Nursing under the hammer

I am no expert of law. However, by right and the privilege of access to the Maltese laws to the lay public, I may make my voice heard with appropriate technicality to defend my colleagues in the nursing profession.

Acourt case which was made close to my heart deliberated that a nurse was implicated seriously in manslaughter. It is my assertion that the adjudicators cannot fully understand the complex dynamics of patients and multidisciplinary teams and the relative responsibility that occurs on a ward as much as a nurse may understand jurisprudence and its relation to the courtroom – no matter the number of experts consulted.

I must inevitably begin with a thought experiment.

A man is given a knife. He has been appropriately assessed and told he is capable of being entrusted with the knife. The man uses the knife to cut an apple but in a moment of confusion, he hurts himself. Whose fault is it? He who gave him the knife? Despite a ‘goahead’ from his superiors? The assessor? Could he have foretold such a tragic fruition of confusion? The victim? A culprit of his own actions?

May we say it was a faulty system leading to the perfect storm? The catalyst for this tragedy is chaos humanised as confusion. Is it not an Act of God? With the electrical impulses in the brain that caused confusion, comparable to the random nature of alighting strike.

The nurse was accused of manslaughter by the courts on the grounds of not foreseeing all the foreseeable dangers in the environment with relativity to the patients. To foresee everything possible is impossible, especially in the precious time of a nurse. Naturally, needles and sharp objects are obvious dangers and are kept well away with suitable foolproof precautions. However, how can one deem a tray of food to be a danger? To foresee everything is impossible. The patient may fling hot soup at another patient, throw the food on the floor and create a risk of slipping, break the tray and hurt himself, or simply leave it there. The only way for a nurse on the go to eliminate all possibility of danger is to deprive the patient of the tray of food.

I find it necessary to discuss certain unavoidable hazards in my defence, for example, choking. It must be said that even a man perfectly in his senses can choke to death, a confused man increases the risk. As the risk of falls may be tackled by a physiotherapist, the speech language pathologist tackles the risk of choking in challenged patients. The speech language pathologist must unfortunately be my sacrificial lamb in defence of the nurse in this case.

Let us say a patient’s food is to be soft and/or mashed by order of the speech language pathologist as a measure to reduce the choking risk. Well, the question arises as to who must mash the food if it is not soft. Here we must examine in detail the role of the nurse. To begin with, it is, by nature, broad; from scrub nurses assisting in theatre to a general nurse treating a patient with severe flu and wiping his nose. The boundaries of a nurse’s duty are the relation of said duty to healthcare. Wiping a patient’s nose, after all, is an action of infection control, general cleanliness and symptom control. Does food preparation enter this domain?

Let us argue, theoretically, that it does. The current nursing curriculum (both BSc and diploma), as far as I am aware, does not teach about mashing food at all. In short, for safety, it should be a reserved act (i.e. exclusive for a profession). After all, “mashing” is vague. How does one know that a piece of food is mashed to a safe degree? Now, the nursing scope of practice declares that the prerequisite of all care (let us ignore nursing boundaries for a moment) is a high quality of training and education. What’s more, the “act” of care requires appropriate competency certified by a proper legal body. Thus we may conclude that the nurse is incompetent to prepare special food. To further compound this, the Speech Language Pathologist code of practice declares that the ultimate responsibility of management as instructed by the Speech Language Pathologist lies with himself.

I have, on a separate occasion, discussed the practice of constant watch, that is 24/7 observation of a patient who is deemed unfit to be alone, and find it relevant in my arguments. One thing is certain: it cannot be lukewarm. You are either with the patient or you are not. Intermittent supervision of the patient, that is, from time to time, is lukewarm. It is a fallacy. Much emphasis is placed on the technicality, which it lacks, of intermittent supervision. It is an insufficient form of diligence from the beginning. What, then, is unjustly harped on about is this diligence being done insufficiently when by nature it is insufficient and vague to the point of uselessness in the context of the case.

Here, I will show how redundant such a form of supervision is in an acute setting. If, per chance, the patient were to choke, the time between realisation, calling for help, calling for higher help, bringing the crash cart and performing the first aid diagnosis is a very long time when an already fragile life is on the line. And this is assuming the supervisor notices immediately, but from time to time it may be at least five minutes before noticing the distressed patient. After all, how long is “from time to time”?

What may be described as being a “duty not done”, i.e. negligence, in the case is constant watch by order of a superior medical professional. The accusations of ‘bad’ intermittent supervision are a veiled question of why constant watch was not put in place. With constant watch being the duty, not created, the nurse in question, seen responsible for the constant watch, is innocent of negligence as the duty did not exist in the first place.

Thus, I humbly write these series of arguments as a warning to fellow nurses and as an attempt to appeal for better justice to the powers that be.