How the bravery of a few can make a real difference to patient care


I first visited Romania in 2011 following a chat with a friend who had been visiting for many years sharing work around infection prevention and control. I was asked to go along and give some teaching about clinical governance and audit to a hospital in Transylvania.

I wasn’t sure what to expect but it seemed like an interesting opportunity so I decided to go along.

What a culture shock! I naively shared some of the improvement work and principles of governance we were working with at that time, and remember the audible gasp when I showed an image of patient harm data displayed on a public area on the ward at the Trusts I was working for in the UK.

I had made the assumption that there would be some acceptance of the harm caused by healthcare as, if you don’t accept that we cause harm how can it get better? When I explored more deeply I discovered that if you make an error in Romania you get fined (up to a month’s salary) so of course no one makes any errors or causes any harm!

Not only that but:

  • There is little nursing hierarchy; nurses are directly answerable to the consultant in charge of the ward.
  • The hospital environment is very poor, lack of equipment (mattresses, beds) with wards dark and crowded.
  • Most patient personal cares are undertaken by the family of the patient so observations are low.
  • There was almost no paperwork –imagine!
  • Corruption still exists in some places with patients charged extra for some treatments.
  • There is no effective nurses union, nurses are known as doctor’s assistants and there is little professional autonomy or identity.

Over the next 2 years I returned twice to the hospital, and gradually changes started to happen, one particular example was from working with a surgical ward team on pressure ulcers. A colleague and I sowed a few seeds around how to prevent pressure ulcers, shared some risk assessments and care plans, and shared a few ideas of what was possible. Amazingly when we returned the following year, the ward team were risk assessing and taking preventative measures and crucially counting and being open about patients getting pressure ulcers on the ward.

So how did this happen?

I have reflected on this over the years and I now believe this is largely due to the courage of a few very special staff (both nurses and doctors).

In the UK yes we have our issues and yes it is sometimes difficult to speak out, but picture yourself as sister on a ward in Romania, with all the constraints to your role, if you want to make a change or challenge corruption where do you start?

I think of myself as someone who stands up for the patients and what is right but I have thought about how I would cope in such an environment? Would I be brave enough to push forward with a change in Romania?

This year when I returned to Romania after a 2 year gap I was heartened to see the massive improvements that have been made to the hospital environment, wards are now bright, light and most necessary equipment is in place, there is evidence of the changes we have introduced over the years for example in infection prevention and pressure ulcers.  

My theme for this year was to introduce the idea of safety huddles at a national patient safety conference and hopefully to start to work with a ward at the local hospital. An ambitious aim when you bear in mind that to be successful the basic building blocks are a flat hierarchy, clear leadership and an acknowledgment of harm caused!

I have some more work to do with the ward in the interim and will keep in touch with what is happening but it will be really interesting to return next year and see if any of the seeds sown have taken root?

So this blog is dedicated to those few very brave individuals who, despite all the difficulties keep on working to provide better safer care in a system that very rarely rewards their efforts and at no small personal risk. I feel privileged to work with these people and always learn as much from them as they do from me. The warmth and hospitality shown to us ensures the visits are also great fun, Romanians certainly know how to have fun!