Editor-in-chief SHANE CUMMINGS argues that when tragedy occurs in the health system, it is tempting to blame individual health professionals, but with a system mired in compromise, expectations on good patient care may need to be re-evaluated.
Yesterday, it was reported in the New Zealand Herald that the names of four Auckland health professionals – three nurses and a doctor (the latter now deceased) – involved in a coroner’s case have had their name suppression overturned. The four health professionals (and an unnamed doctor) were named in a coroner’s report into the 2009 death of 22-year-old Zachary Gravatt, who died at the height of the swine flu pandemic from meningococcal C bacteria.
According to the Herald story, there was medical evidence at Coroner Brandt Shortland’s inquest that the true cause of Mr Gravatt's infection could have been detected sooner had there been regular recording of his vital signs, especially his blood pressure. The coroner placed the emphasis on a failure of the system rather than one of personal, individual failures.
Coroner Shortland’s name suppression orders were overturned on appeal by High Court Justice Whata, who agreed with the coroner’s emphasis on systemic failure and said it "strongly mitigates" any adverse impact of the facts of the case on the individual health workers' reputations.
Sure.
Mr Gravatt’s family have applauded the decision for greater transparency. Parents Lance and Jenny Gravatt are quoted as saying, "it's the last dignity that those who cared for Zachary can give him after he's died – to ... put their hand up and say, 'I was part of the team that looked after Zachary on the day and it didn't work out how we would have wanted it to work out and for that, we are sorry'."
Young Mr Gravatt’s death is unquestionably a tragedy, and my sympathies go out to his loved ones.
But this case opens a dangerous precedent for health professionals. Accepting responsibility for sentinel events is one thing, but this decision feeds into a public perception that health professionals are expected to ‘own up’ to mistakes caused by the flaws in the system – flaws that are generally beyond their control. The spirit of this perception is echoed in the Gravatt family’s words above. Every time a diagnosis is missed, should a nurse or doctor be publicly outed?
Assigning blame
There’s a fine line between blaming a chronically underfunded health system and blaming individual workers for such tragedies. 'Naming and shaming' individuals is not the answer to a system that is bulging at the seams.
In fact, Mr Gravatt’s father, Lance, said it was not his intention that the health workers be publicly named and shamed. However, in the quest for justice, I can understand his desire to have a face held to account rather than a faceless institution.
My grandparents, only in their 60s when they passed away, died from systemic failures. My grandfather died of septicaemia (blood poisoning from a bed sore) and my grandmother contracted meningitis during a short stay in hospital (following a fall at home) and subsequently died. I understand the need to hold someone responsible. If an investigation had been conducted into either case, individual failures may have been pinpointed – were adequate infection control measures in place? Were patients checked on as regularly as they should have been? The list could go on and on.
Individual nurses and doctors could be held to account, but should they?
The New Zealand health system has been moving away from a ‘name and shame’ approach. There are a number of reasons for this. The most significant is the understanding from DHBs and others that systemic pressures can lead to mistakes that can’t be blamed on individual staff members.
Just as importantly, people are driven by emotions. The very act of being 'named and shamed' could conceivably compromise the level of care a health worker can provide. It’s an emotional stigma that person will carry with them throughout their career. Even the most professional nurse cannot stay 100 per cent focussed on quality patient care when a coroner’s inquest hangs over their head or if public slurs stain their reputation.
Understanding the pressures
New Zealand’s health system, like most in the world, is chronically underfunded. Health is a huge burden on the economy, and with the population ageing and contracting more long-term lifestyle-related disease, the future looks dim for our capacity to meet health demand in decades to come. The Government could spend its pennies on health or other nationwide priorities like education (which is suffering its own set of nightmarish systemic failures), transport, or social security. Therefore, health gets a large but ultimately limited slice of the budget pie.
Fiscal pressure is a constant in our hospitals and care facilities.
As a case in point, Hutt Valley DHB staff were recently asked to save $5 per day to help reduce a $2.3m budget blowout, with the background of multiple job losses across the DHB and neighbouring Wairarapa DHB (which are gearing up for a merger).
It is a massive challenge for nurses on the frontline to do the job they trained for, the calling that drives them – to care for patients to the utmost of their ability – while juggling their administrative responsibilities in a system that restricts them, not supports them. How would you save $5 a day on a ward with twenty critically ill patients, a colleague away on sick leave, and just one or two other nurses available to help?
The pressure on nurses comes from every corner.
There is the demand for excellent, mistake-free care from patients and their families. This should be a given.
There is the pressure to do more with less. This is often the area that gets dropped at the expense of improving patient care. How many times has a nurse gone the extra mile to help a patient when the bean counters have said they shouldn’t? How is it that a DHB such as Hutt Valley blew out their budget by so much? It’s not because they’re flushing money down the toilet like an irresponsible corporation. There are no corporate perks like box seats at Westpac Stadium, no free lunches. It’s just the boring stuff like employing more nurses or running a diabetes prevention education programme.
The final pressure on nurses comes from the nurses themselves. They want to do the very best job they can. They want to help people. It sure as hell isn’t about the money or the glamour. In the tug-of-war between patient care and the constraints of the system, the biggest losers are idealism, optimism, and job satisfaction. Nurses want to help people, but sometimes they can’t. Sometimes they’re too busy meeting competing demands to monitor every patient when they should.
The way forward?
The business of nursing (and medicine) inevitably results in failures. Adverse patient reactions and death are an unavoidable part of the job, even when nurses do their absolute utmost. There is no such thing as a 100 per cent success rate.
Nowhere are the stakes higher than in the health system. Every day is literally a life and death struggle. Should our nurses need to apologise anytime their best isn’t good enough, given the constraints they find themselves under?
I’m not making excuses for nurses and other health professionals who make mistakes. We all make mistakes. It happens. But in a system that is inherently built on compromise, perhaps the general public need to re-evaluate their expectations?
Perhaps we the general public should reframe our expectation of health workers from ‘100 per cent infallible’ to ‘doing their best within the constraints they have’?
Will that work for most people?
If not, then the best way to manage a system that fails patients like Mr Gravatt is to consider what is most important in our society and how to fund it appropriately.
It’s about time we as citizens gave thought to our ‘must haves’. I think 100 per cent infallible medical care would be at the top of the list for most people. Schools, roads, and pensions are all important things, but at the end of the day, I’d rather drive around a pothole or do a little home-schooling with the kids than lie sick in a hospital bed wondering if my nurse will be too busy to check on me.
The blame here lies with where we as a society place our importance. It is the apathy of the majority that allows tragedy to slip through the cracks.
If more people lobbied their local politician and demanded more funding for our health system, then we would see a fundamental shift in how our nurses and other health professionals do their jobs. The pressures from administrators wouldn’t be there, so nurses could excel in providing excellent care. Patient would expect – and receive – care that was free from systemic failures.
Perhaps patients like Mr Gravatt would be alive today, and his care-givers – who did their best within the constraints of a flawed system – would not feel named and shamed when they were trying to help?
More coverage:
Click here to read Nursing Review's coverage of the health sector's reaction to the High Court decision.
