Values, virtues and initiatives—time for a conversation
In the last 10 years or more, there has been a proliferation of “innovations” under the guise of improving patient safety and quality improvement. Service and quality improvements have a dominant focus on small‐scale projects, incorporating locally collected “evidence” and engaging in small “tests of change” usually using PDSA (Plan, Do, Study, Act) cycles that get scaled up across organizations if considered to be successful. Whilst there is much to applaud many initiatives that have happened in improving safety in hospitals (in particular), the questions have to be asked—“how many PDSA cycles does it take to change a culture”? and “how many innovations are needed before practice can be considered safe”? Whilst the intuitive appeal of initiatives to help improve particular aspects of practice is very seductive, when will we realize that these innovations are addressing symptoms and not the cause(s) of an erosion of a healthcare system where person‐centredness and compassion are on everyone's lips but the everyday reality is one of survival? A person‐centred healthcare system has values and virtues at its core—values that focus on ensuring that all persons have their personhood respected and taken account of in service delivery models; and virtues that focus on enabling people to flourish in their roles, in order for them to be the best that they can be in any given situation (Buetow, 2016). In a person‐centred healthcare system, all evidence matters and all evidence needs to play into decision‐making. So, in that regard, the way “initiative‐itis” has taken over nursing and health care is concerning at several levels, but of most concern to us is the erosion of individual personhood of nurses and a pretence that success in making these initiatives work somehow enhances staff flourishing. Take, for example, improving safety during drug‐administration. Are tabards with “Do not disturb” front and back really the best way of improving safety during medication rounds? (is the problem not with the idea of “rounds” in the first place?). Whilst there is some (albeit limited) evidence that these tabards work in reducing drug errors (Scott, Williams, Ingram, & Mackenzie, 2010), the message they give to patients (“leave me alone”) is far from person‐centred and the morally compromising situation in which it places nurses in terms of “caring values” is far from acceptable. So yes, whilst it may give nurses the space to just focus on administering the right drug to the right person at the right time, the consequences of this safety initiative are wide‐ranging and of much greater impact.
In the same vein, the compromising of the virtue of “interdependence” can be seen in other initiatives such as “protected mealtimes”. How ridiculous is the exclusion of relatives from hospital wards during “protected” mealtimes? Surely, if we are committed to person‐centred healthcare systems, then partnership in care needs to go beyond models of consultation and feedback and be genuinely focused on care partnership. It has long been recognized (Lennard‐Jones, 1992) that when it comes to enhancing the nutritional status of patients (particularly older people), hospitals have little to be proud of despite a range of initiatives. We know that mealtimes are interrupted by, for example, the consultant and team arriving for their ward round. Clearly, if patients are interrupted they may eat less and the problem of nutrition in hospital, especially of older people, is an identified problem (SCIE, 2009). However, the problem is not only the interruption, the problem is the nurses who should have the authority and the courage to tell the consultant to come back later, when the patient is not eating.