1. Would Roshan’s liability be increased if she was a third-year student nurse, only a few weeks from qualifying?

It is reasonable to expect a higher level of knowledge and skill from a third-year student nurse than that of a first-year student, but Roshan remains unqualified at this point. In consequence, the professional standard (i.e. the Bolam test) does not apply and will not come into play until she has been admitted to the Register. It should be emphasized, though, that this standard applies on the first day that Roshan qualifies and no allowances are made for inexperience (see Wilsher v Essex AHA [1988] 1 All ER 871 [HL]). The reasons for this are that every patient is entitled to a reasonable standard of care from every qualified nurse, regardless of their length of service. The moral of this story is that every nurse should ensure that s/he is competent before undertaking any task, and should be supervised by an appropriate senior colleague until this competence has been achieved.

2. If the healthcare institution looked after small children, people with severe learning disabilities, patients with reading difficulties, or blind people, what purpose would be served by a wet floor warning sign? What other measures would one expect to be in place?

The simple answer to this question is that a warning sign would only be of use if the people to whom it is addressed can read and understand it. Clearly, it would have no such value to the groups mentioned here, but the healthcare institution retains liability for their safety. Under the Occupiers Liability Act 1957, it is stated that an occupier (in this case, the healthcare institution) ‘must be prepared for children to be less careful than adults’ (s2 (3)). By logical extension, the same extra precautions are expected for other groups of people where the risk of harm is reasonably foreseeable.

The form that these precautions take may be context- and situation-specific, but at the very least the area where the floor is wet should be cordoned off so that it is difficult (if not impossible) to enter it. Ensuring that only small areas of the floor are made wet at any one time will go some way to reducing the risk. Similarly, if it is possible to dry the floor immediately (rather than merely allow the moisture to evaporate), this too will eliminate the hazard. Perhaps most importantly, the area should be closely monitored by a member of staff while it remains a hazard so that patients or visitors can be given an appropriate warning whenever they approach it.

Nobody should be under any illusions that this is going to be easy, and it probably represents one of the most advanced skills required of a nurse. Equally, when performed well, it can be extremely rewarding. The first step must be to attempt to establish a rapport with Joe so that he develops trust in you. The nurse should therefore talk to Joe in a calm reassuring manner, using simple straightforward language. It is also vitally important that Joe is listened to whenever he speaks, for this will give some clues to what is distressing him and what he would like to do. The expert on communicating with Joe, of course, is going to be his mother, and she will be in the best position to tell you what works, what does not work, and what certain behavioural patterns exhibited by Joe might mean.

Beyond this, there are several communication aids that are available to assist with this process. Perhaps the best known of these is Makaton, which is internationally recognized and which uses speech, signs and symbols. In addition, there are a variety of software applications that have a large library of photosymbols. Needless to say, these aids all require the training of staff before the latter can be considered competent to use them, but enhanced communication with Joe will go a long way to reducing his anxiety.

For those patients sectioned under the Mental Health Act 1983, legal protection against prosecution in the criminal courts or litigation in the civil courts is afforded to healthcare professionals who physically restrain them ‘unless the act is done in bad faith or without reasonable care’ (s139). Similarly, the Mental Capacity Act 2005 acknowledges that restraint may be necessary for incompetent patients, provided that it is ‘a proportionate response’ (s6). No definitions of ‘reasonable’ or ‘proportionate’ are provided and it would be unfair to expect that they would be, given that each situation will be unique. Nevertheless, we could perhaps say that the level of restraint to be applied should be the minimum necessary to achieve the desired objective.

The Royal College of Nursing (2008: Let’s talk about restraint: rights, risks and responsibility) outlines a variety of measures that have been employed to restrain patients, including physical, mechanical, chemical and psychological methods. The key point to remember here is that they should only be used as a last resort (i.e. when all other strategies have failed), and that they should not be allowed to develop into the norm. The Department of Health (2008: Code of Practice: Mental Health Act 1983) states that restraint ‘must never be used as punishment or in a punitive manner’ (para. 15.8), and the best interests of the patient should always remain the top priority for healthcare professionals. The RCN (2008) goes on to say that ‘... a combination of well-considered environmental features and a workforce that has developed person-centred care reduces the need for inappropriate restraint’ (p4), and this should be the ultimate goal for nurses.

If you felt very strongly that the quality of care on a ward was unacceptably low, to whom should you report this?

Questions of this nature reflect an overlap between the concepts of Confidentiality and Whistle-blowing. There is a duty to report concerns about the quality of care, and the individual who does nothing simply becomes implicated in the wrongdoing. Equally, however, it is important to tell only those who have the means and ability to correct the situation. This does not, therefore, mean that the press or the public should be the first recipients of this information. It is a matter of some debate as to who should be the first point of contact. Ideally, I feel that this should be the manager of the ward, for it is the more open and honest approach. However, the position of the whistle-blower remains a perilous one and you can quickly be branded a trouble-maker if this situation is not handled with sensitivity (despite the fact that the Public Interest Disclosure Act 1998 gives protection to those who are victimized as a result of disclosing information in the public interest). In consequence, it may be preferable to involve your personal tutor. It is reasonable to assume that healthcare institutions should give more attention to such concerns following the publication of the Francis Report (2013) into the scandal at Mid-Staffordshire NHS Trust, but there are no guarantees of this. In consequence, it would be advisable to keep records of any correspondence that you have sent or received concerning this matter. In this way, you will be able to show that you have done all that you could reasonably be asked to do.

If a patient had severe learning disabilities and no relatives, would a breach of his or her confidentiality cause him any harm?

A patient with severe learning disabilities lacks autonomy and is therefore unable to enter into a relationship of confidence. Similarly, it is extremely unlikely that any harm (psychological or otherwise) will be experienced by this patient if his medical details are divulged to others. Nevertheless, every patient has general privacy rights, and such rights extend to children, the unconscious, and the dead. In consequence, if information is to be divulged, it will be justifiable only if:

1. It is in the patient’s best interests.
2. The information is limited only to those who have a need to know and who are therefore in a position to serve those interests.
3. It is the minimum necessary to serve the patient’s interests.

The legal penalties for breach of this patient’s confidentiality seem unlikely, but disciplinary measures remain a strong possibility and healthcare professionals should be mindful of this.

Do you think patient confidentiality is more a myth than a reality?

What can be done to ensure that patients’ medical details are kept safe while ensuring there is good communication between the individual careers involved? How will this promote holistic care of your patient?

Given that healthcare today is a multi-disciplinary team effort, it is inevitable that patients’ medical details will be seen and shared with a large number of people. This is necessary to ensure that appropriate and optimum care and treatment are given, but it puts the concept of confidentiality into perspective. The fact that all healthcare workers (whether qualified or unqualified) are bound by a contractual duty of confidentiality may not be sufficient to allay patient fears or anxieties. Nevertheless, not only is there an individual responsibility to uphold confidentiality, but also every NHS organization has a corporate responsibility in this regard. The Caldicott Report (1997) clarified this responsibility by enjoining NHS organizations to uphold the following principles:

1. If confidential information is required, there should always be a justification for this purpose.
2. Patient-identifiable information should only be used when it is absolutely necessary.
3. When patient-identifiable information is required, only the minimum necessary to achieve the desired purpose should be used.
4. Access to patient-identifiable information should be on a strict need-to-know basis.
5. Everyone who has access to this information is under a duty of confidence.
6. Everyone should understand and comply with the law.

Assessments of compliance with this process are made on an annual basis and Trusts are expected to show year-on-year improvements. This alone should demonstrate the seriousness with which the NHS approaches patient confidentiality and how complacency is to be avoided.