The Correct Choice Seems Obvious From Where We're Sitting
In August, a security guard at Noida District Hospital in India was filmed filling medication syringes. His security uniform is hardly a nursing qualification, and the footage understandably raised concerns about patient safety. According to the hospital’s chief medical superintendent, a nurse attending to patients during an emergency had asked the guard to help. The hospital subsequently ended both workers’ services.
The guard should have refused. The nurse should have known better. The hospital took action. It is a reassuringly tidy account where all the correct choices were obvious. But obvious to whom, and from where?
What's less obvious in the news article is how far such workarounds extend across the country. A brief search turned up reports from other Indian hospitals, of guards suturing wounds, performing electrocardiogram (ECG), measuring blood pressure, administering injections and intravenous (IV) drips, positioning a patient for x-ray imaging, and giving oxygen to an infant.
Common across these tasks was that a guard became the available pair of hands when a clinical task needed doing. In a few facilities, managers acknowledged relying on guards during busy periods. The superintendent at one of these hospitals even noted that such reliance on guards was as an established response to emergency surges.
It was another fine example of how, when the ward gets busy, work travels down the hierarchy until it reaches someone who can least afford to say no.
Noida District Hospital was also stretched, with just 100 staff nurses and 45 doctors serving a daily load of "around 4,000 outpatient department (OPD) patients and 300 inpatients". About sixty nursing posts were vacant, and support staff were in short supply. Hospital officials estimated that they needed at least a hundred more nurses to meet demand, so filling every vacancy would still have left a gap. It was against this backdrop, the hospital’s chief medical superintendent said, that a nurse attending to patients during an emergency asked the guard to help.
It wasn't clear how the guard understood the request. Did he recognize the risks, or did the fact that a qualified nurse had asked him give him reason to think she’d already weighed them? Had he seen others do the same thing without anyone objecting? And if he had doubts, how easy would it have been, from where he stood, to say no? A fair inquiry would want answers to those questions before deciding what it was reasonable to expect of him.
This is where just culture comes in. Before deciding how to respond to someone’s conduct, just culture asks that we try to understand what they knew, what was expected of them, and what they could reasonably have done. The same questions would also apply to the people with authority over staffing and supervision. What did they expect a nurse to do when several patients needed her at once? Who was supposed to back her up? If staff had already raised concerns about coverage, what happened when they did? The camera that shot the video only gave us an obvious view of the unqualified person holding the syringe.
It is dangerously easy, however, to slip into a series of “he should have known better” and “she should have called for help.” A just culture inquiry may examine the guard’s and the nurse’s choices in minute detail, and leave untouched the decisions about staffing and supervision that shaped them. Just culture can become oddly preoccupied with finding the correct category of person to punish. Give the process a flowchart and a sufficiently reassuring title, and we may feel that fairness has been achieved before the person has finished explaining.
Hospitals should thus speak candidly about the conditions that allowed these workarounds to manifest. When hospitals leave staff with the same pressures and make it harder to speak openly about how they cope, unsafe shortcuts may simply go underground. While the guard and the nurse may have been dismissed, the staff who remain still have a ward to run. They’ll find ways to get through the shift, and some may be riskier than the practice that first came to light.
A hospital can get very good at deciding what to do after someone makes an unsafe choice. Just culture expects that it get just as good at making the safer choice possible for its staff. Give the guard a boundary he can recognize before he’s asked to cross it, and the backing to say no. Give the nurse qualified colleagues so that patients can be cared for without resorting to risky workarounds. With a little luck and a good deal of planning, the right choice might be as obvious on the ward as it has always been from where we’re sitting.
If you were reviewing this case, what would you want to ask the guard, the nurse and the people who ran the ward before deciding what a fair response would look like?
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