Territorial wars, imaginary boundaries and the patient journey

This blog is personal and some will have a problem with me writing about it, truth is I will probably end up in some trouble for posting this.

For most of my career I have had a foot in two worlds.  One world is inside of a hospital as a highly specialised nurse with the other world being out of hospital as an ambulance practitioner.  These worlds are governed by separate bodies with different regulations and scopes of practise.  The sad part is that these governing bodies do not recognise the other’s training, skills or competencies.

For example as undergraduate nurse I had to demonstrate competency in intubation and I had to demonstrate it again as critical care nurse student.  As critical care nurse and educator I have been involved in training paramedics, medical students and nurses to perform this and other skills.  In one of my previous jobs I was required to demonstrate proof of intubation competency on a yearly basis.  However as ambulance practitioner I am not allowed to intubate a patient as the governing body and ambulance act do not recognise my nursing competency or scope of practice.

Recently…in my private vehicle, dressed for a business meeting I came across a patient.  There was an airway problem and there was equipment on scene to intubate and resolve the airway problem.  No one else on scene was skilled to intubate. Just to reiterate…intubation is a skill that I’m deemed competent to perform, it falls within my scope of nursing practice, I have experience executing the skill and I’ve taught paramedics and medical students to perform it.  The problem was that I was in the wrong territory where none of the before mentioned are recognised… yet I treated the patient based on my nursing scope, competencies and also my conscience.

That I resolved the airway issue and that we could now ventilate the patient, appears to be a non-factor…. a formal complaint was laid against me for treating the patient according to my nursing scope in paramedic territory.  I see the enquiry as a suggestion from my paramedic colleagues that the acceptable patient management would’ve been to continue non-ventilating the patient and as such withhold that fighting chance for survival.  Why?  Because of territory…

The irony is…if I did that, if I managed the patient according to my out of hospital (ambulance practitioner) scope, if I did not intubate, if I disregarded my nursing scope, training and experience, the nursing board would’ve (rightfully) take action against me for negligence.

This territorial fight is not ok; it is not ok to say that a patient should rather die than recognise our colleague’s competencies in our territory.

Healthcare is defined as a series of interconnected processes and the end product which is the healthy patient. Are we nurses and paramedics not bound in this definition of healthcare and in the patient journey? If the reason for the existence of the healthcare system is a healthy patient would it not be in the patient’s best interest that practitioners capable of executing a skill being allowed to execute it based on patient requirement regardless of territory?

There seems to be an absolute conviction that healthcare is territorial and divided.  I believe that healthcare is one.  No function in healthcare can stand alone, and neither should they.  When we fight about territories we create barriers between functions that are dependent on each other. The compelling context that glues us together should be the patient and a shared interest in the patient journey.

In healthcare our governing bodies create the boundaries, these are typically functional boundaries.  In other words the boundaries groups specialised functions together to better manage them.   So the boundary of where we practice is actually arbitrary.  And yet, time and again we find ourselves trapped and our patient care crippled by these boundaries and even worse we allow the boundaries to create territories, that is fiercely protected.  It is so fiercely protected that we start believing that it is fair to withhold life saving measures from patients due to functional territory.

Regardless of speciality, field of practice or board that we belong to, we should never settle for less than the best possible patient outcome within our scope and competency regardless of where we are. Because if we don’t, we fail to understand our interdependency.   How can we not share the one goal of health care which is a healthy patient as outcome?

How can any practitioner be conditioned to think that it’s in the patient’s best interest to let them die rather than allow a competent colleague to practise within their territory? Sounds like sick system….

-x-

Pre-empting comments on scope:  My scope as per the South African Nursing Council. (http://www.sanc.org.za)   

 COMPETENCIES FOR CRITICAL CARE NURSE SPECIALIST (ADULT)

  1. NATURE OF SPECIALISATION

Critical Care Nursing is care of patients with life-threatening illnesses and injuries and it occurs within a continuum from the scene of initial incident or onset of critical illness such as home through stabilisation, transfer/transportation, emergency and intensive care up to and including transfer to care in lower acuity levels/ step down units.

Specific competencies

2.4.3 Executes airway management in accordance with the patients’ needs or state of respiratory failure, e.g. position, anatomical alignment……….. including intubation (oropharyngeal, nasopharyngeal, endotracheal)

2.4.7 Initiates/performs advanced resuscitative procedures informed by the patient’s cardiopulmonary status and technological parameters, using advanced airway management techniques, cardioversion, defibrillation, external cardiac pacing and emergency drugs, among others, as spelt out in the care management tools such as protocols or Advanced Cardiac Life Support (ACLS) algorithm

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Healthcare, the elephant in the room?

This past weekend I attended interesting debates at the Franschhoek literary festival.   Some discussions I attended were around politics. Areas addressed were party politics, opposition parties, political leadership, strength of parties, potential focus areas for political parties. It was insightful and repeated priorities included governance, trust in leadership, economic growth, education, social grants. Well-known names included Max Du Preez, Prince Mashele, Eusebius McKaiser, Salam Badat, Richard Calland, Stephen Grootes and Adam Habib.

I know that none of the above authors/speakers has a focus on healthcare, access to healthcare, health system functioning or potential impact of not having a functional public health sector. However I still find it interesting that there was no mention of health care manifestos or the importance of healthcare as a political tool. Think Obama 2008 and Obama 2014…it even feels strange not to type Obamacare. Affordable health has been a key concept during Obama’s campaign and subsequent presidency. In the USA Healthcare has consistently been in the news and has in many ways been a political driving force.

I agree that education, transformation and economic growth are vital to our country. However I can’t help but feel that healthcare should at the very least share an equal priority with the above and that it deserved mention.

Health systems offer value beyond health and impacts on quality of life, which includes other related factors such as level of income, nutrition, environment, safe water and sanitation. Health systems are widely recognised to be vital elements of the social fabric in every level of society.

We all require baseline health to be economically productive or to attend school. Should we or a family member fall ill we have an expectation that one should not need to spend an entire day at a clinic or an entire month’s income on medication. Our jobs should not be threatened as at it is for some because off spending a day in a queue at a clinic for medication. It should not be disruptive to our daily routine to attend to a clinic for cough medicine. Neither should out of pocket purchases financially ruin us and be unaffordable.

Beyond the debates at the literary festival, analysing the political party manifestos of the six bigger parties for the May 2014 elections the main priority areas across the parties focused on job creation, safety, education, skills development, entrepreneurship.

Yet again healthcare was typically mentioned close to the bottom of the lists and some parties only had a one-liner discussing their views on health care. Is this enough? In 2011 Healthcare was the third greatest expense of the South African government, and yet healthcare is not mentioned as a top priority on the manifestos?

In South Africa healthcare access for all is constitutionally enshrined but we need to consider whether we are failing.

  • We don’t have enough beds for sick people.

The amount of beds per population in the public health sector has declined. In 1986 during apartheid the bed: population for black people was 4.2 per 1000 persons and for white people it was 8.2 per 1000 beds. The current ratio in the public sector is 0.9 beds per 1000 people. When private facilities beds are included it’s only 1.6 beds per 1000 persons. (National Care Facilities Baseline Audit 2013)

  • We have more people and fewer beds. 

The population growth rate in 2012 was 1.2% with an estimated 52 million people living in South Africa. In 1995 the population   was estimated to be 41 million.

  • Health expenditure has not changed.

According to the World Health Organization in 2004 our government spent 8.4% GDP on health. In 2010 our government spent 8.4% of GDP on health. So effectively we might be spending less on health.

  • We have fewer medical practitioners.

Medical practitioners in 1998: 6.7 per 1000 people. Medical practitioners in 2011: 4.5 per 1000. It is estimated that most of them are working in the private sector.

  • Our nurses are old.

According to the South African Nurses Council in 2005 36% of all nurses registered were over the age of 50. In 2013 45% of all nurses registered were above 50 years of age. This is potentially disastrous as these nurses are likely to retire in the next 10 – 15 years.   Only 4% of all nurses registered with the council are under the age of 30. Nursing is just not an attractive career option.

Ignoring the importance of a healthy society seems to be a global trend. Service delivery sectors in Africa received 70% of the foreign direct investment in 2012. However Healthcare investments were not even listed within the top ten sectors to receive investments.

So my question is: is it healthy to ignore health care?