A chief nurse post typically has the remit of both the leadership of the Trust's Patient Advice and Liaison Service (PALS) and complaints teams, in addition to the professional leadership of registrants. Over the past decade, the issues that have been reported to me for decisions have changed. This is due to a number of reasons, such as greater public awareness of what to expect in healthcare and of how to raise concerns. Workplace culture is also changing, particularly in terms of application of the 2010 Equality Act, and an evidence base from academics such as West (2017) in raising of awareness of the impact of culture on the quality of care that we deliver.
Of interest, the Nursing and Midwifery Council (NMC) is currently trialling a contextual tool to understand the culture that registrants are practising within when incidents have occurred.
The NMC states
‘Our role is to set the standards in the Code, but these are not just our standards. They are the standards that patients and members of the public tell us they expect from health professionals. They are the standards shown every day by those on our register.’
There are a number of areas of the NMC Code for us to consider in this context:
Over the past year when a patient or member of staff raises a concern or complaint, I have asked myself: is this a patient safety issue? I don't mean the obvious complaints or concerns raised that escalate an obvious patient safety issue where physical harm has occurred; I mean in relation to the psychological harm that may have occurred, causing the complaint to be raised. An example would be the use of racist or abusive language.
The World Health Organization (2020) defines patient safety as the prevention of errors and adverse effects to patients. The Care Quality Commission (2015) defines prolonged psychological harm as psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days.
We are increasingly faced with complaints from patients their families and, indeed, staff, in relation to behaviours rather than actual practice that has affected them, and it is critical that we consider a proportionate and systematic approach to handling these.
I was delighted when NHS Improvement published A Just Culture Guide (2018). This updated and replaced the incident decision tree developed by the National Patient Safety Agency. The Just Culture tool aims to support a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.
The tool guides managers through a series of questions that help clarify whether there truly is something specific about an individual that requires support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counterproductive.
The tool aims to help reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly, no matter what their staff group, profession or background.
The guide does not replace the need for an investigation—the aim of investigations is system learning and improvement. However, I am finding it increasingly useful in the absence of any other tool to guide my decision-making around patient and staff concerns. In particular, I find that, as we approach a more formal review of an issue, either via a grievance or disciplinary hearing, that individuals will often share a health issue that they feel contributed to their actions. Once deliberate harm has been ruled out, the next consideration is one of health, and here at an early stage, we are able to broach the subject with individuals around potential health issues that we can support.
As West (2017) suggests, developing cultures for high-quality care is not about fluffy away days, it is about getting under the skin of how we do things around here, in a systematic fair way. In my opinion, the stages of the Just Culture tool are a useful approach to the presenting issues facing senior nurses.