“Focus on the values of nursing to boost care – not checklists”
Nurses must ensure that ward rounds do not become tick-box exercises
Task-focused nursing is making a comeback. Tick-box lists of tasks are designed to ensure patients’ needs are met in a systematic way. Some schemes, such as intentional rounding, even tell nurses or healthcare assistants to finish up with: “Is there anything else I can do for you – I have the time?”
In a speech earlier this month, the prime minister said formal nursing rounds are needed because of acknowledged shortcomings in nursing care, especially in that of older people. Rounds and checklists may be a safety net but will they provide compassionate care – or be a paper exercise?
In 2011, the Care Quality Commission’s report, Dignity and nutrition Inspection Programme: National Overview, blamed the failure of management on poor care, stating: “People were spoken over, and not spoken to; people were left without [a] call bell… or not given assistance to do the basics of life – to eat, drink, or go to the toilet.” It also indicated a lack of compassion. “‘Care’ seems to be broken down into tasks to be completed – focusing on the unit of work, rather than the person,” it found.
Ironically, one aspect of the changes to nursing in the 1970s, aimed at increasing professional status, was to move away from task-orientated nursing and hierarchical leadership. In the 1980s, when Project 2000 proposals were published, Nursing Timescontributed its own critique, condemning the traditional model of nursing by caricaturing it. A series of satirical letters supposedly written by the old-fashioned “Sister Plume” parodied her punctilious attitude. In one she commented: “I have long considered that we do our young girls a disservice by insisting on all the psychology and technology (this is far better left to the medical men) instead of concentrating more on ‘bottoms and bowels’” (Russell, 1988). Paradoxically, bottoms and bowels, pressure ulcer prevention and toileting are now on the intentional rounding checklist.
Changes to nursing, and the diminishing of the sister’s role, reflect deeper cultural shifts in society. Hierarchy and authority are seen as negative constraints undermining individual freedom. Governments and the Royal College of Nursing have recognised the problems around care and attributed this to a need to strengthen leadership, but reports show that despite their efforts, serious shortcomings persist and cannot just be blamed on shortages.
Sister Plume would have been shocked it has come to this. Maybe she was luckier than today’s sister – she had control over her nurses and ward. Back then, commitment to patients was expected to override all other considerations. Nurses existed for patients’ needs, however menial, and their job was to ensure this. They embodied a system that patients trusted and esteemed.
Prime minister, it is the values of Sister Plume’s system and not mechanical rounds and checklists that will improve care.
Dr Ann Bradshaw is a senior lecturer in adult nursing at Oxford Brookes University
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Care Quality Commission (2011) Dignity and Nutrition Inspection Programme: National Overview. London: CQC.
Russell S (1988) Sister Plume’s Notes on Nursing. Basingstoke: Macmillan.