El antígeno O está involucrado en la interacción innata de B parapertussis con los

This research has highlighted the importance of how a nurse responds to a genuine “terrible mistake” who often hold up their hands and adopt the principles of professional duty of the candor with their employer. It was important to embrace the disclosure of errors requires a culture that promotes professional courage, while recognising the potential for multiple actions at multiple levels across the organisations. Non-punitive or open culture policies recognised

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that multiple reasons may cause an error (Tocco and Blum, 2013; Institute of Medicine, 1999), including human factors. Ullstrom et al (2014) reports that their research highlighted a lack of organisational support or unstructured and unsystematic support. Without support or sufficient feedback, the health-care professional will find it difficult to emotionally process the situation and reach the opportunity of disclosure and closure (Ullstrom et al, 2014). This was reflected by participant 6:

“I think that’s a big step for people, a learning curve to realise when you went wrong, look at making improvements, think right, I can see now. Maybe they didn’t at the time, their judgements were clouded…you investigate that. Actually saying sorry, it’s such a big thing

for us, as an employer. Acknowledge it, learn from it, move forward” - Participant 6.

NHS England have committed to the principles and practices of Human Factors to optimise human performance. It has been recognised that a deeper understanding of the behaviour and conduct of people, and their interactions with others in complex healthcare environments, is needed (NHS England, 2013). It is more commonly recognised that delivering current healthcare can result in people, teams and the organisation being under great pressure (HEE England, 2015). Nurses work in unpredictable and dynamic situations with an expectation of making difficult decisions. At times, decision making can be compromised which impacts on the patient experience and quality of care, performance of the nurse and others.

There is a responsibility for the nurse when caring for their patients, to tell the truth about an error, even when they may run the risk of professional vulnerability. There may be a fear of the repercussions, disciplinary action, and an emotional reaction to the error by the employer (Pereira, 2009). Even though some nurses are relieved when they do report an error to their employer (Christensen, 1992). Peyrovi et al’s cohort study reveals that nurses prefer not to report their errors because of the stigma and damage to the professional reputation (Peyrovi et al, 2015). However, many nurses accept responsibility and blame themselves for serious- outcome errors (Meurier, 1998). It is essential to act after errors are reported, with interventions aimed at protecting the welfare of patients (Robinson Wolf and Hughes, 2008). However, the “second victim” (P9) may be the nurse who can experience emotional distress following a genuine mistake (Ullstrom et al, 2014). Ullstrom et al (2014: 325) state that this “distress has been shown to be similar to that of the patient, the 'first victim”’. Ullstrom et al (2014) report that the impact on the healthcare professional is dependent on the healthcare organisation’s response to the mistake.

4.7.2 “Breach of the Code”

Nurses and Midwives have a professional responsibility to adhere to the Code (NMC, 2018). This research has revealed employers will refer to the Code if a nurse fitness to practise is in

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question. Aligned with the publication of the Duty of Professional Candor (GMC and NMC, 2015) explaining that every healthcare professional must be open and honest with patients, colleagues, employers and relevant organisations when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. The Duty of Professional Candor highlights that healthcare professionals must: tell the patient when something goes wrong, apologise, offer an appropriate remedy or support, and explain the short and long term effects of what has happened.

There has been national, political, and legislation drivers to ensure health-care organizations and their employees to embrace an open reporting culture (Berwick, 2013; NHS England, 2015). Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 has been published with specific requirements for health-care organisations to follow if there is a concern about a patient’s care and treatment. The Care Quality Commission can prosecute for a breach of parts 20(2)a and 20(3) of this regulation by embedding Human Factors principles within its assessment of how safe, effective, caring, responsive and well-led organisations are; with a particular focus on developing just and open cultures (NHS England, 2015).

4.7.3 “Just under the radar”

The Department of Health (2006: 82) report that healthcare professionals may find their practice called into question yet for “an overwhelming majority, an episode of sub-standard performance will not spell the end of their career,” illustrated in table 19. However, this is not reflected by participant 4’s experience who explains multiple events leads to a possible dismissal:

“There was a clear issue about capability and also performance in there. So you might have multiple events that lead to … the sort of accumulative effect of potential, level of dismissal” -

Participant 4.

It is important to reflect on other disciplines who manage the risk of underperforming people. For example, in Australia, the National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA) (2016) state that identification and management of human factors is critical for the effective and reliable minimisation of risk. NOPSEMA (2016) state that by understanding those human factors which influence employees, responsible parties are able to implement targeted solutions to improve human reliability and reduce error. In healthcare, a number of factors can induce an error in the workplace; this can be at individual and organisational levels but with the appropriate intervention the majority of nurses will continue in their roles. However, if these factors are poorly managed and the environment

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was fraught with obstacles, there is a likelihood for things to continue to go wrong or a pattern of repeated errors. Participants described concerns which mirrored the guidance document published by Department of Health (2006) and National Patient Safety Agency of low level concerns, illustrated in the table below.

Table 19 Handling Concerns about the Performance of Healthcare Professionals: Principles of Good Practice

It is evident it is everyone’s responsibility to ensure patient safety and the protection of the public. The Department of Health (2006) states that effective and efficient performance procedures should aim to maintain the quality of the service and ultimately protect the welfare of the nurse. Yet Manojlovich’s (2005) study found that nursing leadership helped to explain 46% of the variance in nursing practice behaviours overall. This was identified by participants who highlighted the significant role of a Nurse Leader.

“There are others (registrants) who have been poorly performance managed and with a lack of courage perhaps or a lack of robustness …because it does happen if you’ve got weak ward managers or weak team managers, and then that pattern of behaviour which is allowed

to fester, leads to a further transgression which is a more serious nature” - Participant 18.

“So I think there’s something about people not being confident about dealing with poor performance” - Participant 17.

Handling Concerns about the Performance of Healthcare Professionals: Principles of good practice Concerns about performance may relate to:

Low standard of work, for example, frequent mistakes, not following a task through, inability to cope with instructions given

An inability to handle a reasonable volume of work to a required standard Unacceptable attitudes to patients

Unacceptable attitudes to work or colleagues, for example, un-co-operative behaviour, poor communication, inability to acknowledge the contribution of others, poor teamwork, lack of commitment and drive

Poor punctuality and unexplained absences Lack of skills in tasks/methods of work required Lack of awareness of required standards Consistently failing to achieve agreed objectives Acting outside limits of competence

Poor supervision of the work of others when this is a requirement of the post A health problem

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Performance management triggers the factors that may place a nurse at further risk of repeated unwanted behaviour. This performance management involves establishing the personal mitigating factors, education and training needs, alongside environmental and systemic issues. On occasion, the nurse’s characteristics are factored into the performance management review of the evidence following repeated incidents, such as identifying “she was a bit odd and she is a bit strange and do you remember that incident and that incident” (P4). A number of participants commented on the strength of the leader to follow up on concerns if a nurse was performing “just under the radar”. It is apparent employers adopted Braithwaite and Ayres’ (1992) model of “responsive regulation”, frequently referring to the strategies of open dialogue to support an early career nurse but recognised that the managers need support too, discussed in the Chain of Expectations chapter. Best practice advocated the “person taking action should be of appropriate seniority and experience with access to appropriate clinical and human resources advice” (DOH, 2006: 13).

“It’s about talking about the competence of the individual to be able to do whichever job it is they are employed to do” - Participant 17.

However, Maxfield et al (2008: 149) explain that health-care professionals “frequently recognize error, poor judgment, or incompetence in colleagues, yet it is extremely rare that they confront the person involved in the error, or report it to supervisory personnel.” Instead, a nurse whose performance or conduct is “just under the radar” may be highlighted by a “patient complaint”.

4.7.4 “Patient complaints”

By reflecting on the history of nursing in Florence Nightingale’s view, good nurses were good people who cultivate certain virtues or qualities in their character (Bradshaw, 2011). As Nightingale reiterated in letters to probationer nurses, it is what the nurse is inside that counts, “the rest is only the outward shell or envelope” (Nightingale, 1859 a; 1859b). Therefore, good interpersonal skills, the ability to communicate and interact with people from a variety of backgrounds are an important part of nursing. They form the foundation of the nurse-patient relationship. Peplau (1999: 13) considers nursing to be a “significant, therapeutic, interpersonal process, defining it as a human relationship between an individual who is sick, or in need of health services, and a nurse specially educated to recognize and to respond to the need for help”.

In this study, the participants explained how the ability to form human relationships influenced the patient’s feelings towards the nurse influenced by the nurse’s character traits, for example lack of social and communication skills. It is apparent this increased the patient’s nervousness and enhanced their perception of the nurse’s lack of competence, knowledge and skill,

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compared to the “friendly” nurse described by participant 6. This is discussed in the “characteristics and values wanted and unwanted in nurses” chapter.

“(She would) just do the obs(ervations) and walk off. And some patients would say, they don’t want her, don’t let her near me…So they obviously picked up that she didn’t have the

skills, they didn’t feel safe with her. She didn’t talk to them” - Participant 5.

Reinertsen and Clancy (2006) argue that when patients entrust themselves to nursing care, the nurse makes two implicit, but important, professional promises: nurses promise to do everything possible to help them; and while they are going about that task, they promise not to hurt them.