Care to remember? Why it's just common sense.

Those who work with me know that there are topics in health care that I need no encouragement to get up on my soapbox about. The centrality of patients and families, the importance of team working, and the ability to think and act responsibly to influence decision-making are issues central to my professional values base. A further area equally important to me is the fundamental importance of bedside care. In health care delivery, any role, structure or process that does not explicitly contribute to this, is an enigma to me. Clearly, there is much undertaken that is not directly related to clinical work, but that enables clinicians to care through educational, management, clinical support and commissioning activities, to name but a few. However, anything that diverts precious resource (staff, time, money and attention) away from patient care, loses my vote. One of the recent changes in health care that challenges me is the focus and attention on health targets, with the increasing profile of audit and reporting against compliance. Do not get me wrong, I am all for effective service evaluation, realistic solution-focussed planning and meaningful learning from performance. However, there are times where I wonder how some of our current systems and processes improve patient care. For example, infection prevention is clearly an important focus in health care. The public must be assured that when they enter hospitals they will be cared for in safe organisations. The principle of infection prevention is absolutely supportable. What is less convincing is the system that has been put in place to assure this. There is increasing reliance on bedside audit, inspection and documentation, followed by more audit and then root cause analysis. There is such emphasis on these approaches that other aspects of patient care pale into insignificance. Where is the balance? Where is the commonsense? From this position on my soapbox, I have been struck by recent reports from other public sector areas. For example, the tabloids (O‘Neill, 2008) have identified rejection by the police of a target driven, performance management culture where adherence to procedure is seen as paramount. Four police forces in England have returned to a commonsense policing approach enabling use of initiative and discretion, not paperwork, for the benefit of the public. I then found myself reading about a headmaster who, at an Independent School Council conference, criticised health and safety teaching within the educational system as replacing commonsense thought, judgement and personal responsibility (Paton, 2008). Finally, returning to a recent health care survey (Royal College of Nursing, 2008), 88% of nurses perceived an increase in non-essential paperwork in their job over the last 5 years, with little or no access to administrative support. The survey of 1700 nurses demonstrated that band 5 and 6 nurses spend nearly one-fifth of their working hours (7.3 h) on paperwork. What links all these issues together is the growing call for a commonsense approach to work that enables the police to police, teachers to teach and nurses to nurse. So what would happen if critical care staff adopted a commonsense approach to care? Is adopting a commonsense approach as simple as it sounds? Commonsense consists of what most people agree on. A commonsense view is based on the knowledge and experience that most people should allegedly have. Therefore, what is commonsense to you may not be commonsense to me. In the complex health care world we work in, with multiple stakeholder involvement and diverse agendas to be met, identification and agreement of what commonsense is, may not be that easy to achieve. Commonsense may not be that common! Does that mean we should reject all attempts at influencing a commonsense approach to care? I do not believe so, but I think we should accept and embrace that complexity of our working world, understand how it shapes our practice and how we can influence it. Health care organisations have traditionally been perceived as rational, mechanistic systems. However, there is growing debate that scientific management theory with its emphasis on hierarchy and high levels of bureaucracy, will not work for complex unpredictable organisations, such as hospitals (Plsek & Wilson, 2001). Resultantly, a concept gaining increasing profile is complexity-based organisational thinking (Anderson & McDaniel, 2002). Three of the key tenets suggest that