The Yomiuri ShimbunYOKOHAMA — An investigation into a series of poisoning deaths at Oguchi Hospital (now called Yokohama Hajime Hospital) in Yokohama has found that a nurse allegedly mixed antiseptic solution into patients’ intravenous drips. Suspect Ayumi Kuboki, a former nurse at the hospital, has cited her lack of confidence in communicating with patients and their families and her own incompetence as motives for the alleged incidents. We spoke to three experts about the stress that nurses deal with, their relationships with patients and what kind of risk management is required for medical institutions. The following are excerpts from the interviews.
(From The Yomiuri Shimbun, Sept. 6, 2018)
Essential for nurses to share their concerns
The recent case in which a nurse allegedly murdered patients at a hospital has tarnished people’s trust in nurses. I have offered consultation to nurses who said they have difficulty communicating with patients and families, and are under stress. However, a nurse’s job is to help people. Good self-awareness and the ability to manage stress are essential for them.
Nurses also help patients eat and use the bathroom. Because they interact with patients every day, they often hear complaints from patients who are reluctant to voice such complaints to doctors, and many nurses think that receiving such complaints is an important part of their job. Certified nurse specialists in psychiatric mental health nursing (see ) share the concerns of nurses in charge of caring for difficult patients and offer advice. They also listen to patients before deciding which course of action should be taken. By understanding the circumstances that patients are in, nurses do not feel heavy stress.
Certified nurse specialists in psychiatric mental health nursing are responsible for nurses’ mental health, which was already drawing attention around the 1980s. Nurses are working under tense situations in which they have to deal with matters of life and death, and, in some cases, they are suffering from taking on burdens from patients’ lives. They often suffer from heavy mental burdens in emergency medical care and struggle in dealing with the gap between the ideal and the reality. About 25 years ago, I worked for three years at a hospice providing care to patients nearing the end of their lives. Every day, I was desperately asking myself what would be beneficial for patients and their families. However, if what a patient really wishes is “I don’t want to die,” I cannot help fulfill this wish. During the 1980s, mental burnout due to a dilemma similar to this surfaced among nurses.
The more passionate nurses are, the more frustration they feel about their lack of skills. They tend to reflect on their conduct and feel their mental burden increase as a result. However, nurses are not working alone. If there are patients who need special care, it is possible to lessen the burden on individual nurses by, for example, assigning in rotation multiple nurses to those patients. Nurses will only be able to provide good care for others if their own mental health is good.
In the past, even in the nurses’ station there was the feeling that it wasn’t good for nurses to voice their personal opinions about specific patients. Under such an atmosphere, however, nurses often got caught up with their awareness that a certain patient is hard to handle. In order for nurses to become more aware of their own personalities and the way they think, there need to be opportunities for nurses to hold meetings with their colleagues where they can share opinions about patients.
Because nursing is a job that involves people, distress related to human relationships is unavoidable. I believe the psychological burden on nurses can be lessened if nurses as a team share what they feel and talk with each other.
— This interview was conducted by Yomiuri Shimbun Staff Writer Takahito Higuchi.
■Certified nurse specialist in psychiatric mental health nursing
Experts who listen to patients and their families, and provide mental health care. They also advise nurses, helping them maintain a good relationship with patients, and provide mental health support for nurses themselves. After graduation from a nursing-related graduate school, at least five years of practical training is required. Psychiatric nurses are certified by the Japanese Nursing Association; as of Sept. 4, 291 people had obtained certification.
■Motoko Hirai / Certified nurse specialist in psychiatric mental health nursing at Tokyo Yamate Medical Center
Hirai, 54, became a certified nurse specialist in psychiatric mental health nursing in 2003, after completing a master’s degree course at the graduate school of the College of Nursing Art and Science Hyogo. She has also written about nurses’ mental health.
Spotting the signs, providing early support
The Oguchi Hospital incident has something in common with other cases of abuse at nursing homes. At such facilities, people tend to fall into two categories: those who provide support and those who receive it, or those who provide care and those who are cared for. This could lead to hierarchical relationships forming. The situation is the same in hospitals. Both are workplaces where staff work to help others, and negative feelings about their work sometimes develop, such as concerns about the amount of time spent providing support. Also, both environments are closed off.
People can easily become influenced by the positions they are in, and develop desires to control others. Stanford University psychologist Philip Zimbardo conducted an experiment in 1971 in which students were randomly assigned to be either “guards” or “prisoners” in a mock prison. When spending the night there, Zimbardo found that the behavior of the “guards” was similar to abuses committed by guards in real prisons. The experiment demonstrated the difficulty people had controlling themselves and the unexpected fragility of their consciences.
As terminal care is a field in which people are close to death, it is obvious that caregivers experience stress.
Stress can make it harder to apply the brakes on abuse. About 25 years ago, when I worked as an instructor at a facility for intellectually disabled children, many staff members lived in the facility with the children. In such an environment, staff members with differences in child-raising or educational policy easily developed stress.
I frequently witnessed scenes of caregivers tying children’s feet to a bed or resorting to violence. I even found myself raising my voice at my colleagues.
However, there is a big difference between this behavior and homicide. Ayumi Kuboki, the suspect in the Oguchi Hospital incident, reportedly explained her motives, saying, “I worried about what I would say to bereaved families when patients died.” This represents a simplistic and childish way of thinking. People have the control to stop themselves from doing things that they should not do. As communication via social media and the internet becomes more common, face-to-face interactions are decreasing. Consequently, children tend to lack opportunities to mature.
It seems that Kuboki was not in the right frame of mind. It is necessary to have supportive work environments, in which the mental state of caregivers is checked for signs of distress. It is often the case that abuse in care facilities is a result of staff members suffering from nervous breakdowns after caring for people with behavioral and other disorders. People in the field should examine each case as the problem of the entire facility, and discuss ways to solve them.
If people in managerial positions talk to their staff members and listen to their concerns, that could make all the difference.
Once a month, I teach dance, such as “Matsuken Samba,” at a facility for people with intellectual disabilities in Aizuwakamatsu, Fukushima Prefecture. Caregivers also take part in the class. Sharing simple pleasures in their daily lives could lift the atmosphere in such facilities, nurturing not only fellowship but also affection among the people there.
— This interview was conducted by Yomiuri Shimbun Staff Writer Erika Noguchi.
■Kazuhiko Ichikawa / Professor at the University of Aizu, Junior College Division
Ichikawa, 58, worked at a vocational aid center and a nursing home for children with intellectual disabilities, among other facilities, before assuming his current post. He specializes in welfare measures for people with disabilities. Ichikawa is the author of such publications as “Shisetsu Gyakutai” (Abuse in care facilities).
Operate based on assumption of crimes in hospitals
Hospital management in Japan is based on the belief that human nature is fundamentally good. Many people think of hospitals as places that treat disease and injury, and assume that everyone working there is a good person. Although this optimism is a good point for Japan, it also makes hospitals vulnerable to crime.
The Oguchi Hospital incident shows how dangerous it can be to operate a hospital based on the premise that people are fundamentally good. It’s time to change that view.
In other countries, hospitals are seen as places where various people visit, and there could be crimes and other risks — totally different from the view in Japan. There’s also the risk of people getting their hands on drugs that could be used for criminal purposes.
In this particular case, an easily accessible antiseptic solution was used, not a strictly controlled hazardous substance. This is a blind spot.
Outside Japan, security measures are taken on the assumption of potential risks. For example, a university hospital in South Korea is equipped with an alarm system to prevent the abduction of newborn babies. A Cambodian hospital opened by Kitahara International Hospital in Hachioji, Tokyo, controls entries and exits in each room through IC cards.
The suspect, Ayumi Kuboki, is said to have looked for opportunities to poison her patients’ intravenous drips with antiseptic solution, for example, while her colleagues were doing their rounds.
There were no security cameras installed at the hospital at the time. I don’t think that is a problem in itself. When cameras are used, staff feel uneasy knowing that they are being watched. The use of IC cards, on the other hand, can discourage staff members from committing a crime without putting them under undue pressure. Many companies widely use IC cards in Japan, but hospitals are still lagging behind in that regard.
In foreign countries, hospitals are also very strict when it comes to investigating the backgrounds of new doctors and nurses, requiring candidates to present original copies of their qualifications and obtaining confirmation from the issuing authorities. Foreign hospitals also sometimes conduct reference checks, contacting previous employers of the candidates to ask about their attitudes toward their work.
There had been other problems prior to this recent incident, including missing medical records. Were the same thing to happen in a foreign hospital, it would soon carefully investigate who was to blame and why. I believe this attitude of foreign hospitals can serve as a reference for Japanese medical institutions.
We mustn’t just treat this incident as a special event. We must think that hospital staff members might break the law on the spur of the moment because they’re worried about “monster patients” who repeatedly make unreasonable requests, or due to personal relationships within the hospital.
However, because establishing risk management measures doesn’t directly increase profits, there’s a tendency for hospital operators to assume that their hospitals are fine without such steps. Therefore, small and mid-size hospitals are often reluctant to implement appropriate safety measures.
The government must compile guidelines requiring hospitals to monitor the whereabouts and movements of their staff.
— This interview was conducted by Yomiuri Shimbun Staff Writer Yuka Isogawa.
■Toshiki Mano / Professor at Chuo University graduate school
Mano, 56, specializes in medical management. He is a physician with a doctorate in medicine and in economics. He is a panel member for the Office of Metropolitan Hospital Management, and is also the author of “Iryo Kiki: Korei Shakai to Inobeshon” (Medical crisis: Aging society and innovation).
■Outline of Oguchi Hospital incident
On Sept. 20, 2016, at Oguchi Hospital, a male inpatient, 88, died of poisoning after an antiseptic solution was added to his intravenous drip. The body of another 88-year-old male inpatient who had passed away two days earlier was also found to contain elements of the antiseptic solution, and the Kanagawa prefectural police began investigating the case as serial murders.
The suspect, Ayumi Kuboki, was working as a nurse at the hospital. She was arrested three times in July and August this year on suspicion of the murders of the two male inpatients, as well as a female patient, 78. Kuboki confessed to the crimes, claiming that she had trouble explaining to patients’ families about their deaths and aimed to poison the patients so they would die while she was off duty. Kuboki has been detained for experts’ examination since Sept. 3.Speech