All the boxes were checked!
Last week I was among a group of nurses and midwives listening to a report of what was to us, a shocking and sad example of midwifery care.
The reporter was a health professional, a nurse. She was also the mother of the woman who luckily, finally, after a 30-hour labour birthed a baby girl. The story informed us that the parents had in fact presented with a birthing plan for a natural and non-interventionist approach.
Listening to the report of a very prolonged and difficult labour raised the question among listeners as to when it would be expected that a professional should step in and use their knowledge and expertise to assist the mother and limit the risks of foetal distress, which as the labour progressed were evident.
Not being there I am in no position to make judgement but as you can imagine the discussion dissected and examined the report closely. This was only part of the story. The young mother genuinely believed she was going to die and had said she had reached the point where all she wanted was to see her baby before she passed away.
There was damage, a considerable amount of blood was lost and catheterisation and IV’s were in place. The tale got worse. Postpartum this young mother who had only been offered Panadol during this labour was returned to her room with the baby and her husband while still losing large clots and in a state of total exhaustion.
Calls for assistance over the next day or so experienced 3 hour waits until the buzzer was answered. Blood loss continued and it was the husband who undertook assistance to shower and change clothing.
Difficulty with attaching to the breast, large blood clots, and pain were the constant experience of this mother in spite of having both her husband and mother present. It was in fact her mother who undertook the care and education for teaching breast feeding and baby bathing.
The baby was still covered in meconium 24 hours after birth.
The interrogation of the new grandmother by those present was intense. The new parents had participated in antenatal education and planning classes. Their birth plan was a considered plan. They believed in midwifery led birthing. They were, they thought informed and prepared for the experience.
The reality of the first day after birth after such a prolonged labour simply added to the trauma. The amount of support and teaching that would be expected was simply not given. To add to the overall helplessness was the fact that notes left on the bed at time of discharge had checklists for all cares, education, postpartum follow ups ticked off as having been carried out. They were not.
As someone who constantly nags and harps about documentation being the saviour for us faced with a complaint I had to sit back and consider what might be the consequences if someone who made a complaint was faced with a fraudulently completed proof of care. Was there a disparity between what the midwives believed they did and what in fact this young mother heard or was capable of absorbing given her situation? Was it deliberate or ill-considered when all these activities were checked off?
As a listener I could see many areas that were grounds for complaints. Most of us know someone who bears tales about the care of their loved ones and many folk carry anger and dismay about the way they or their family or friends were treated. The closer you are to someone the more intense your feelings and certainly your expectations of the service provider.
Whether a complaint will be lodged is not the point here however. The standard of care on any measure fell short. The extraordinary delays for responding to buzzers were such that family members left the room to seek help and found the staff all “sitting around the desk”.
While opinion and judgements abounded with the hearing of the report, as I say I wasn’t there but I was certainly shocked and distressed on a number of levels hearing such precise and informed statements of failure about my profession. The ripple effect for such negativity about this experience is unmeasurable but there is no doubt this blog is part of that.
The temptation is to yell and point fingers of course, the desire to motivate and correct failures, to prevent future suffering. The question to me is how individuals with specialist knowledge and expertise who have the right to claim they are professionals individually and as a group employed in a specialty area, lacked the will or insight to assess and provide care. We should evaluate ourselves, judge our own actions, be our own critics and take personal responsibility for our work.
If there is a culture of slackness, lack of knowledge or skill, inability to meet needs we are obliged to resolve the gaps. By being our own personal judge and jury we take our professionalism seriously and satisfy our professional standards. None of us would be comfortable finding that observers saw us as inept, inadequate or unsatisfactory. None of us would want to be found so wanting in the performance of our duties.
There are some fabulous webinar recordings by Pam Savage regarding Nurses and the Law on the Nurses for Nurses Network . The Nurses for Nurses Network provides good information and CPD on an array of nursing topics in a range of easy learning ways including webinars and quizzes on the latest information that Nurses need to know – remember the Nurses for Nurses Network was created by Australian Nurses for Nurses ! www.nursesfornurses.com.au