LETTER TO THE EDITOR
Dear Editor,
The article ‘A nurse's duty to warn of risks extends to aftercare as well as initial consent’ in the 8 March 2018 issue of the British Journal of Nursing (Griffith, 2018) admonishes nurses to inform patients during initial consent and discharge education about post-surgical risks to be aware of and actions to take in case of an adverse event. Nevertheless, the author missed the mark by implying that discharge education for patients' aftercare is solely the responsibility of nurses and, in so doing, fails to outline potential solutions for providers on the care team to enhance communication at discharge.
Having the care team involved, especially the nurse and physician, in providing discharge instructions increases the likelihood that all necessary components of discharge education will be discussed. Ashbrook et al (2013) noted that having such comprehensive discharge education can promote patient understanding, is essential to guarantee a peaceful transition from hospital to home, and may abate preventable re-hospitalisation.
As described in Griffith's article, in the case of Spencer v Hillingdon Hospitals NHS Trust (2015), a nurse was grossly negligent when she gave a leaflet on aftercare of surgical incision and cautioned a man to contact the ward or his GP should any concern arise, after surgical repair of his inguinal hernia. The Agency for Healthcare Research and Quality (AHRQ) in the USA designated venous thrombosis or pulmonary embolism after major surgery or invasive vascular procedure as a quality indicator of outcome among surgical patients. It indicated that postoperative patients who receive general anaesthesia are markedly at risk owing to immobility, tissue damage from surgery, and medication. Nevertheless, it was further noted that once thorough postoperative care is rendered such incidences can be avoided (AHRQ, undated). However, the patient in the aforementioned situation was not so fortunate and developed both deep vein thrombosis and, subsequently, a pulmonary embolism in each lung. Therefore, one could conjecture that by neglecting to educate the patient about the risk of blood clots in the veins and disclose its reportable cardinal symptom of calf pain, the nurse is to be blamed for the poor surgical outcome of the patient.
On the other hand, accountability for the safety and quality of patient care outcome should not be left exclusively to the nurse. In a survey taken by physicians and nurses on communicating discharge instructions to patients, researchers found that discharge education was more successful if there was communication on what to provide between nurses and physicians (Ashbrook et al, 2018).
Therefore, in the circumstances in Spencer v Hillingdon Hospitals NHS Trust (2015), if there had been increased communication between the physician and nurse with a focus on patient safety, chances are post-surgery risks would have been relayed in the discharge education. Consequently, the dual physician–nurse involvement in the patient's discharge process may have reduced the occurrence of the adverse outcome.
It is also imperative to make sure that patients comprehend the gravity of their health state, the projected risk and benefits of their treatment and aftercare, adverse reactions that may surface after leaving the hospital, and what to do if they occur (Griffith, 2018). This can be ascertained by the patient voicing understanding of what was imparted and/or a return demonstration. Sehgal et al (2011) proposed that a ‘desirable solution to share discharge education information’ would be ‘a structured format and consistent time for communication that ensures both nurses and physician understands what education needs to be provided and by whom’.
Author's response
Thank you for reading my article and taking the time to comment. The article's focus was on the extent of the duty to warn of risk since the UK Supreme Court's decision in Montgomery V Lanarkshire HB (2015). The doctrine of informed consent is a relatively recent development in UK law with the UK Supreme Court's ruling in 2015, but it is very familiar to US health professionals, such as yourself, as it has formed a fundamental part of health law in the USA since the Canterbury v Spence case in 1972; it is well settled law that, as you suggest, does not need further explanation to US nurses.
The impact and reach of the Montgomery ruling and the move to a prudent patient test rather than the professional Bolam test (1957) in the UK is still being explored in the UK courts, which is why the focus of this article was on the duty of UK nurses.
Team working and strategies for information communication are vital elements of care and treatment but were outside the scope of this article.