Don’t panic Mr Manwaring…

When I trained as a nurse, I recall the ongoing debate of the ‘theory/practice gap’. In the advent of the Health & Safety turbo-charged steamroller (recently convereted here to run on “Duty of Care” fuel), over the last 20 years or so, I would like to declare the “panic/common-sense gap” our new clear winner.I know I’m not the first to post on this topic, and surely am not the only one to have noticed or take issue with this. However, I am interested in the international perspective on this and will state from the outset, I’ve never seen in-patient healthcare quite so bad as I have where I am for being a Nanny State & Big Brother combined.

Health & Safety will hereafter be referred to as H&S (or UB, for “utter bollox”, depending on context and my mood). I’d like to resurrect the Health & Safety argument (without mentioning the “R” word), and try to consolidate a few ideas on this wonderful ‘guiding principle’ of H&S in modern health care; mostly because today I was accosted by a junior nurse who declared that patient X was kicking a ball in the garden with no shoes on; and what was I going to do about it?

I am sure we are all aware of the wonderful advances H&S has brought to create a healthy and safe working and living environment of our staff and clients. However, when first introduced, I believe there was a UB oversight in not assuring there was an adequately installed braking system applied, and consequently, it has now flattened virtually all of us (except UB officers, who are not allowed to leave their office by virtue of their own work instructions to remain safe at all times).

I have witnessed some bizarre and ironic UB decisions and behaviours over the time (like putting “wet floor signs” in the middle of walkways for people to trip over; not allowing staff to do simple chores because they aren’t ‘trained’ in, say, replacing a light bulb - so you must work in the dark until the electrician arrives or attending a 2 day “food handling course” to butter toast and make tea).

Anyhow, I can just about live with the ones that only make my job harder; it entertains me to call out the plumber on double time to open a cupboard and turn off the stop-cock for a leaking shower.

However, I get a little more agitated when such ‘precautions’ spill over into the patients’ daily living. The event today involved a patient with history of hurting his toe before - and concerns that the family were litigous prompted the nurse in question to seriously consider the fact we had a “duty of care” to instruct (not ask) him to apply some protective footwear to kick a ball. She declared this to be an UB issue that, as senior supervisor, I was responsible for.

Now, having already become a little peeved at this sort of over-restrictive UB practice, I’ve already reviewed some of the legal, professional & ethical parameters that are called into question on such issues. I shall attempt, in educational fashion (so I can use this for my portfolio, of course) to summarise them here.

Duty of Care: The legal garb.

DoC is important when it comes to “negligence”.

Lord Atkin determined that a ‘duty of care’ was similar to the principle of ‘love thy neighbour’:

You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour.

When a service is provided to someone, there is a professional duty of care. This means, as health care workers, we must ensure we maintain a safe and healthy environment for our clients to avoid being “negligent”.

The principles for negligence of duty of care are generally laid out:

1. Was it foreseeable that the action (or inaction) of a particular person or organisation would expose another party to harm or damage?
2. Is there a relationship of ‘proximity’ between the two parties?
3. Is the action or inaction of one party the cause of the other party’s damage or loss?

It is also necessary to recognise the legal principle of volenti non fit injuria, which means “to a willing person, no harm is done”. Essentially, this means, a practitioner is not liable for the damage caused by another person to themselves as a result of action or inaction they took if they knew such act could have led to harm (bearing in mind that mental impairment may be relevant for impaired judgement and insight here tho).

Professionally, my governing body requires me to promote good health. Nowt wrong with that idea. Nowhere though does it tell me I’m supposed to whip and coerce that person into doing my bidding because they choose to make a dodgy decision, and this is for good reason. It’s called the right to self-determination. This is something nurses certainly could do with remembering. It covers a wide range of issues too - like when and what to smoke (let alone ‘if’!); how to spend their own money; what to eat or drink (especially relevant when a diabetic comes on the ward - how many patients have a choice to consume a “non-diabetic” food substance if they so choose?).

Ethically; well, let’s see. On the one hand, I’m meant to protect and preserve the patient’s overall wellbeing. But I’m also meant to support their individuality and recognise their uniqueness. The overall wellbeing doesn’t just mean not breaking a toe either. It might include the sense of feeling like a grown up, perhaps?

As a student nurse I remember my cohort getting 2 wards of EMI patients out to play cricket on a rare sunny warm day. The staff weren’t too impressed. One fella who took a turn at bowling, took a turn at falling over too. Staff began to set in ‘panic’ mode but once he’d tried and found out he couldn’t really do that so well anymore, he modified himself and bowled underarm. Which at 80+ was probably a wise thing.

The recent UK Capacity Act will be an interesting Act to follow in this regard. Proper use of the provisions of this Act may lead to indicate that (even mentally ill) patients can actually make decisions for themselves, about themselves.

I kinda hope it does go that way and isn’t used to simply prove who can’t decide for themselves. In the near future, I hope the “panic/common-sense” divide becomes the battle of the H&S vs Capacity Acts.

I’m interested to know if the UB Act still invokes performance to this extent of idiocy in the international arena. Please, tell me I’m not the only one who suffers this madness?