“Promoting Patient Centred Care in Times of Change – the Challenge for Nurses and Midwives”
Speech by the Ombudsman for Children, Emily Logan, at the Royal College of Surgeons Annual International Nursing and Midwifery Research Conference
I am delighted and honoured to have been asked to address the opening ceremony of the International Nursing & Midwifery Research & Education Conference. I note the Faculty of Nursing at the RCSI is delighted to be celebrating the 30th anniversary of the conference. At a time of such significant political and economic change – at a time when the public sector more generally has been the subject of much criticism, I believe that the nursing profession can be the positive face of the so called ‘transformed’ public sector. Nurses are not powerless – they are the direct link to patients – learning from that interaction every day – and should therefore see themselves not as passive recipients of decision making from above but as active participants of the change that is to come.
By way of background and to place my comments this evening in some context for you I should explain that I began my career in 1982 in paediatrics in Temple Street Children’s Hospital where I developed my long standing interest in health and subsequent interest in social justice for children.
My first encounter of this kind was in A&E in Temple Street Hospital; I was looking after a toddler who was, I was told, an NAI. There was an imprint of a cooker ring on his bottom, inflicted by his parents to stop him crying.
At that time a philosophy of patient or family-centred care had not yet developed. Parents and families were actively discouraged from staying by their childs’ bedside, visiting hours were restricted and the only corner of the hospital that would countenance open visiting was the oncology ward.
It was also a time of significant poverty, social deprivation, exclusion and discrimination. I remember being asked to give a cup of tea ‘to the VHI mother’.
And although we look back with some nostalgia for those days I also know that they were days filled with endless lists of task oriented duties, sometimes fear, where we were not encouraged to challenge but to accept certain practices.
Now I have the honour of being the first Ombudsman for Children in Ireland.
An Office established through primary legislation. It is an enormous privilege and an enormous challenge. I was interviewed for the post by a group of fifteen young people from diverse communities ranging from 11 to 18 years of age. Just three adults participated in the interview process. I was appointed by Her Excellency President Mary McAleese and report directly to the Oireachtas. Sometimes people ask me if I found it difficult to make the switch from nursing to being an Ombudsman for Children. This year’s conference theme of promoting patient centred care in times of change resonates very much with my own role as Ombudsman for Children – like you, I am trying to promote the interests of a group – in my case – children – in times of change. Much of my 23 years experience in nursing relates to my current role. I am working with children, I am working with families, I am dealing with parents who are upset and frustrated by a system they don’t understand. And as a mechanism of last resort it is a little like dealing with people who have been in A&E for a week and now want to vent their upset.
This interaction with the beneficiaries of my work is really powerful and so too should the unique interaction nurses have with their patients. Our office is a national human rights institution. While I account nationally to the Oireachtas, at an international level I report through the UN structures on the progress of children’s rights in Ireland.
So what do I mean by a human rights-based organisation?
The work of our office is underpinned by the principles of the UN Convention on the Rights of the Child.
Stated simply – there are three fundamental principles:
The principle of non-discrimination
The principle of best interests
The right to express a view on decisions affecting them
Ultimately, our work is aimed at building a culture of respect for children’s rights: this means changing attitudes and mental habits, and making sure that the right questions are being asked when we are designing and delivering services to the people we serve.
And while our focus is children the principles of respect and dignity are equally applicable in the adult environment.
One of the principal motivations behind the elaboration of international human rights norms is to find agreement on what needs to be done. There are of course many other rich sources of guidance on what entitlements of individuals and communities are but it is precisely this variety which makes internationally agreed standards so important. Negotiations of diverse peoples with unique legal, philosophical and religious traditions are indeed complex. It is very difficult to develop a common ground between States with very different opinions. Of course such negotiations are subject to the unpredictability of international politics and leads to what are necessarily compromise texts, ones which might have been stronger. However, there is great value in the fact that they are internationally agreed by States because political endorsement can increase compliance with human rights standards. The elaboration of legally binding human rights standards that are widely accepted by the international community play no small part in encouraging a State to progress its human rights agenda.
A rights based approach places an emphasis on individuals or in this context your patients as active agents in securing their rights. This is much more achievable when your patients are adults. Do we ask our patients what they think, do we actively engage with patients to understand what it feels like to loose your autonomy and sense of control over your health?
Healthcare professionals are well placed to advocate on behalf of their patients. They can point to the State’s obligations and argue for improvements. This empowers people, their families and also the professionals working with and for them.
Our office provides an independent complaints handling service in relation to services provided by public bodies to children. The key criterion for any intervention I might make is that a child has or may have been negatively affected by the action or the inaction of a public body. We look at administration and processes and whether a person was treated in a manner that it fair and reasonable.
Often I will hear from families about individuals and the difference they have made to the health experience. For many families this attachment represents trust and confidence that someone hears what they have to say.
An Ombudsman with an express human rights brief is a relatively new concept in Ireland. It is new because in addition to providing the well understood complaints handling service, I am also charged with a statutory mandate to promote the rights and welfare of children. This second, far more wide-reaching and powerful function of the Office affords me great discretion in terms of how we achieve this goal. But rather than bombard you with human rights theory I would like you to go encourage you to think about the application of the basic principles of human rights in a healthcare environment – which can be applied to your theme of promoting patient centred care – put simply – are respect and dignity.
My role, as Ombudsman for Children, is to give a voice to those children and young people who have experienced or who are experiencing difficulties. Many families have contacted my Office because they do not know where else to go for help. I believe that if I am to make a difference that I have a responsibility to place the realities of children’s lives into the public domain and speak out on behalf of those who think that they won’t be believed or are unable to do it for themselves.
Nursing can give voice to their patients, they are more able to represent them and to bridge the gaps between decision makers and patients.
We are all operating in a time of greater accountability but we often only see ‘management’ as those that we account to, we need to develop a culture where we understand that we also account to our patients.
I referred to my own training and how that was a culture of command and control, where practices went unchallenged. Research has the power to challenge practice, to produce evidence for why something should change.
It is imperative that nurses see themselves as contributors to a culture where it is safe for staff to express concerns or to challenge practice.
How are human rights relevant to providing a public service?
The language of human rights can sometimes seem distant from day to day reality, or as something left to the courts and legal debate, but it is ultimately about everyday concerns.
As Eleanor Roosevelt – one of the main architects of the Universal Declaration of Human Rights – once said, universal human rights begin in small places close to home and unless they have meaning there, they have little meaning anywhere. The task of advancing the realisation patients rights is about putting in place the necessary conditions for people to live with dignity and respect. Anyone whose job is to make sure that those conditions are in place for patients is helping to ensure that their rights are respected.
The public service and challenges posed by current situation in Ireland. As with all other sectors of society, those in the public service are facing huge challenges at present.
However, some of the discourse around how the public service operates has been inaccurate and unfair; it is important to challenge the myths and negative stereotypes that abound. Choosing to enter the public service should be a source of pride .
The State has a responsibility for meeting its human rights obligations but it is those in the public service that deliver on this; they are the ones who act on the behalf of our whole society to make sure that we offer children the best we have to give
To summarise I wish to leave you with three main points:
1. Promoting a patient centred approach in times of change
This means changing attitudes and mental habits, and making sure that the right questions are being asked when we are designing and delivering services to the people we serve.
2. Considering how Human Rights can bring about positive change to the public sector.
A rights-based approach places an emphasis on individuals as active agents in securing their rights. Healthcare professionals are well placed to advocate on behalf of patients. .
3. Nursing having the courage to find its own voice. For a long time, nurses have operated in a top down culture that has allowed others to determine the environment in which they work. Nursing needs to find its own voice in a space that is not simply shaped by industrial relations concerns. Nursing needs to find the courage to use this voice in a way that may not always be popular to promote all that is good about the profession, and to speak up for vulnerable patients who have no voice of their own.
ENDS
