understand
was how there were nurses
on my wards who trained at
the same time as I did, in the
same system, so why had they
allowed those standards to slip?
Why could I see the lack of compassion and they couldn’t? I still
haven’t found the answer to
that and I’m not sure I ever will
but for me the art of compassion is a crucial thing. “
He stresses this with the thirdyear students at the hospital. “If
they don’t like what they are
hearing from me, I make it very
clear to them: do not apply for a
job at my hospital”.
A clearly emotional Mr Ovington told delegates that this has
been “the toughest job” of his
career: “It has tested me, it has
brought me to tears, and yet it
is the proudest job to have in
the world to be at Stafford. “
If he is successful in his aim
to restore pride in nursing care
while raising standards in his
hospital it will certainly be a job
well done.
Warning
Perhaps the final words on
the conference should be those
of Mr Doran, who issued a stark
warning to those who make
decisions on hospital funding:
“The experience of Mid Staffordshire must be heard and
understood by our Minister, our
government and senior management in the HSE. Regardless
of the financial pressures,
everyone must heed the findings of the inquiry in England
and we must all ensure that
patient care is never demoted
to second place.”
Attending the conference were (l-r): Diana Walsh, INMO member, and Claire Mahon,
INMO Executive Council member
At the conference were (l-r): Miriam Wiltshire, management consultant, and
Janice Smyth, director RCN, Northern Ireland
Sheila Dickson, INMO president, and Prof Anne Scott, deputy president and registrar, DCU
Dec 2011/Jan 2012 Vol 19 Iss 10
Conference-Safe practice-AMTH.indd 3
07/12/2011 14:24:33