Ebook PDF Critical Conversations For Patient Safety An Essential Guide For Health Professionals PDF

(eBook PDF) Critical Conversations for
Patient Safety: An Essential Guide for

Health Professionals
Visit to download the full and correct content document:
https://ebooksecure.com/download/ebook-pdf-critical-conversations-for-patient-safety
-an-essential-guide-for-health-professionals/
CRITICAL CONVERSATIONS FOR PATIENT SAFETY
This book illustrates the link between patient safety and
communication and focuses on key areas where ineffective
communication results in adverse patient outcomes.
It is written in an interprofessional way with experts representing a
wide range of disciplinary perspectives.
The real-life patient stories and critical thinking activities profile

authentic scenarios that will cause you to re-examine your personal
beliefs and professional behaviours.
CRITICAL CONVERSATIONS
Importantly, this book will help you to develop critical conversation
skills that are fundamental to safe and patient-centred
clinical practice.
FOR PATIENT SAFETY

A N E S S E N T I A L G U I D E F O R H E A LT H P R O F E S S I O N A L S
edited by Tracy Levett-Jones

“In my view, all who read this book, whether student or health professional, foreword by Bruce Barraclough AO
edited by Tracy Levett-Jones

will be stimulated to reflect on their own performance in order to improve their
critical conversations and the care they give their patients.”
Bruce Barraclough AO
Copyright © Pearson Australia (a division of Pearson Australia Group Pty Ltd) 2014—9781486004270—Levett-Jones/Critical Conversations for Patient Safety 1e
CVR_LEVE4270_01_LT_CVR.indd 1 10/09/13 11:48 AM

vii
Contributors
Ms Deborah Armitage, BN MN
Clinical Nurse Consultant Older Person Acute Care, John Hunter Hospital
Dr Penny Barrett, RN RM PhD MEd BEd (Nursing), FACN
Mental Health Specialist, Warner’s Bay Private Hospital
Ms Katja Beitat, MA Communication and Media Science, M International Business and Law
Senior Communications Officer, NSW Health Care Complaints Commission
Dr Jane Conway, RN, BHSc, (Nursing), B Nurs (Hons1), Grad Cert HRM, Grad Dip FET, DEd
Health Workforce Development Consultant, Conjoint Associate Professor, The School of Nursing
and Midwifery, The University of Newcastle.
Dr Anne Croker, PhD, BAppSc (Physio), GradDipPubHealth
Post Doctoral Research, University of Newcastle Department of Rural Health, Northern NSW
Adjunct Research Associate, Education for Practice Institute, Charles Sturt University
Dr Jim Croker, MBBS, FRACP, GradCertPaedRheum
Rheumatologist, Visiting Medical Officer and Director of Physician Training (Tamworth Rural Referral
Hospital), Conjoint Senior Lecturer (University of New England)
Ms Jenny Day, RN, Ass Dip Community Health Nursing (Occupational Health), BHSc (Nursing),
MEd (Adult Education), PhD Candidate
Lecturer, The School of Nursing and Midwifery, The University of Newcastle
Dr Tania De Bortoli, BAppSc (Speech Pathology), BA (Hons) PhD
Sessional Lecturer Charles Sturt University, Private Practitioner
Ms Helen Buchanan, MSc BHA; RM RN Grad Cert Clin Ed,
Refugee Programs Coordinator, Northern Settlement Services
Associate Professor Owen Carter, DPsych BA (Hist.) MSc (Pub. Hlth.)
Research Director, Office of the Pro-Vice-Chancellor (Health Advancement), Edith Cowan University
Associate Professor Jared Dart, BSc BA MBBS PhD
General Practitioner, Researcher and Health Management Consultant
Associate Professor, School of Medicine The University of Queensland
Chief Investigator, NHMRC Centre for Research Excellence Quality and Safety in Integrated
Primary/Secondary Care
Ms Kim Elkovich, RN, BAppliedS, Post Grad Dip Psych,
Sessional Academic, The School of Nursing and Midwifery, The University of Newcastle,
Self Employed Consultant–A Higher Self Pty Ltd
Mr Wayne Farmer, B Clinical Sc, B Chiropractic Sc, Ass Dip Health Sc
Resolution Officer, NSW Health Care Complaints Commission
Emeritus Professor Cindy Gallois, BSc MA PhD FASSA
Faculty of Social and Behavioural Sciences, University of Queensland
Dr Conor Gilligan, PhD, B.BiomedSci (Hons)
Senior Lecturer in Health Behaviour Science, School of Medicine and Public Health, The University
of Newcastle
Dr Miriam Grotowski, B.Med, FRACGP, DipPsychiatryED
General Practitioner, Tamworth; Conjoint Lecturer The University of Newcastle
Professor Colleen Hayward, DipTch B Ed B Sc Grad Cert (Cross Sector Partnerships)
Pro-Vice Chancellor (Equity and Indigenous), Edith Cowan University
viii critical conversations for patient safety
Associate Professor David Hewett, MBBS MSc PhD FRACP

Head, Phase 2 MBBS Program, University of Queensland
Ms Jacqueline Hewitt, RN, Grad Cert Emergency Nursing, Masters Advanced Practice Nursing
Clinical Nurse Consultant, John Hunter Hospital
Professor Isabel Higgins, RN, RICN, AssDipNurseEd, MN, PhD
Professor of Nursing, Older Person Care, The School of Nursing & Midwifery, The University of
Newcastle
Clinical Chair Centre for Practice Opportunity and Development, Hunter New England Local Health
District
Dr Kerry Hoffman, RN, BSc, Grad Dip. Ed., Dip. Health Sc., MN, PhD
Lecturer, The School of Nursing & Midwifery, The University of Newcastle
Dr Graeme Horton, MB BS MEnvStud GDipRural FRACGP FARGP
Senior Lecturer in Medical Education and General Practice, School of Medicine and Public Health,
The University of Newcastle
Dr Carolyn Hullick, Bachelor of Medicine UON (B Med Hons) Graduate Diploma of Paediatrics
UNSW, Fellow of Australasian College for Emergency Medicine (FACEM)
Senior Staff Specialist, Division of Emergency Medicine, John Hunter Hospital
Professor Rick Iedema, PhD (Usyd)
Professor, Director, Centre for Health Communication, UTS
Associate Professor Ashley Kable, PhD, RN, Dip Teach Nurs Ed, Grad Dip Health Service
Management
Deputy Head of School (Research) School of Nursing and Midwifery, The University of Newcastle
Professor Tracy Levett-Jones, PhD, RN, MEd & Work, BN, DipAppSc (Nursing)
Director of the Research Centre for Health Professional Education, Deputy Head of School
(Teaching and Learning), The School of Nursing & Midwifery, The University of Newcastle
Dr Lesley MacDonald-Wicks, BHS(N&D)Honours, PhD, GCTT, AdvAPD
Senior Lecturer, Nutrition and Dietetics, School of Health Sciences, The University of Newcastle
Professor Elizabeth Manias, RN CertCritCare BPharm MPharm MNurs PhD FACN(DLF) MPSA
MSHPA
Professor, Melbourne School of Health Sciences
Professor Sian Maslin-Prothero, RN, RM, DipN, CertEd, MSc, PhD
Professor of Nursing (Clinical), Edith Cowan University and Sir Charles Gairdner Hospital
Dr Daniel McAullay, BSc, MAE & PhD
Manager Population Health, Aboriginal Health Council of Western Australia
Dr Jonathan Mould, PhD, MSc, RSCN, RGN, RMN, Adult Cert Ed
Senior Lecturer and Simulation Coordinator, School of Nursing and Midwifery, Edith Cowan
University
Professor Eimear Muir-Cochrane, BSc (Hons) RN, Grad Dip Adult Education MNS, PhD
Credentialled MHN
Professor of Nursing (Mental Health), School of Nursing and Midwifery, Faculty of Health Sciences
Flinders University
Professor Kim Oates, MD DSc MHP FRACP FRCP FAFPHM
Director of Undergraduate Quality and Safety Education, Clinical Excellence Commission, Emeritus
Professor, Sydney Medical School
Mrs Deb O’Kane, RN, ENB603 GradDip CN MN Grad Cert HE
Lecturer (Mental Health), School of Nursing and Midwifery, Faculty of Health Sciences, Flinders
University
contributors ix
Dr Sue Outram, PhD, RN, BA

Senior Lecturer, Discipline Lead, Health Behaviour Science, School of Medicine and Public Health,
The University of Newcastle.
Ms Lorinda Palmer, MN, RN, BSc., Dip. Ed, Grad Dip (Nurs), PhD candidate
Ms Victoria Pitt, RN, MNur (Research), Grad Dip Nurs (Pal.care), Grad Cert Tert Teaching, Dip
ApSc (Nursing), PhD candidate
Professor Dimity Pond, BA Dip Ed MBBS FRACGP PhD
Professor of General Practice, School of Medicine and Public Health, The University of Newcastle.
Dr Rachel Rossiter, D.HSc, RN, MN (NP), M.Counselling, B.Counselling, B.HlthSc
Senior Lecturer, The School of Nursing & Midwifery, The University of Newcastle
Professor Cobie Rudd, PhD, MPH, BHlthSc(N), RN
Pro-Vice-Chancellor (Health Advancement), Edith Cowan University
Ms Robin Scott, MClinSc (MentalHNurs) RN(AP) MACN, MACMHN, CPMHN(C)
Clinical Nurse Consultant, Rural Critical Care Emergency & Outreach Mental Health
Associate Professor Moira Sim, MBBS, FRACGP, FAChAM, PGDipAlcDrugAbStud
Head, School of Medical Sciences, Edith Cowan University
Stephen Spencer, B Nurs (Hons), RN, PhD Candidate
Clinical Nurse Specialist, John Hunter Hospital
Catherine Stoddart, BSc (N), MSc (P.M.), MBA, PhD Candidate
Chief Nursing and Midwifery Officer, Department of Health WA and WA Telstra Business Woman of
the Year 2012
Dr Teresa Stone, PhD, RN, RMN, BA, M Health Management, GradCert Tertiary Teaching
Professor of International Nursing, Yamaguchi University, Faculty of Health Sciences, Japan
Dr Natalie Strobel, PhD, Postgrad Dip Clin Ex Sci, Bsc
Collaborative Research Network Research Fellow, Office of the Pro-Vice-Chancellor (Health
Advancement), Edith Cowan University
Ms Diane Tasker, B(Phty), PhD Candidate
Private Physiotherapy Practitioner, Mountain Mobile Physiotherapy Service
Professor Jill Thistlethwaite, B.Sc MBBS PhD MMEd FRCGP FRACGP DRCOG
Professor of Medical Education, Director of the Centre for Medical Education Research and
Scholarship, The University of Queensland - School of Medicine
Ms Anna Treloar, MA MPHC RN
Lecturer, The School of Nursing and Midwifery, The University of Newcastle, MHNIP Nurse at
Integral Health, Armidale
Associate Professor Pamela van der Riet, PhD, RN, MEd, BA Dip ED (Nursing), ICU/CCU cert
Deputy Head of School, The School of Nursing & Midwifery, The University of Newcastle
Ms Jeannette Walsh, MHSc, BSocStud, MAASW
Violence and Abuse (Adult) Prevention Program Co-ordinator, Child, Youth, Women and Families
Health, South Eastern Sydney Local Health District
Dr Carla Walton, B.Sc (Psyc), D.Psyc (Clin), Grad Dip Adult Psychotherapy, MAPS
Senior Clinical Psychologist, Centre for Psychotherapy, Hunter New England Mental Health Service
Dr Bernadette Watson, BA (Hons.) PhD
Senior Lecturer, School of Psychology, University of Queensland
Professor Anne Wilkinson, Ph.D., M.S.
Professor and Cancer Council WA Chair, Palliative and Supportive Care
School of Nursing and Midwifery, Edith Cowan University, Perth Australia
x critical conversations for patient safety
preface
A landmark study undertaken in Australia identified that between 10 per cent and
16 per cent of patients are harmed whilst receiving healthcare and that at least 50 per
cent of these adverse events are preventable.1 The Quality in Australian Health Care
Study, as it became known, transformed our understanding of patient safety. In another
significant study examining sentinel events in healthcare settings communication
errors were implicated in over 70 per cent of cases.2 Health professionals, along with
the general public, were justifiably asking ‘how could this be?’ and ‘what is being done
about it?’. It was against this background that the idea for Critical Conversations for
Patient Safety was conceived.
Healthcare is increasingly complex; this complexity coupled with inherent human

performance limitations, even in experienced, skilled, and committed health
professionals, means that errors will inevitably happen. However, patient-safe
communication and effective teamwork can help prevent these errors from becoming
consequential and harming patients.
It is critically important that health professionals have well developed interprofessional

communication skills, the capacity to create environments in which individuals can
speak up if they have concerns, and that they share a common ‘critical language’ to alert
team members to potentially unsafe situations. Equally important to safe healthcare
are effective therapeutic communication skills, a commitment to patient-centred care,
and the ability to recognise patients who are vulnerable and at particular risk of harm
from poor communication.
Critical conversations
The etymology of the word conversation means to share, inform, unite and participate.
It refers to the imparting or interchange of thoughts, opinions or information by speech,
writing or other forms of communication. In healthcare a ‘critical conversation’ is one
that signals the need for immediate attention, addresses a situation that has (or could)
cause patient (or staff ) harm, or that focuses attention on practices or processes that
call for improvement. In essence a ‘critical conversation’ is a communication interaction
where important information is shared or an interchange of thoughts or opinions
occurs, and that serves to unite health professionals and the recipients of healthcare to
achieve one common goal – improved patient safety and wellbeing.
1 Wilson, R. et al. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia,
163, 458–471.
2 Joint Commission. (2004) Sentinel Events Statistics, in Leonard, M., Graham, S. & Bonacum, D. (eds)
The human factor: The critical importance of effective teamwork and communication in providing
safe care. Quality and Safety in Health Care. 13: i85–i90.
preface xi
The kaleidoscope
The image of a kaleidoscope has been used as the cover design and as the recurring
visual theme throughout this book. A kaleidoscope is a mystical instrument that guides
scattered and diverse pieces into a harmonious whole. The kaleidoscope is the perfect
metaphor for this book as Critical Conversations for Patient Safety brings together a wide
array of diverse disciplinary perspectives and authentic patient stories to create a rich
and patterned literary whole. The images illuminated by a kaleidoscope are constantly
shifting and this is reflective of the evolving and complex nature of contemporary
healthcare. Lastly, a kaleidoscope depends upon reflection to create the symmetrical
and nuanced images. In Critical Conversations it is the reflections of patients, authors
and readers that bring the final work to life.
In writing this book our intent was to stay true to the vision of interprofessional
collaboration. In doing so over 50 health professionals and academics from different
disciplines and different contextual backgrounds came together to write the chapters.
What became apparent is that despite the differences in our professional roles and
experiences, it was the commonalities between our views and our commitment to safe
and effective patient care that dominated. We shared many understandings about ‘what
mattered most’ and you will see these echoing throughout the book. Patient-centred-
care, working in partnership with patients and families, respect, reflective practice,
self-awareness, and valuing other professions . . . these concepts and more resonated
with each of us and are integrated throughout Critical Conversations. Importantly, the
content of each chapter is grounded in and informed by the authors’ contemporary
research in the fields of communication and patient safety.
Patient stories
Stories define:
Who we are.
Where we have come from.
Where we are going . . . and
What we care about.
Stories give life!

Dana Winslow Atchley III, artist, storyteller and musician, 1941–2000
This book presents a montage of real patient stories. A montage combines several
contrasting textual images to make a composite picture and creates the sense that
images and understandings are blending together, overlapping and forming a new
creation. In a montage, different voices, perspectives and points of view are presented.
Montages presume an active reader who constructs interpretations that build on one
another as the stories unfold.
xii critical conversations for patient safety
Stories or narratives provide the building blocks of the montage. Narratives are stories
that relate the unfolding of events, human action and feelings.3 Although stories vary
in form, they are ubiquitous, and storytelling is one of the oldest and most significant
of human activities.4 It is in the telling and hearing of stories that people disclose and
make sense of their own experience, as well as that of others.5 Narratives compel the
reader to ‘brood’ upon or ‘dwell with’ the story. The stories included in each chapter
of Critical Conversations are designed to bring the book to life and illustrate the key
learning outcomes. Pseudonyms have been used for most of the stories except where
permission has been given.
We have juxtaposed positive and negative stories throughout the book. Like a
silhouette, the darkness and shadows created by negative stories provide a contrast to
the illumination cast by the positive stories profiled; each provides greater clarity and
insight into the meaning of the other.
We hope you enjoy reading Critical Conversations for Patient Safety. More importantly
we hope that it helps you to develop the critical conversation skills that are fundamental
to safe and patient-centred clinical practice.
Tracy Levett-Jones and the ‘Critical Conversations’ writing team
3 Muller, J. (1999). Narrative approaches to qualitative research in primary care. In B. Crabtree &
W. Miller (eds), Doing qualitative research (2nd ed., pp. 221–238). London: Sage.
4 Rubenstein, R. (1995). Narratives of elder parental death: A structural and cultural analysis. Medical
Anthropology Quarterly, 9(2), 257–276.
5 Churchill, L. & Churchill, S. (1982). Storytelling in medical arenas: The way to self-determination.
Literature and Medicine, 1, 73–79.
xiii
How to use this book

While there is no one way to read this book here are some suggested approaches. Start
with Chapter 1, it will help you to understand the relationship between patient safety
and communication and how critical conversations can make a difference. Chapter 2
outlines the key attributes of patient-safe communication and Chapter 10 the key
attributes of therapeutic communication. With the foundation knowledge from these
chapters you will be ready to explore the other chapters. Scan the list of contents
selecting the topics that interest you most, that you are currently studying, or that you
have encountered in your clinical practice. If you are studying, your educators may
recommend certain chapters as part of your course work.
Learning outcomes and key concepts are listed at the beginning of each chapter to
provide clarity and focus. They orientate you to what you will learn and help you to
transfer your learning to new clinical situations.
Suggested readings and web resources are provided at the end of each chapter for
you to extend your learning.
Critical thinking activities and guided reflection questions encourage you to

maximise your learning. The activities are designed to help you think broadly, critically
and creatively about what you have learned and, most importantly, how your learning
will inform your practice.
Educators can use the chapters, patient stories and critical thinking activities in multiple
ways – as stimulus materials prior to or during tutorial activities or online learning;
as a stimulus for self-directed learning, assignments, or for continuing professional
development activities. Additionally, a number of the patient stories provide approp
riate preparatory activities for simulation sessions and can also be used as a framework
for the development of simulation scenarios or role plays. The reflective thinking
activities can be extended upon and contextualised by adding specific questions that
align with subject or program objectives.
‘Something to think about’ sections and text boxes provide helpful links, hints, advice,
and critical thinking questions.
A glossary of terms is provided on page 244.
xiv
Acknowledgments
Firstly, I would like to acknowledge and offer sincere thanks to my wonderful writing
team. Their commitment to patient safety and patient-centred care, along with their
broad range of experiences and insights bring every chapter to life. Their contributions
have resulted in a book that will inspire, motivate and engage health professionals and
students alike.
Next I would like to thank the expert clinicians, academics and students who reviewed
the book for accuracy, authenticity and relevance. Their insights were invaluable.
Finally, thank you to the editorial and production team at Pearson, including Mandy
Sheppard, Acquisitions Editor; Sophie Attwood, Editorial Coordinator; Janet McKeown
Copyright and Pictures Editor; Caroline Stewart, Production Controller; and Felicity
McKenzie, Copy Editor.
Reviewers
Melanie Carstairs, Bachelor of Nursing Graduate, The University of Newcastle
Madeline Jones, Bachelor of Physiotherapy student, The University of Newcastle
Tyler Jones, Bachelor of Nursing student, The University of Newcastle
Peter Sinclair, Lecturer, The University of Newcastle
John Wormington, Solicitor, McDonald Legal Pty Ltd, Charlestown NSW
Sandra Campbell-Crofts, PhD Candidate, University of Tasmania
Professor Cobie Rudd, Pro-Vice-Chancellor (Health Advancement), Edith Cowan

University
Renee Brighton, Lecturer and PhD Candidate, University of Wollongong
Professor Kerry Reid-Searl, Assistant Dean Simulation, CQUniversity
Sharon Laver, Lecturer in Nursing. Deputy Program Leader (BN), Charles Sturt
University
Georgina Neville, First Year Coordinator and Associate Lecturer, Griffith University
Dr Gilly Smith, Senior Lecturer, Edith Cowan University
Sue Dean, Lecturer, Faculty of Health, University of Technology Sydney
Professor Eimear Muir-Cochrane, Chair of Nursing (Mental Health), Flinders University

and Adjunct Professor University of South Australia
Penny Paliadelis, Associate Professor and Dean of the School of Health Sciences,
University of Ballarat
Dr Sharon Bourgeois, Associate Professor, University of Wollongong
xv
foreword
Contemporary clinical practice is extremely complex, involving the appropriate use of
science and technology in a team environment. But the diagnosis and management
of patients also depends on clinical judgment that is influenced by the verbal and
nonverbal cues received while taking a history, undertaking a health examination and
providing care. Clearly, effective communication is vital.
While most health professionals regard themselves as good communicators, and

many are, much of the interchange between professionals and between professionals
and patients or families does not meet the required standards. The healthcare
safety and quality literature clearly identifies that deficiencies in communication
are a common root cause of much harm to patients through significant adverse
events. This lack of effective communication is not limited to the highly stressed,
highly technical situations of the operating room or the intensive care unit but is
evident at all levels of the system. The trust that necessarily underpins all heathcare
encounters is generated from interpersonal relations between patients and those
caring for them and only to a slightly lesser extent from the interpersonal relations
between members of the caring team. The more complex our health system
becomes and the more diverse the situations where care is delivered, the more
important effective teamwork becomes. Good communication is key to the delivery
of safe, high-quality care.
The authors and editor of this book have clearly had as their aim the improvement
of healthcare safety and quality through improving communication and have
focused on critical conversations. They have achieved a very accessible and
readable text with the dominant issues about health professionals’ communication
with healthcare consumers, our patients, being dealt with by experts across a wide
range of disciplines. They start with the basics, address very appropriately some
difficult issues that require improvement, such as interprofessional collaboration,
handover, and open disclosure, but also address the very personal skills and
attributes required in specific and challenging situations that all healthcare
professional need to manage.
Excellence in communication, the ability to both share ideas and to listen to others,
is necessary to provide patients and their families with the experience they need and
desire, while they are receiving the best clinical care. This requires an understanding
xvi critical conversations for patient safety
that it is respect, courtesy and above all else, compassion in our dealings with patients that converts a
technical therapeutic episode into a life-changing, caring experience. In my view, all who read this book,
whether student or health professional, will be stimulated to reflect on their own performance in order to
improve their critical conversations and the care they give their patients.
Bruce Barraclough AO
Emeritus Professor University of Western Sydney,
Chair, Australian E Health Research Centre
formerly, President of the International Society for Quality in Health Care
This page intentionally left blank.
Chapter 1
The relationship between
communication and patient safety
T r a c y L e v e tt - J o n e s L e s l e y M a c D o n a ld - W i c k s K i m Oat e s
Learning outcomes
Chapter 1 will enable you to:
b discuss the relationship between communication and patient safety
b outline the nature and significance of clinical errors that are attributed to
ineffective communication
b reflect on the importance of effective communication from the patient’s
perspective
b consider the contextual and interpersonal risk factors that interfere with
patient-safe communication
b reflect on your own level of communication competence to identify areas of
strength and possibilities for improvement.
Key concepts
Patient safety, patient-safe communication, critical conversations, communication risk factors
The greatest problem with communication is the illusion that
it has been accomplished.
(George Bernard Shaw)
Introduction
When seeking healthcare, people hope and trust that their health-related problems will
be appropriately managed and that their care will be safe and effective. However, despite
the best intentions of health professionals, a seminal study identified that between
10 per cent and 16 per cent of patients are harmed while receiving healthcare (Wilson et
al. 1995), resulting in distress, hospital admissions, permanent injury, increased length of
hospital stay, and even death. Of these adverse events, at least 50 per cent are preventable
(Weingart et al. 2000). Although the reasons for adverse patient outcomes are diverse,
ineffective communication has been identified as the most common cause (Leonard,
Graham & Bonacum 2004). Indeed, a ground-breaking study examining 2455 sentinel
events in healthcare settings revealed that over 70 per cent were caused by communication
errors (Leonard, Graham & Bonacum 2004). Deficiencies in communication between
health professionals and between health professionals and patients continue to feature in
many coroners’ reports and quality improvement investigations, and over the last decade
there have been repeated calls for improvement.
The opportunity to improve the current situation through increased attention to the
teaching of communication skills has been advocated as the most promising way
forward and a pragmatic strategy for reducing healthcare errors (Baker et al. 2005; World
Health Organization 2011). Effective interprofessional communication (between health
professionals from different disciplines), intraprofessional communication (between
2 critical conversations for patient safety
health professionals from the same discipline) and therapeutic communication

(between health professionals and patients) are increasingly recognised as core
competencies for all health professionals. Despite this, many students, graduates,
educators and clinicians assume that communication skills are either inherent or acquired
almost serendipitously through repeated exposure to clinical practice. However, to
become a skilled and safe communicator requires active engagement in deliberate
learning activities, determination and repeated practice; it also requires reflection,
particularly on activities designed to improve performance. This chapter and the ones
that follow provide the foundation for these types of learning activities by illustrating
the link between patient safety and communication from a wide range of disciplinary
perspectives. The real-life patient stories, learning activities and critical thinking questions
profile authentic and sometimes challenging situations that will cause you to re-
examine many taken-for-granted assumptions as you reflect on your personal beliefs and
professional understandings. Importantly, this book will enhance your communication
competence and ability to practise in a way that promotes patient safety and wellbeing.
Va n e s s a’s s to r y
Vanessa Anderson was born in 1989 and was 16 years old at the time of her death. She lived with
her parents, Warren and Michelle, on Sydney’s North Shore. Vanessa enjoyed good health; her only
known medical conditions were asthma and migraine headaches; she did not drink or smoke.
On Sunday 6 November 2005, Vanessa was competing in a golf tournament when, on the fifth
hole, she was struck by a golf ball on the right side of her head. Vanessa was taken to hospital,
vomiting several times en route. A CT scan was performed, and she was subsequently transferred
to another, larger hospital. She was diagnosed as having a closed depressed right temporal
skull fracture with temporal brain contusions. On the basis of her Glasgow Coma Score (GCS),
the neurosurgical fellow classified Vanessa’s head injury as mild. He then telephoned the on-call
consultant neurosurgeon to advise him of Vanessa’s condition, but told him that she would be
transferred to the local children’s hospital. He did not subsequently advise the consultant that
Vanessa was not transferred but had been admitted to an adult ward instead.
On Monday 7 November at 8.30 am, a senior medical resident, an intern on her first day in
the neurosurgical unit and a nurse practitioner conducted a ward round. During the round the
resident changed Vanessa’s analgesic regime from Tramadol to Codeine Phosphate. The intern
was responsible for making notes in Vanessa’s medical records, but the notes she made were
inadequate and did not include the author of the notes, the results of the physical examination
and the ward-round attendees.
At approximately midday, the consultant neurosurgeon visited the ward and was told that
Vanessa had been admitted under his care. He discussed the CT results and formed the view
that she most likely had dural lacerations with bone fragments. He was unhappy about the poor
communication which meant that he had only just become aware of Vanessa’s admission and
because of this her surgery could not be scheduled until the following day.
Early in the afternoon of the same day, in response to Vanessa’s severe pain, the resident
prescribed the analgesics Panadeine Forte (2 tablets four times a day) and Endone (5 mg six times
a day, PRN). Between 4.30 pm and 5.30 pm, an anaesthetic registrar conducted a pre-operative
chapter one The relationship between communication and patient safety 3
consultation. In response to Vanessa’s ongoing pain, she increased the dose and frequency
of the Endone to 5–10 mg, three-hourly. She did not record a maximum dose. She misread the
medication chart and thought that Vanessa had been prescribed Panadeine, not Panadeine Forte
(Panadeine contains 8 mg of codeine and Panadeine Forte 30 mg). The anaesthetic registrar did
not discuss her course of action with the nurses or the neurosurgical team.
That evening Vanessa was given two Panadeine Forte tablets at 7 pm and 12 am. She was
also given 10 mg of Endone at 8 pm and 11 pm. At 1 am on the morning of Tuesday 8 November,
Vanessa buzzed for assistance. The nurse who responded observed that Vanessa could not move
and sounded distressed. She lifted Vanessa’s arm and it fell down limply on the bed. The nurse
took some observations, and noted that Vanessa’s breathing was normal, that she was warm to
touch and of normal colour, and that she had no shaking or stiffness. The nurse did not check
Vanessa’s lower limb movement or her GCS. Had she done so, Vanessa’s GCS would have scored
below 5, signalling that emergency medical intervention was necessary. However, the nurse
did not believe that Vanessa was in immediate danger, and thinking that Vanessa was probably
having a bad dream did not escalate her concern. Later she returned to Vanessa and performed
a set of neurological observations, including calling her name, asking if she was okay (to which
she responded ‘yes’), and requesting her to lift her arms and push her feet against the nurse’s
hands. Vanessa could do all these things, and the nurse felt that the earlier event was not clinically
significant, and that her initial view that Vanessa was simply having a bad dream was correct. The
nurse did not document the events or her observations in Vanessa’s chart, nor did she consult the
registrar or the consultant.
At 2 am Vanessa went to the toilet and was given a further 10 mg of Endone. The nurse later For further
admitted that the dose of 5–10 mg Endone three-hourly struck her as unusual and that it was rare information about
for this order to be charted in conjunction with regular Panadeine Forte. However, she felt that this
Vanessa Anderson’s
was what the doctors wanted so she did not express her concerns to the anaesthetic registrar or
story, go to
the consultant.
<http://www.
Vanessa’s observations were due again at 4 am; however, the nurse decided not to do these
ipeforqum.com.au/
observations because Vanessa had been neurologically unchanged when she conducted the
modules/>.
observations at around 2 am. Vanessa’s father, Warren Anderson, arrived on the ward at around
3.45 am and sat in Vanessa’s darkened room and fell asleep. At around 5.30 am the nurse entered
Vanessa’s room and found her unresponsive. An emergency was called and CPR administered.
Vanessa was pronounced dead at 6.35 am. The formal finding from a later coroner’s inquest was
that Vanessa died from a respiratory arrest due to the depressant effect of opiate medication.
Although Vanessa’s death undoubtedly resulted from a series of system and human errors,
any one of the health professionals involved may have prevented this tragic outcome had they
communicated in an effective and timely manner. The NSW Deputy State Coroner, Magistrate
Milovanovich, made the following statement in relation to the findings of the coronial inquest:
The death of Vanessa Anderson at the very young age of 16 years was a tragic and avoidable
death . . . the circumstances of Vanessa’s death should constantly remain in the forefront of
the minds of all medical practitioners, nursing staff and hospital administrators. Vanessa’s
case should be used as a precedent to highlight how individual errors of judgment, failure
to communicate, failure to record accurately and poor management of staff resources,
cumulatively led to the worst possible outcome for Vanessa and her family.
Source: Inquest into the death of Vanessa Anderson, Coroner’s Court, Westmead, Sydney, 24 January 2004.
(Professor Tracy Levett-Jones was given permission by Vanessa’s family to use her story in teaching students and
health professionals about patient safety from the perspective of patients and their families.)
Patient safety and communication

Patient safety is defined as actions undertaken by individuals and organisations to protect healthcare
recipients from being harmed by their healthcare (National Patient Safety Foundation 2008). It is
important to note that patient safety is not limited to physical safety but also includes psychological,
emotional and cultural safety. Patient safety is an attribute of trustworthy healthcare systems
that work to minimise the incidence and impact of, and maximise recovery from, adverse events
(Emanuel et al. 2008). Patient safety is considered to be one of the most important issues facing
healthcare today. Health professionals need highly developed communication skills in order to
manage the complexity and competing tensions that define contemporary healthcare organisations.
Communication is much more than the provision of information, instructions or advice. It is a
two-way interaction where information, meanings and feelings are shared both verbally and non-
verbally and when the message being conveyed is understood as intended (Dunne 2005). Many
health professionals think that effective communication means giving patients clear, unambiguous
information in a timely manner. This is true, but it is only part of the story. Communication involves
listening as well as talking. When we listen to patients, we are less likely to jump to erroneous
conclusions because we haven’t seen the whole picture (this is referred to as premature closure).
Patients expect to be communicated with in ways that are inclusive, accurate, timely and
appropriate. The Australian Charter of Healthcare Rights (Box 1.1) outlines patients’ rights in
regards to healthcare and emphasises that communication and working in partnership with patients
underpin safe care. Indeed, communication is considered by many people to be one of the most
important aspects of quality healthcare. In 2009 Australian patients and their families were surveyed
in an attempt to clarify what their priorities were when undergoing healthcare (New South Wales
Health 2009). The list in Box 1.2 demonstrates the importance of communication to the survey
participants’ healthcare experience and illustrates the particular elements of communication that
they believed were key. It is noteworthy that the only other clinical concern mentioned was in
relation to pain management.
Effective communication impacts on patient outcomes in many ways. Studies have
demonstrated a relationship between effective communication and compliance with medication and
rehabilitation programs, reduction in stress and anxiety (Harms 2007), improved pain management,
self-management, mood, self-esteem, functional and psychological status (Goleman 2006),
symptom resolution, reduced length of hospitalisation, improved coordination of care, reduced
costs (Mickan & Rodger 2005), reduction in surgical mortality and post-operative complications
(Vats et al. 2010), enhanced patient satisfaction and wellbeing (Mickan & Rodger 2005), improved
Box 1.1 The Australian Charter of Healthcare Rights

Safety – a right to safe and high-quality care
Respect – a right to be shown respect, dignity and consideration
Communication – a right to be informed about services, treatment, options and costs in a clear and open way
Participation – a right to be included in decisions and choices about care
Privacy – a right to privacy and confidentiality of provided information
Comment – a right to comment on care and having concerns addressed
Source: The Australian Charter of Healthcare Rights, Health Quality and Complaints Commission, Australian Commission on Safety
and Quality in Health Care, Jan 2012.
chapter one The relationship between communication and patient safety 5
Box 1.2 Patient survey: Top priorities for healthcare

• Healthcare professionals discussing anxieties and fears with the patient
• Patients having confidence and trust in healthcare professionals
• The ease of finding someone to talk to about concerns
• Doctors and nurses answering patients’ questions understandably
• Patients receiving enough information about their condition/treatment
• Test results being explained understandably
• Patients having enough say about and being involved in care/treatment decisions
• Being given information about patient’s rights and responsibilities
• Staff doing everything possible to control pain
Source: New South Wales Health Nursing and Midwifery Office, Essentials of Care Project. © New South Wales Ministry of Health for
and on behalf of the Crown in right of the State of New South Wales.
patient safety, and error reduction (Abbott 1998). In contrast, poor communication can lead to Patient-safe
hostility, anger, confusion, misunderstanding, lack of trust, poor compliance and greatly increased communication is
risk of error and patient harm. a means by which
Patient-safe communication is a goal-orientated activity focused on preventing adverse events health professionals
and helping patients attain optimal health outcomes. It is a means by which health professionals gather and share
gather and share information, clarify and verify accurate interpretations of information, and information, clarify
establish a process for working collaboratively with both patients and other health professionals and verify accurate
to achieve common goals of safe and high-quality patient care (Schuster & Nykolyn 2010). Every interpretations
aspect of patient care depends upon how well healthcare professionals communicate with each of information,
other and the patients they care for. Clinical decisions based on incomplete or misinterpreted
and establish a
information are likely to be inappropriate and may cause patient harm and distress. For health
process for working
professionals, unsafe communication is considered to be a breach of professional standards and a
leading cause of litigation (Trede, Ellis & Jones 2012). Examples of this may include: collaboratively
with both patients
• inadequate or inaccurate advice on self-management
and other health
• failure to communicate in ways that the patient and their family can understand professionals to
• failure to disclose the risk of interventions and potential complications achieve common
• failure to obtain valid consent to an intervention/procedure goals of safe and
• failure to maintain client confidentiality high-quality patient
• failure to give the patient an opportunity to ask questions care (Schuster &
Nykolyn 2010).
• failure to respond appropriately to those questions
• failure to respect the opinion of a patient (even though the patient’s opinion may be medically
inaccurate, their observations usually are accurate and can be very valuable)
• failure to realise that, from the patient’s point of view, there is no such thing as a ‘silly question’
• failure to realise that the way we talk with patients (courteous, respectful, clear and jargon-
free) can be just as important as the content of what we actually say to them
• failure to communicate with other relevant health professionals to provide a reasonable
standard of care
• failure to communicate with supervisors/administrators when patient safety is in jeopardy

• failure to warn authorities when to do so would be in the public interest.
Health professionals should be aware that there are six groups of patients who are at particular
risk of harm from poor communication: older people, children, people with mental illness, people
who do not speak English, people with sensory impairment (e.g. diminished hearing or limited
verbal ability), and people with cognitive changes (e.g. delirium or dementia). The skills needed for
patient-safe communication when caring for these groups are discussed in Chapters 10–16.
When many and varied healthcare professionals (including doctors, midwives, dentists, nurses,
pharmacists, social workers, dieticians, physiotherapists, psychologists, and others) are involved in
patient care, ensuring exchange of accurate information in a timely manner can be difficult. Patient-
safe communication is a complex and context-dependent process and many human and system factors
influence how effectively it transpires. Despite health professionals being well intentioned, there are
numerous factors that can impact on their ability to engage in patient-safe communication. Figure
1.1 illustrates some of the risk factors for communicating safely with both patients and other health
professionals. Communication risk factors have the potential to distort the clarity of the message
being conveyed and impede the effectiveness of the process. This can lead to misinterpretation, time
wasting, frustration and inaccurate decision making (Schuster & Nykolyn 2010, p. 25). The outer
circle in this figure depicts strategies that have been identified as preventing or overcoming risk
factors, improving communication and promoting patient safety. Throughout this book, these risk
factors and strategies will be defined, discussed and applied to a range of clinical stories.
Box 1.3 Critical conversations and patient safety

In January 2004 Mr Graham Reeves was admitted to a hospital in the United Kingdom for removal of a badly
diseased right kidney. He had seen the surgeon a month before who documented the need for removal of the
right kidney in the patient’s case notes. However, possibly due to a transcription error, the hospital admission
slip wrongly said ‘left kidney removal’. This error was transcribed to the theatre list. One of the surgeons checked
the X-ray in the operating theatre. But it was the wrong way round and he misread the diseased kidney as the
one on the left. The second surgeon did not look at the X-ray. Early in the operation, a medical student looked
at the X-ray and said she thought it was the right kidney which should be removed. The surgeon told her she
had made a mistake and continued operating, removing the left kidney (the normal kidney). Mr Reeves died
of kidney failure five weeks later.
Had there been a greater culture of openness, where junior staff were encouraged to ask questions and where
their concerns were taken seriously, Mr Reeves would not have died. Training in techniques such as CUS would
have also helped the student be assertive and to escalate her concerns in a respectful way.
Using critical conversations to promote

patient-safe communication
The hierarchical nature of healthcare environments presents one of the key risk factors for effective
communication. Traditional healthcare cultures can make it difficult for health professionals to
raise concerns and be assertive when they are worried about patient safety. This is exacerbated by
power differentials and a lack of psychological safety. The use of critical language can create clearly
agreed upon communication processes that help improve communication and avoid the tendency
to speak indirectly or deferentially when feeling intimidated. One example of critical language is
Another random document with
no related content on Scribd:
a point which His Majesty's Government can afford to concede.
I think it would have a deplorable effect in Cape Colony and
Natal to obtain peace by such a concession." Mr. Chamberlain
agreed with the High Commissioner, writing in reply: "His
Majesty's Government feel that they cannot promise to ask for
complete amnesty to Cape and Natal rebels who are in totally
different position to burghers without injustice to those who
have remained loyal under great provocation, and they are
prepared substantially to adopt your words, but you must
consider whether your last line is strictly applicable to
Natal." Mr. Chamberlain made numerous other criticisms of Lord
Kitchener's suggested letter, and amended it in many
particulars, the most important of which related to the form
of government under which the late republics would be placed.
Lord Kitchener would have said: "Military law will cease and
be at once replaced by civil administration, which will at
first consist of a Governor and a nominated Executive with or
without an advisory elected Assembly, but it is the desire of
His Majesty's Government, as soon as circumstances permit, to
establish representative Government in the Transvaal and
Orange River Colony." His political superior instructed him to
change the statement as follows: "For 'military law will
cease' say 'military administration will cease.' It is
possible that there may be disturbed districts for some time
after terms have been accepted, and Governor of Colonies
cannot abandon right of proclaiming martial law where
necessary. In the same sentence omit the words 'at the same
time' and 'at once' and substitute at the beginning the words
'at the earliest practicable date.' For 'consist of a
Governor' down to 'Assembly' read 'consist of a Governor and
an Executive Council composed of the principal officials with
a Legislative Council consisting of a certain number of
official members to whom a nominated unofficial element will
from the first be added.' In place of the words 'to establish
representative government' substitute 'to introduce a
representative element, and ultimately to concede to the new
Colonies the privilege of self-government.' It is desirable at
this stage to be quite precise in order to avoid any charge of
breach of faith afterwards."
Out of the instructions he received, Lord Kitchener finally

framed the following letter to Commandant Botha, sent to him
on the 7th of March: "With reference to our conversation at
Middelburg on 28th February, I have the honour to inform you
that in the event of a general and complete cessation of
hostilities and the surrender of all rifles, ammunition,
cannon, and other munitions of war in the hands of the
burghers or in Government depots or elsewhere, His Majesty's
Government is prepared to adopt the following measures:
"His Majesty's Government will at once grant an amnesty in the

Transvaal and Orange River Colonies for all bona fide acts of
war committed during the recent hostilities. British subjects
belonging to Natal and Cape Colony, while they will not be
compelled to return to those Colonies, will, if they do so, be
liable to be dealt with by the law of those Colonies specially
passed to meet the circumstances arising out of the present
war. As you are doubtless aware, the special law in the Cape
Colony has greatly mitigated the ordinary penalties for high
treason in the present cases.
"All prisoners of war now in St. Helena, Ceylon, or elsewhere

will, on the completion of the surrender, be brought back to
their country as quickly as arrangements can be made for their
transport.
"At the earliest practicable date military administration will

cease and will be replaced by civil administration in the form
of Crown Colony Government. There will therefore be, in the
first instance, in each of the new Colonies a Governor and an
Executive Council, consisting of a certain number of official
members, to whom a nominated unofficial element will be added.
But it is the desire of His Majesty's Government, as soon as
circumstances permit, to introduce a representative element
and ultimately to concede to the new Colonies the privilege of
self-government. Moreover, on the cessation of hostilities a High
Court will be established in each of the new Colonies to
administer the law of the land, and this Court will be
independent of the Executive.
"Church property, public trusts, and orphans funds will be

respected.
"Both the English and Dutch languages will be used and taught
in public schools where parents of the children desire it, and
allowed in Courts of Law.
"As regards the debts of the late Republican Governments, His

Majesty's Government cannot undertake any liability. It is,
however, prepared, as an act of grace, to set aside a sum not
exceeding £1,000,000 to repay inhabitants of the Transvaal and
Orange River Colonies for goods requisitioned from them by the
late Republican Governments, or, subsequent to annexation, by
Commandants in the field being in a position to enforce such
requisitions. But such claims will have to be established to
the satisfaction of a Judge or Judicial Commission appointed
by the Government to investigate and assess them, and if
exceeding in the aggregate £1,000,000, they will be liable to
reduction pro rata.
"I also beg to inform your Honour that the new Government will
take into immediate consideration the possibility of assisting
by loan the occupants of farms who will take the oath of
allegiance to repair any injury sustained by destruction of
buildings or loss of stock during the war, and that no special
war tax will be imposed on farmers to defray the expense of
the war.
"When burghers require the protection of fire-arms such will

be allowed to them by licence and on due registration,
provided they take the oath of allegiance. Licences also will
be issued for sporting rifles, guns, &c., but military
firearms will only be allowed for means of protection.
{513}
"As regards the extension of the franchise to Kaffirs in the

Transvaal and Orange River Colony, it is not the intention of
His Majesty's Government to give such franchise before
representative government is granted to these Colonies, and if
then given it will be so limited as to secure the just
predominance of the white races. The legal position of
coloured persons will, however, be similar to that which they
hold in Cape Colony.
"In conclusion, I must inform your Honour that if the terms

now offered are not accepted after a reasonable delay for
consideration they must be regarded as cancelled."
On the 16th of March the following reply came from the Boer
Commandant: "I have the honour to acknowledge receipt of your
Excellency's letter stating what steps your Excellency's
Government is prepared to take in the event of a general and
total cessation of hostilities. I have advised my Government
of your Excellency's said letter; but, after the mutual
exchange of views at our interview at Middelburg on 28th
February last, it will certainly not surprise your Excellency
to know that I do not feel disposed to recommend that the
terms of the said letter shall have the earnest consideration
of my Government. I may add also that my Government and my
chief officers here entirely agree to my views." This ended
the negotiations.
A discussion of the negotiations in Parliament occurred on the

28th of March, when Mr. Bryce (Liberal) said "they were agreed
that the Government took an onward step when they allowed the
peace negotiations to be entered into, and it was important to
observe that, not only Lord Kitchener, but Sir Alfred Milner
was persuaded that General Botha meant business. It was
possible there were causes at work with which the House were
not acquainted which caused the negotiations to be broken off.
General Botha wrote to Lord Kitchener:—'You will not be
surprised to hear that my answer is in the negative.' One of
two things must have happened—either Lord Kitchener heard from
General Botha something that the House had not heard of, or
else General Botha was so much struck by the difference
between the terms which Lord Kitchener had discussed and the
terms contained in the letter that he conceived a distrust of
us altogether and believed that the Government would not
accept what Lord Kitchener had offered. He thought the
Government were right in asking that the oath of allegiance
should be taken, that they were entitled to insist upon the
provision that all hostilities must cease, and that they could
not pledge themselves as to the precise time when they would
bring back the prisoners. But there were three points on which
there were substantial differences between the terms Lord
Kitchener appeared to have offered and the terms in the final
letter. The first is the question of amnesty for the Cape
rebels. Lord Kitchener and General Botha appeared to have come
to an agreement on that subject. General Botha did not object
to the disfranchisement of the Cape rebels, and Lord Kitchener
did not appear to have conveyed any suggestion whatever of
anything except disfranchisement. He could conceive nothing
more likely to turn back the pacific desires of the Boers than
the fact that they found that, instead of the Cape rebels
having nothing but disfranchisement to fear, they were to be
held subject to the Cape laws as to treason. He was not
arguing whether that was right or wrong. The question was what
the Boers would think, and he put it to the House that it was
the most natural thing that they should be struck by the
contrast between the terms which Lord Kitchener appeared to
offer and the terms which were offered when the final letter
came, and that that was just the point upon which brave men,
feeling for their comrades, would be inclined to stand out.
They would be told that they would displease the loyalists at
the Cape if they did not exact all the penalties for treason.
He hoped they would never in that House consider it any part
of their business to satisfy the vindictive feeling of the
colonists at the Cape."
As to the difference between the terms of future government

for the inhabitants of the late republics proposed by Lord
Kitchener and those laid down by the Colonial Secretary, Mr.
Bryce said: "He should like to have known what the proposals
were that General Botha made with regard to a modified
independence, for he thought it was quite possible that it
might turn out in the long run that some kind of what was
called modified independence, protection, would be a great
deal easier for this country to work than a system of Crown
colony government. He thought the contrast between the
elective assembly which Lord Kitchener offered and the purely
arbitrary and despotic system which the final letter conveyed
must at once have struck the Boers as indicating the
difference between the views which the military man on the
spot entertained and the proposal which they might expect from
the Government. Of course there were objections to the
immediate grant of self-government. So also there were
objections to any course, and that course should be chosen
which was open to the fewest objections. But the proposal of
Crown colony government was, of all courses, the worst that
could be suggested. It had been suggested that members of the
Liberal party had asked for full-grown representative and
responsible government, but they never had suggested that.
What they had objected to was Crown colony government. They
admitted that when the war ended there must be an intermediate
period of administration, military or civil, but there was all
the difference in the world between an admittedly provisional
administration understood to be provisional and the creation
of the whole apparatus of Crown colony government. The Boer
population had an aversion to Crown colony administration,
associated in their minds with the days of Sir Owen Lanyon,
and an arbitrary form of government it was known to be. Of
course it was arbitrary; honourable members who questioned
that could not know what Crown colony administration was. The
existence of a nominated council did not prevent it being
arbitrary inasmuch as the members were obliged to vote as they
were directed by the Governor. He could not help thinking that
Lord Kitchener might, if he were asked to do so, throw some
light on a remarkable expression in the letter from General
Botha in which he said, after the mutual interchange of views
at their meeting, Lord Kitchener would not be surprised to
learn that he was not disposed to recommend the terms
proposed."
{514}
The radical Mr. Labouchere was sharper in his criticism: "He

held that it was nonsense to call the terms offered to the
Boers liberal and lenient; they were neither. We had burnt
their farms and desolated their country, and then we offered
them a small gift of money to put them back on their farms
while we took away their independence and their flag. He
honoured the men who resisted, no matter at what cost, when
the question was the independence of their native land. How
right General Botha was in distrusting the alterations made by
the Secretary for the Colonies in the matter of the gift was
shown by the right honourable gentleman himself, when he said
that, whereas the gift was to be limited to a certain sum, the
loyalists were to be paid first. In that case what would
remain to the burghers of the two colonies? The position of
the Boers in the Empire under the terms of the Colonial
Secretary would be little better than that of Kaffirs. As far
as ultimate self-government was concerned, they were to put
their faith in the Colonial Secretary. If he might offer them
a word of advice it would be—Put no faith in the Colonial
Secretary; get it in black and white. We had lost a great
opportunity of ending the war and settling South Africa. Peace
won by the sword would create a dependency in which racial
feuds would go on and the minority would be maintained over
the majority by a huge British garrison. The Dutch majority
was certain to increase every decade. The Transvaal farmers
lived in a poor, rude manner which English people would not
accept. …
"He did not particularly admire the Boers. To his mind they
had too much of the conservative element in them; but, judging
between the Afrikanders and the English who went to South
Africa, whilst fully recognizing that among the latter there
were many respectable men, he thought, taking them
collectively, the Boers were the better men. If we wanted to
maintain our rule in South Africa the Boers were the safest
men with whom to be on good terms. What were the Boers ready
to do? As he read the correspondence, they were ready to enter
the area of the British Empire, but only upon terms. Surely
our problem was to find terms honourable to us and to them,
which would lead to South Africa becoming one of those great
commonwealths connected with the Empire such as existed in
Australia and Canada. He suggested that, in the first place,
we should offer a full and absolute amnesty. He urged that the
Orange State and the Transvaal should as soon as possible be
made self-governing colonies. The Orange State was regarded by
every Englishman who had written about it as a model State. As
to the Transvaal, he admitted there was a difficulty, but he
would suggest that the main area of the country should be
separated from the Rand. The Rand might be administered by a
governor, a military governor if they liked, while in the rest
of the country the Dutch would have a majority. If this course
were adopted, instead of our giving some sort of pecuniary aid
to the Transvaalers, they might be paid a reasonable rent for
the Rand district, of which they would be deprived. … They on
that side of the House would be perfectly ready to agree to
the establishment of a provisional government, military or
civil—he should himself prefer Lord Kitchener to Sir Alfred
Milner—to carry on the country while they were arranging for
the colony to be self-governing. They were accustomed to be
told that Sir Alfred Milner was a sort of divine pro-consul.
He believed Sir Alfred Milner to be a most honourable man, and
very intelligent in many walks of life; but the truth was that
he began life as an Oxford don and then became an official in
the Treasury, facts which militated against his success in
practical politics. He believed that a man like Lord Dufferin
would do more for the cause of peace in South Africa than all
our soldiers."
SOUTH AFRICA: The Field of War: A. D. 1901 (February-April).

The High Commissioner, Sir Alfred Milner, on the situation
and prospects.
Leave of absence obtained by Sir Alfred.
A British Blue Book, made public in London on the 18th of

April, contains an interesting despatch from Sir Alfred
Milner, frankly reviewing the general situation in South
Africa, as it appeared to him on the 6th of February, when he
wrote, from Cape Town, and giving his forecast of future
prospects. The following are the more important passages of
the communication:
"A long time has elapsed since I have attempted to send to you
any general review of South African affairs. The reason is
twofold. In the first place, I am occupied every day that
passes from morning till night by business, all of which is
urgent, and the amount and variety of which you are doubtless
able to judge from the communications on a great variety of
subjects, which are constantly passing between us. In the next
place, I have always hoped that some definite point would be
reached at which it might be possible to sum up that chapter
of our history which contained the war, and to forecast the
work of administrative reconstruction which must succeed it.
But I am reluctantly forced to the conclusion that there will
be no such dividing line. I have not the slightest doubt of
the ultimate result, but I foresee that the work will be
slower, more difficult, more harassing, and more expensive
than was at one time anticipated. At any rate, it is idle to
wait much longer in the hope of being able to describe a clear
and clean-cut situation. Despite the many other calls upon my
time, and despite the confused character of the present
position, I think it better to attempt to describe, however
roughly and inadequately, the state of things as it exists
to-day.
"It is no use denying that the last half-year has been one of
retrogression. Seven months ago this Colony was perfectly
quiet, at least as far as the Orange River. The southern half
of the Orange River Colony was rapidly settling down, and even
a considerable portion of the Transvaal, notably the
south-western districts, seemed to have definitely accepted
British authority, and to rejoice at the opportunity of a
return to orderly government, and the pursuits of peace.
To-day the scene is completely altered. It would be
superfluous to dwell on the increased losses to the country
caused by the prolongation of the struggle, and by the form
which it has recently assumed. The fact that the enemy are now
broken up into a great number of small forces, raiding in
every direction, and that our troops are similarly broken up
in pursuit of them, makes the area of actual fighting, and
consequently of destruction, much wider than it would be in
the case of a conflict between equal numbers operating in
large masses.
{515}
Moreover, the fight is now mainly over supplies. The Boers
live entirely on the country through which they pass, not only
taking all the food they can lay hands upon on the farms,
grain, forage, horses, cattle, &c., but looting the small
village stores for clothes, boots, coffee, sugar, &c., of all
which they are in great need. Our forces, on their side, are
compelled to denude the country of everything moveable, in
order to frustrate these tactics of the enemy. No doubt a
considerable amount of the stock taken by us is not wholly
lost, but simply removed to the refugee camps, which are now
being established at many points along the railway lines. But
even under these circumstances, the loss is great, through
animals dying on the route, or failing to find sufficient
grass to live upon when collected in large numbers at the
camps. Indeed, the loss of crops and stock is a far more
serious matter than the destruction of farm buildings, of
which so much has been heard. I say this not at all as an
advocate of such destruction. I am glad to think that the
measure is now seldom if ever resorted to. At the same time,
the destruction of even a considerable number of farms, having
regard to the very rough and inexpensive character of the
majority of these structures in the Orange River Colony and
Transvaal, is a comparatively small item in the total damage
caused by the war to the agricultural community.
"To the losses incidental to the actual course of the

campaign, there has recently been added destruction of a
wholly wanton and malicious character. I refer to the injury
done to the head-gear, stamps, and other apparatus of some of
the outlying mines by Boer raiders, whose sole object was
injury. For this destruction there is, of course, no possible
excuse. … Fortunately the damage done to the mines has not
been large, relatively to the vast total amount of the fixed
capital sunk in them. The mining area is excessively difficult
to guard against purely predatory attacks having no military
purpose, because it is, so to speak, 'all length and no
breadth'—one long thin line, stretching across the country
from east to west for many miles. Still, garrisoned as
Johannesburg now is, it is only possible successfully to
attack a few points in it. Of the raids hitherto made, and
they have been fairly numerous, only one has resulted in any
serious damage. In that instance the injury done to the single
mine attacked amounted to £200,000, and it is estimated that
the mine is put out of working for two years. This mine is
only one out of a hundred, and is not by any means one of the
most important. These facts may afford some indication of the
ruin which might have been inflicted, not only on the
Transvaal and all South Africa, but on many European
interests, if that general destruction of mine works which was
contemplated just before our occupation of Johannesburg had
been carried out. However serious in some respects may have
been the military consequences of our rapid advance to
Johannesburg, South Africa owes more than is commonly
recognized to that brilliant dash forward, by which the vast
mining apparatus, the foundation of all her wealth, was saved
from the ruin threatening it.
"The events of the last six or seven months will involve a

greater amount of repair and a longer period of recuperation,
especially for agriculture, than anybody could have
anticipated when the war commenced. Yet, for all that, having
regard to the fact that both the Rand and Kimberley are
virtually undamaged, and that the main engines of prosperity,
when once set going again, will not take very long to get into
working order, the economic consequences of the war, though
grave, do not appear by any means appalling. The country
population will need a good deal of help, first to preserve it
from starvation, and then, probably, to supply it with a
certain amount of capital to make a fresh start. And the great
industry of the country will need some little time before it
is able to render any assistance. But, in a young country with
great recuperative powers, it will not take many years before
the economic ravages of the war are effaced.
"What is more serious to my mind than the mere material

destruction of the last six months is the moral effect of the
recrudescence of the war. I am thinking especially of the
Orange River Colony, and of that portion of the Transvaal
which fell so easily into our hands after the relief of
Mafeking, that is to say, the country lying between
Johannesburg and Pretoria, and the border of Bechuanaland.
Throughout this large area the feeling in the middle of last
year was undoubtedly pacific. The inhabitants were sick of the
war. They were greatly astonished, after all that had been
dinned into them, by the fair and generous treatment they
received on our first occupation, and it would have taken very
little to make them acquiesce readily in the new regime. At that
time too, the feeling in the Colony was better than I have
ever known it. The rebellious element had blown off steam in
an abortive insurrection, and was glad to settle down again.
If it had been possible for us to screen those portions of the
conquered territory, which were fast returning to peaceful
pursuits, from the incursions of the enemy still in the field,
a great deal of what is now most deplorable in the condition of
South Africa would never have been experienced. The vast
extent of the country, the necessity of concentrating our
forces for the long advance, first to Pretoria and then to
Komati Poort, resulted in the country already occupied being
left open to raids, constantly growing in audacity, and fed by
small successes, on the part of a few bold and skilful
guerrilla leaders who had nailed their colours to the mast.
The reappearance of these disturbers of the peace, first in
the south-east of the Orange River Colony, then in the
south-west of the Transvaal, and finally in every portion of
the conquered territory, placed those of the inhabitants who
wanted to settle down in a position of great difficulty.
Instead of being made prisoners of war, they had been allowed
to remain on their farms on taking the oath of neutrality, and
many of them were really anxious to keep it. But they had not the
strength of mind, nor, from want of education, a sufficient
appreciation of the sacredness of the obligation which they
had undertaken, to resist the pressure of their old companions
in arms when these reappeared among them appearing to their
patriotism and to their fears. …
{516}
"As the guerrilla warfare swept back over the whole of the
western Transvaal, and practically the whole of the Orange
River Colony, its effect upon the Cape Colony also became very
marked. There was a time, about the middle of last year, when
the bulk of the Dutch population in the Cape Colony, even
those who had been most bitter against us at the outset,
seemed disposed to accept the 'fait accompli,' and were
prepared to acquiesce in the union of all South Africa under
the British flag. Some of them even began to see certain
advantages in such a consummation. The irreconcilable line
taken in the Cape Parliament, during its recent Session from
July to October, was a desperate effort to counteract this
tendency. But I doubt whether it would have succeeded to the
moderate extent to which it has, had it not been for the
recrudescence of the war on the borders of the Colony, and the
embittered character which it assumed. Every act of harshness,
however necessary, on the part of our troops, was exaggerated
and made the most of, though what principally inflamed the
minds of the people were alleged instances of needless cruelty
which never occurred. Never in my life have I read of, much
less experienced, such a carnival of mendacity as that which
accompanied the pro-Boer agitation in this Colony at the end
of last year. And these libels still continue to make
themselves felt. …
"The present position of affairs, alike in the new territories

and in a large portion of the Cape Colony, if by no means the
most critical, is possibly the most puzzling that we have had
to confront since the beginning of the war. Naturally enough
the public are impatient, and those who are responsible for
the government of the country are bombarded with most
conflicting advice. On the one hand, there is the outcry for
greater severity and for a stricter administration of Martial
Law. On the other hand, there is the expression of the fear
that strict measures would only exasperate the people.
Personally, I am of the opinion, which I have always held,
that reasonable strictness is the proper attitude in the
presence of a grave national danger, and that exceptional
regulations for a time of invasion, the necessity of which
every man of sense can understand, if clearly explained and
firmly adhered to, are not only not incompatible with, but
actually conducive to, the avoidance of injustice and cruelty.
I am satisfied by experience that the majority of those Dutch
inhabitants of the Colony who sympathize with the Republics,
however little they may be able to resist giving active
expression to that sympathy, when the enemy actually appear
amongst them, do not desire to see their own districts
invaded, or to find themselves personally placed in the
awkward dilemma of choosing between high treason and an
unfriendly attitude to the men of their own race from beyond
the border. There are extremists who would like to see the
whole of the Cape Colony overrun. But the bulk of the farmers,
especially the substantial ones, are not of this mind. …
"The inherent vice, if I may say so, of almost all public

discussion of our South African difficulties is the tendency
to concentrate attention too exclusively upon the Boers. Say
what we will, the controversy always seems to relapse into the
old ruts—it is the British Government on the one hand, and the
Boers on the other. The question how a particular policy will
affect, not merely our enemies, but our now equally numerous
friends, seems seldom to be adequately considered. And yet it
would seem that justice and policy alike should lead us to be
as eager to consider the feelings and interests, and to retain
the loyalty, of those who are fighting on our side, as to
disarm the present enmity and win the future confidence of
those who are fighting against us. And this principle would
seem an the easier to adhere to because there is really
nothing which the great body of the South African loyalists
desire which it is not for the honour and advantage of the
Mother Country to insist upon. Of vindictiveness, or desire to
oppress the Afrikanders, there is, except in hasty utterances,
inevitable in the heat of the conflict, which have no
permanent significance, or in tirades which are wholly devoid
of influence, no sign whatever. The attitude of almost all
leading and representative men, and the general trend of
public feeling among the loyalists, even in the intensity of
the struggle, is dead against anything like racial
exclusiveness or domination. If this were not so, it would be
impossible for a section of pure bred Afrikanders, small no
doubt in numbers but weighty in character and position, to
take the strong line which they do in opposition to the views
of the majority of their own people, based as these are, and
as they know them to be, upon a misconception of our policy
and intentions. These men are among the most devoted adherents
to the Imperial cause, and would regard with more disfavour
and alarm than anyone the failure of the British nation to
carry out its avowed policy in the most complete manner. They
are absolutely convinced that the unquestioned establishment
of the British supremacy, and the creation of one political
system from Cape Town to the Zambesi, is, after all that has
happened, the only salvation for men of their own race, as
well as for others. Of the terms already offered, a great
majority, I believe, of the South Africans at present in arms
on our side entirely approve. There is, no doubt, an extreme
section who would advocate a sterner attitude on our part, but
they are not numerous, and their feelings are not lasting. The
terms offered by Lord Kitchener, which are, in substance,
identical with repeated declarations of policy on the part of
His Majesty's Government, are generally regarded as a generous
and statesmanlike offer, as one which, if firmly adhered to,
will ultimately be accepted, but as an offer which we cannot
afford to enlarge. On the other hand, there is a very general
desire that no effort should be spared to make the generous
character of our intentions widely known, and to encourage any
disposition on the part of the enemy to parley, with the object
of making them better acquainted with the terms on which we
are prepared to accept their submission.
"If I might sum up the predominant, indeed, the almost

unanimous feeling of those South Africans who sympathise with
the Imperial Government, I should describe it as follows:—They
are sick to death of the war, which has brought ruin to many of
them, and imposed considerable sacrifices on almost all. But
they would rather see the war continue for an indefinite time
than run the risk of any compromise which would leave even the
remotest chance of the recurrence of so terrible a scourge in
the future. They are prepared to fight and suffer on, in order
to make South Africa, indisputably and for ever, one country
under one flag, with one system of government, and that system
the British, which they believe to ensure the highest possible
degree of justice and freedom to men of all races.
{517}
But, with that object accomplished, they are willing, and,
indeed, ready, to bury racial animosities. They have fought
against the principle of race oligarchy in one form, and they
do not wish to re-establish it in another. For the attainment
of that object, they would rely for the present on the
vigorous prosecution of the war in which they are prepared
themselves to take the most active part, coupled with every
inducement to the enemy to come in on the terms already
offered, and for the future, as soon as public security is
assured and the circumstances permit, on the extension to the
newly acquired territories of a system of Colonial
self-government. For my own part, I have no doubt that this
attitude is a wise one, and that it only requires persistence
in it, in spite of the discouraging circumstances of the
moment, to lead us to ultimate success."
Great Britain, Papers by Command, Cd. 547.
The same Blue Book made known the fact that, on the 3d of
April, Sir Alfred Milner applied for and obtained leave of
absence for three months from his duties in South Africa.
SOUTH AFRICA: The Field of War: A. D. 1901 (April).

The situation.
Early in April it was announced that the seat of government of

the South African Republic had been transferred from
Pietersburg to Leydsdorp in the Zoutpansberg by the
Vice-President, General Schalk-Burger, which seems to indicate
the beginning of another stage of the South African war. The
Boers are said to have been for some time past collecting
great quantities of cattle and sheep in the fastnesses of the
Zoutpansberg, where also they have ample supplies of
ammunition, and intend making it a point of ultimate
resistance as well as a base of present operations.
SOUTH AFRICA: The Field of War: A. D. 1901 (April).

The cost of the war to Great Britain as stated
by the Chancellor of the Exchequer.
In his speech (April 18), on introducing the budget for 1901,

in the House of Commons, the Chancellor of the Exchequer, Sir
Michael Hicks-Beach, made the following statements of the cost
of the war to Great Britain: "I would remind the Committee
that so far we have borrowed towards the cost of the war
£67,000,000—£13,000,000 Treasury bills, £10,000,000 Exchequer
Bonds maturing rather less than three years hence, £14,000,000
Exchequer Bonds maturing about five years hence, and
£30,000,000 War Loan maturing in 1910. Now, Sir, in what mode
may we fairly borrow such a large sum as we now require? This
can no longer be considered a small war. In cost it is a great
war. Let me just make a statement to the Committee as to what,
so far, the estimated cost of this war has been. In 1899-1900 the
Estimates were £23,217,000. Last year they were £68,620,000,
and this year's Estimates amount to £60,230,000, including in
each case the interest on the sums borrowed. That amounts to
over £152,000,000. I must ask the Committee to remember that
in those figures I include the cost of both the South African
and Chinese wars. Then I have to add a million and a quarter
for this year's borrowing, making in all over £153,000,000.
That is double the cost of the Crimean War, and when I look
back at the Peninsular War I find the two most expensive years
were 1813 and 1814. The forces engaged, of course, were very
much smaller than those engaged now; but in those two years
the total cost of our Army and Navy amounted to £144,581,000.
This amount is less than the charges of the South African and
Chinese wars. Therefore, I think I am justified in saying that
in cost this has been a great war. I think, then, it is clear
we can no longer, in borrowing towards the cost of it, rely
upon temporary borrowing. We have already £67,000,000 of
unfunded debt borrowed for this purpose and maturing within
the next ten years. We have also some £36,000,000 of 2¾ and 2½
per cent., redeemable in 1905. Therefore, whatever may be the
prosperity of the country, whatever may be the condition of
our finances, it is perfectly obvious to my mind that the
stanchest advocate of the redemption of the debt will have
ample scope for his energies in the years that are now before
us. For this reason I propose to ask the Committee to extend
the powers of borrowing which they gave me in previous Acts,
to Consols."
----------SOUTH AFRICA: End--------
SOUTH AFRICAN REPUBLIC, The.
See (in this volume)

SOUTH AFRICA (THE TRANSVAAL);
also,
CONSTITUTION (GRONDWET) OF THE SOUTH AFRICAN
REPUBLIC.
SOUTH AUSTRALIA.
See (in this volume)

AUSTRALIA; and CONSTITUTION OF AUSTRALIA.
SOUTH CAROLINA: A. D. 1892-1899.

The Dispensary Law.
In 1892 the Legislature of South Carolina passed an Act,

commonly called the Dispensary Law, which caused turbulent
agitations in the State, and excited much interest in the
country at large. It was based upon the principle of what is
known as the Gothenburg system of regulation for the sale of
intoxicating liquors, making the traffic a State monopoly,
carried on by officials, under rigorous restrictions, with
profit to the public treasury, and none else. It provided for
the creation of a State Board of Control, under the direction
of which a Commissioner, appointed by the Governor, should
purchase all intoxicating liquors allowed to be sold in the
State, and should furnish the same to such agents (called
"dispensers") in the several counties as might be appointed by
county boards to sell them, in accordance with the regulations
prescribed. It required all liquors purchased by the
Commissioner to be tested by an official chemist and declared
to be pure and unadulterated. It allowed nobody but the
official "dispensers" to deal in any manner with any kinds of
intoxicating liquors after the 1st of July, 1893. It forbade
the selling of such drinks by the authorized salesmen to
minors and drunkards, and it required all who bought to sign
and date a printed or written request, stating their residence
and age.
The law was fiercely resisted in many parts of the State by

mobs, and powerfully assailed in the courts; but Governor
(afterwards Senator) Tillman, who then occupied the executive
chair, gave it resolute enforcement and support. The attack in
the courts had momentary success in 1894, the Supreme Court of
the State rendering a decision adverse to the
constitutionality of the law; but, meantime, the Legislature,
in 1893, had made changes in the Act, and its new enactment
was held to be untouched by the judgment of the court.
{518}
Before a new case could be brought to issue, the retirement of
one of the justices of the Supreme Court brought about a
change of opinion in that tribunal, and the law in its new
form was sustained. Disorderly resistance to the enforcement
of the law was long kept up; but in the end such resistance
seems to have been mostly overcome.

Ebook PDF Critical Conversations For Patient Safety An Essential Guide For Health Professionals PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ebook PDF Critical Conversations For Patient Safety An Essential Guide For Health Professionals PDF

Uploaded by

Copyright:

Available Formats

(eBook PDF) Critical Conversations for

Patient Safety: An Essential Guide for

The real-life patient stories and critical thinking activities profile

FOR PATIENT SAFETY

edited by Tracy Levett-Jones

edited by Tracy Levett-Jones

CVR_LEVE4270_01_LT_CVR.indd 1 10/09/13 11:48 AM

Associate Professor David Hewett, MBBS MSc PhD FRACP

Dr Sue Outram, PhD, RN, BA

Healthcare is increasingly complex; this complexity coupled with inherent human

It is critically important that health professionals have well developed interprofessional

Stories give life!

Tracy Levett-Jones and the ‘Critical Conversations’ writing team

How to use this book

Critical thinking activities and guided reflection questions encourage you to

A glossary of terms is provided on page 244.

Madeline Jones, Bachelor of Physiotherapy student, The University of Newcastle

Tyler Jones, Bachelor of Nursing student, The University of Newcastle

Peter Sinclair, Lecturer, The University of Newcastle

John Wormington, Solicitor, McDonald Legal Pty Ltd, Charlestown NSW

Sandra Campbell-Crofts, PhD Candidate, University of Tasmania

Professor Cobie Rudd, Pro-Vice-Chancellor (Health Advancement), Edith Cowan

Renee Brighton, Lecturer and PhD Candidate, University of Wollongong

Professor Kerry Reid-Searl, Assistant Dean Simulation, CQUniversity

Dr Gilly Smith, Senior Lecturer, Edith Cowan University

Sue Dean, Lecturer, Faculty of Health, University of Technology Sydney

Professor Eimear Muir-Cochrane, Chair of Nursing (Mental Health), Flinders University

Dr Sharon Bourgeois, Associate Professor, University of Wollongong

While most health professionals regard themselves as good communicators, and

Emeritus Professor University of Western Sydney,

Chair, Australian E Health Research Centre

formerly, President of the International Society for Quality in Health Care

health professionals from the same discipline) and therapeutic communication

Patient safety and communication

Box 1.1 The Australian Charter of Healthcare Rights

Box 1.2 Patient survey: Top priorities for healthcare

• failure to communicate with supervisors/administrators when patient safety is in jeopardy

Box 1.3 Critical conversations and patient safety

Using critical conversations to promote

Out of the instructions he received, Lord Kitchener finally

"His Majesty's Government will at once grant an amnesty in the

"All prisoners of war now in St. Helena, Ceylon, or elsewhere

"At the earliest practicable date military administration will

"Church property, public trusts, and orphans funds will be

"As regards the debts of the late Republican Governments, His

"When burghers require the protection of fire-arms such will

"As regards the extension of the franchise to Kaffirs in the

"In conclusion, I must inform your Honour that if the terms

A discussion of the negotiations in Parliament occurred on the

As to the difference between the terms of future government

The radical Mr. Labouchere was sharper in his criticism: "He

SOUTH AFRICA: The Field of War: A. D. 1901 (February-April).

A British Blue Book, made public in London on the 18th of

"To the losses incidental to the actual course of the

"The events of the last six or seven months will involve a

"What is more serious to my mind than the mere material

"The present position of affairs, alike in the new territories

"The inherent vice, if I may say so, of almost all public

"If I might sum up the predominant, indeed, the almost

Great Britain, Papers by Command, Cd. 547.

SOUTH AFRICA: The Field of War: A. D. 1901 (April).

Early in April it was announced that the seat of government of

SOUTH AFRICA: The Field of War: A. D. 1901 (April).