Care to remember? Why it’s justcommon 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, clin-

ical support and commissioning acti-

vities, 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 report-

ing 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 organ-

isations. The principle of infection pre-

vention 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 iden-

tified rejection by the police of a target

driven, performance management cul-

ture where adherence to procedure is

seen as paramount. Four police forces

in England have returned to a common-

sense policing approach enabling use of

initiative and discretion, not paper-

work, 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 com-

monsense thought, judgement and per-

sonal 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 demon-

strated 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, teach-

ers 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 experi-

ence 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 tradi-

tionally been perceived as rational,

mechanistic systems. However, there

is growing debate that scientific man-

agement theory with its emphasis on

hierarchy and high levels of bureau-

cracy, will not work for complex unpre-

dictable organisations, such as

hospitals (Plsek & Wilson, 2001). Resul-

tantly, a concept gaining increasing

profile is complexity-based organisa-

tional thinking (Anderson & McDaniel,

2002).

Three of the key tenets suggest that

• relationships and interactions

within complex adaptive systems

are more important that the ac-

tions of individual units that

make up the organisation;

• a simple set of rules, rather than

detailed policy and guidelines are

used;

• organisational change is achieved

not through challenging resis-

tance, but through highligh-

ting attractors to change and

identifying factors and skilled

change champions to facilitate

development.

EDITORIAL

ª 2008 The Author. Journal Compilationª 2008 British Association of Critical Care Nurses, Nursing in Critical Care 2008 • Vol 13 No 5 223

Can complex adaptive system con-

cepts assist our understanding in how

to shape practice? Does it make com-

monsense? Some wholeheartedly may

say ‘yes’ because it fits their world view.

Others may not be swayed by its claims

of addressing perceived limitations of

traditional approaches and have con-

cerns about its scientific underpinning

and evaluation. While an exciting and

challenging concept, I would like to see

more work on how practitioners can

use this approach in the world of

everyday practice. For example, using

complex adaptive system thinking to

explore identification and utilisation of

a simple set of rules to guide practice,

rather than become overwhelmed by

a mountain of protocols. Staying in the

here and now – what do I want to see

change? What seems at odds with

commonsense practice?

For me, there is a commonsense

point that surely must be recognised:

systems do not create safety or perfor-

mance, competent people do. As

a result, effective compliance with

infection prevention measures results

from engendering a culture to support

staff to take responsibility for, and

empower, their own practice. This is

achieved through effective clinical lead-

ership, resources for education and

professional development, team collab-

oration and supportive infrastructure.

There is a need for audit and evalua-

tion, but it requires reprioritisation

within the total care management

resource to enable greater time to care

for patients and families, teach others

to develop bedside critical care skills

and support development of practi-

tioners and clinical leaders.

So, as I climb off my soapbox, I

challenge you to consider this – what is

commonsense caring to you? What

would your practice look like? What

would you change and what would

you wish to keep? More importantly,

how would patients benefit? Think

back on all those coffee room conversa-

tions, those night duty debates that you

have ever had with colleagues – what

did you say then? And then when you

get your wish, how could you cham-

pion the change? What would you

need to sustain the change? This is

your personal invitation to step onto

your soapbox..

Maureen Coombs

Consultant Nurse Critical Care

Southampton University

Hospitals Trust

Southampton

UK and

Senior Lecturer

University of Southampton

Southampton

UK

E-mail: maureen.coombs@

suht.swest.nhs.uk

REFERENCESAnderson R, McDaniel R. (2002). Managing

healthcare organisation: where profession-

alism meets complexity science. Health Care

Management Review; 25: 83–92.

O’Neill S. (2008). Top police boycott official

paperwork. Times online; 31 May 2008.

http://www.timesonline.co.uk/tol/news/

uk/crime/article4036339.ece (accessed 4

June 2008).

Royal College of Nursing (2008). Nurse

spend more than a million hours every

week on mountain of paperwork, says

RCN. Royal College of Nursing; http://

rcn.org.uk/newsevetns/press_relseases/uk/

nurses_spend_more_than_a_mill (accessed

4 June 2008).

Paton G. (2008). Head: why health and safety is

dangerous. The Daily Telegraph; Thursday 5

June, p. 11.

Plsek PE, Wilson T. (2001). Complexity, leader-

ship, and management in healthcare or-

ganisations. British Medical Journal; 323:

746–749.

Editorial

224 ª 2008 The Author. Journal Compilationª 2008 British Association of Critical Care Nurses