In an article titled 'The crisis in caring: An evidence-based response', Fergus O'Ferrall (2013) addresses several widely reported failures of health professionals in Ireland and the United Kingdom to provide even the minimal expected level of care for hospitalised patients. He asks: 'Why does a hospital stop being sensitive to patients' needs and their distress? What about the consultants doing their ward rounds every day? Did none of them hear the cries and smell the smells? What about the hospital's Director of Nursing? If the buck does not stop with her or him, who does it stop with?'

Buck-stopping and responsibility

For the buck to stop with someone, it means that person is expected to take responsibility for making decisions in line with her or his role in a given situation. It means saying 'the buck stops here'. Avoiding responsibility for making such decisions is called passing the buck. The phrase, the buck stops here, became popular in the United States in 1945 when President Harry S. Truman displayed it as a sign on his desk in the Oval Office. It became his motto for taking responsibility for making decisions that affected the wellbeing of the nation. 

These phrases probably originated in the Wild West American Frontier days when gambling, particularly playing poker, was popular. Most everyone carried a knife and many knives had a handle made from the antler of a deer; a buck-handled knife. As a game of poker proceeded, a buck-handled knife was placed in front of the person whose turn it was to deal the cards; the buck stopped with the person who was responsible to deal. But a person who didn't want to take responsibility could pass the buck to someone else (Mathews 1951).

O'Ferrall's (2013) article is an urgent appeal to health professionals to take responsibility for implementing their particular role in the multidisciplinary care of patients. He highlights a long-standing and distinctive role of the nursing profession; continuous watching, protection and safeguarding of patients and ensuring unconditional respect for their dignity. When the nursing profession passes the buck on these responsibilities, a crisis in caring occurs.

Where the buck stops in nursing

When O'Ferrall (2013) indicates that the ultimate responsibility for care of patients in hospitals lies with nurses he is airing a historical truth (Black 2005). But it is all too easy to say that the buck stops with the Director of Nursing. In fact, for nurses this would be a cop-out; a failure to face our situation squarely. The buck stops with each one of us at each of our distinctive professional responsibilities.

For example, take the Careful Nursing critical circle of clinical responsibility. First up, the buck stops with watching-assessment-recognition, an activity whereby clinical, staff nurses are at the frontier of patient care. In this 'first-alert' position we are responsible to identify the often-subtle indicators of physiological complications patients can develop. Simultaneously, the buck stops with our being responsible to have the knowledge and skill required for clinical reasoning and decision-making leading to collaborative, inter-professional judgements and actions, and intra-professional nursing judgements and actions; nursing diagnosis, outcomes and interventions. Next up, the buck stops in front of patients. Here it points to our responsibility to engage their participation in planning and implementing their care, as they are able. 

Imagine what it would mean for patients if we passed the buck on any of these responsibilities. It would mean that our practice had become a form of gambling, of playing poker with patients' recovery; even with their life. 

In the Careful Nursing therapeutic milieu dimension the buck stops everywhere. It stops repeatedly in fount of how we are in ourselves: Are we calm? Are we unconditionally respectful of the dignity of human persons? Are we kind to ourselves and to one another? Are we intellectually engaged? Are we attentive, patient, empathic, kind and compassionate in our care of patients? 

Buck-stopping and patient safety

The crisis in caring addressed by O'Ferrall (2013) is, in essence, a failure to keep patients safe. Patient safety means – The Buck Stops Here! – for each one of us in every aspect of our practice. 

References

Black N. (2005) Rise and demise of the hospital: A reappraisal of nursing. British Medical Journal, 331 (7529), 1394-1396.

Mathews, M.M. (1951) (Ed.) A Dictionary of Americanisms on Historical Principles. Chicago, University of Chicago Press, 198-99.

O'Ferrall F. (2013) The crisis in caring: An evidence-based response. Studies: An Irish Quarterly Review, 102 (407), 324-335. www.carefulnursing.ie/go/publications/related_reading

Therese Meehan