Courage is one of the nursing 6Cs
"Courage enables us to do the right thing for the people we care for, to speak up when we have concerns. It means we have the personal strength and vision to innovate and to embrace new ways of working." (NHS England, 2015).
Why should we need courage to come to work? Why do we need to find this strength to do our job? Why do patients have to rely on us to have courage to keep them safe? Being able to speak up, to innovate and implement new ideas should be a way of normality. We should not have to feel threatened, inadequate or ‘the pest’.
I would like to share my experience the other shift. A story of ‘courage’ and advocating for patient safety within a clinical setting.
Working in Black escalation is hard. Working on an acute surgical ward we have elective patients that are booked in weeks in advance, often we have to cancel cases to make sure the flow of patients keeps moving through the hospital. It’s a constant raft of bed meetings and handovers to various managers about who can go home, who is medically fit to move off, why can they go home today, why are they not ready...
Much of the day is consumed by this. It feels like a conveyor belt, laden with sick patients – some will go home but some will slip off the edge. I feel like we are trying to keep everyone moving in the right direction and not to lose anyone down the cracks in the process. So, what happened that shift that made me apprehensive about raising concerns about a patient and their care?
It was 4:30pm. A patient arrives from the emergency department (ED), his NEWS Score was 5. This is a high score and this score has increased since his admission to ED, so this patient was deteriorating.
He was in his late 60s, ordinarily a fit man. A stoic man, who doesn’t like to cause a fuss. He is lying in bed, he has intravenous fluids running. He is pale, he has mottling over his tummy and has a pain score of 8/10. His family is by his bedside compliant and submissive with current plans of care.
He had been admitted to our ward with a perforated duodenum (a hole in the bowel). It is written in the notes, which is barely legible, that this man is for conservative management. This means that there will be no surgical intervention and he will be treated with medicines only while the hole ‘self-repairs’. In my experience as a nurse in this area, these types of perforations do not heal themselves.
What do I do?
Firstly, I assess the patient. I perform an ABCDE assessment. I look at his observations and his fluid chart, his blood results. I take some further blood, along with a venous blood gas.
Collecting numerical data on sick patients is a way of communicating to doctors. As nurses, we see subtle changes to our patient; they may become more confused, more clammy, pale, agitated or ‘just different’. This type of information is difficult to articulate and quantify. So, finding a common language within the multidisciplinary team is vital to ensure your concerns are taken seriously.
After I take the blood, the patients family ask me if I am concerned. I ask them why they have asked this question, as this is not something that relatives usually ask… unless they have concerns too.
The relatives are concerned about the decision not to operate at this point. They see that their loved one is unwell and can see he is getting worse since admission. They feel that they have not been listened to.
I call the surgeon to come and reassess, he is about to go home – but kindly comes up before he goes.
"…but, we are just the peasants…"
This was the response from the family when I asked them what their concerns were. They felt that their opinion was not credible. This made me feel so sad. Even relatives and carers feel unempowered to speak up. This offers little hope for the patient lying in bed. The patient’s wife claims that she is worried sick, she knows that he is getting worse. She feels she is watching him deteriorate in front of her eyes. She wants someone to listen to her and act on her concerns.
The next set of observations show that his NEWS is now 7. He has deteriorated further, despite the patient looking the same.
At this point the surgeon is in the room. He is also assessing the patient.
"...In my view, I think you are a little better Sir."
The patient’s wife looks at me. I look at her. We both know that this is not the case. What are my options?
I agree with the surgeon. Regurgitate what he has explained to the patient back to her and agree with ‘watching and waiting’. This is not advocating for the patient or the family and, on my part, negligent. Losing the trust of a family is a complete failure in care.
I disagree with the surgeon, risking his response to be defensive. By being confrontational, I risk him not engaging with anything I say – especially in front of the patient and relatives.
Once the surgeon is out of the room, I place a medical emergency call. This is within our escalation policy. However, this may damage the relationship we have with our surgeons by going ’above their head’. We have to work together on a daily basis. We need to trust them, and they need to trust us.
I didn’t do any of the above, which is a breach of the Trust's escalation policy. This is a ‘work as imagined’ (policy) and ‘work as done’ is how it actually works. I am aware of what I should be doing but choose to escalate my concerns with the parent team. If I was to place a medical emergency call out now – the surgeon is left with feelings of disempowerment, failure and mistrust. Like I say, we have to work as a team. If the patient was deteriorating quickly, and we were unable to get any help and he was not receiving the treatment then of course a medical emergency call would be placed.
I decided not to agree or disagree. I stated facts. Facts that could not be ignored.
"Patient [X] NEWS score has increased from 5 to 7, his blood pressure has dropped by 30 mmHg, his heart rate is 130 bpm, he has been oliguric but now in the last hour, anuric despite having 4 litres of fluid. His venous lactate remains high. He is deteriorating."
There was a pause. The surgeon looked at me and agreed. We both then made the plan that he would call his consultant and I would get intensive care involved.
The patient went to theatre within the next hour or so. He is recovering well.
There are many themes at play here. Cognitive bias from the surgeon, fear from the surgeon to call his consultant out of hours, fear from asking for help. 'Imposter syndrome' from the nurse – I can’t disagree with a surgeon – "I’m just a nurse". Hierarchy has a place in healthcare but, when looking after sick patients, hierarchy is a huge barrier to escalating that patient to receive the right care in a timely fashion.
Courage was displayed by the nurse (myself) in speaking up to the surgeon. The surgeon showed courage in listening to the nurse and asking for help to his consultant.
We should not need courage to keep our patient safe.