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Is nursing’s great challenge care of the elderly?

A recurring theme in negative reports about nursing quality in the NHS seems to be the care given to older patients. Clare Lomas investigates what can be done to meet the challenge

Last month TV agony aunt and former nurse Claire Rayner described the way some nurses treated elderly patients as “cruel” and “demeaning”.

In a foreword to a report from the Patients Association, of which Ms Rayner is president, she said it was “sickening” to see how some parts of the profession had changed since she was a nurse, and called for “bad” nurses to be struck off the register.

The report, which made for tough reading, concentrated on 16 examples of poor patient care, taken from a database of hundreds received by the charity from relatives of patients in England.

It cited elderly patients being left lying in their own urine and faeces, having call bells taken away from them, and being left without food and drink. The report was, unsurprisingly, reported widely by the national media.

But it is only the latest in a long line of reports to criticise NHS trusts for poor fundamental patient care, and in particular older patients.

A now infamous report from the former regulator the Healthcare Commission, published in 2007, revealed that patients at Mid Staffordshire NHS Foundation Trust had been left in “wet or soiled” sheets. In 2007 an equally high profile report from the commission also found “significant failings” in basic patient care at Maidstone and Tunbridge Wells NHS Trust.

Nurse Margaret Haywood risked her job when she went undercover for the BBC in 2005 to expose poor elderly nursing care at a hospital in Brighton. She has since been struck off the register by the NMC for breaching patient confidentiality, a decision which she is currently appealing.

Inadequate NHS care is not exclusive to the elderly, but it is nurses who work with older people who appear to be continually coming under fire, particularly around issues related to patient dignity.

“It would be easy to say this is just a nursing issue, but it is a lot broader than that,” said University College London nurse consultant for older people Jonathan Webster. He highlighted a range of factors that impacted on nursing care.

“There are a lot of factors around delivering essential nursing care, such as the skill mix of the workforce, and how organisations promote practice around the care of older people. I am not defending poor practice, but a lot of elements come into play,” he told Nursing Times.

RCN’s advisor in nursing older people Pauline Ford said trusts needed to recognise that delivering effective nursing care to older people required a highly skilled workforce that needed to be supported and encouraged.

“We do not condone poor or abusive practice. But instead of punishing nurses, we need to look at the culture of NHS organisations, and explore what is allowing this environment to happen,” she said.

“The majority of nurses who look after older people are highly motivated and committed, but they are overstretched and overloaded. Organisations need to start recognising the level of complexity involved in the care of older people, and start having conversations with ward based staff about what needs to happen to change practice.

“Nurses need resources and good leadership to be able to deliver effective care to older people. In organisations where staff feel supported and valued, visible clinical leadership is very apparent,” she added.

This lack of support apparently exists in spite a range of formal guidance and other efforts. The Department of Health published the national service framework for older people in 2001.

Since then there have been a raft of policies and campaigns aimed at improving the fundamental hospital care of older people.

For example, a 2006 campaign from the British Geriatric Society – called Behind Closed Doors – was aimed at improving toileting care, and the Hungry to be Heard campaign, launched by the charity Help The Aged in the same year, was designed to improve hospital food and assistance with eating for elderly patients.

More recently, the RCN launched a campaign to champion patient dignity last June, giving nurses the practical tools “to ensure compassionate care and challenge poor practice where it exists”.

Despite the push to improve hospital care for elderly patients, examples of poor basic care keep on being highlighted. Some suggest this is a wider reflection of the way older people are viewed by modern society.

One of the key aims of the NSF for Older People was to root out age discrimination in the NHS. But almost ten years after the document was published, ageism is still rife, said Deborah Morris, directorate manager for specialist services for older people at the Royal Liverpool and Broadgreen University Hospitals NHS Trust.

“The NHS is a microcosm of society, and society is still ageist. Poor standards of care for older people have always existed, yet until something sensational happens, nothing is done,” she said.

“The NSF is a really positive tool that has helped build change in older people’s nursing, and putting it under the spotlight has forged a surge of service improvements. However, unless we continue to champion older people and push for more service improvements, they won’t happen. The leadership on this and the commitment has to come from the top” she added.

With the NSF for Older People due to run out next year, trusts need to go back and look at what has been achieved in order to move forward, said Mr Webster. 

“There is lots of guidance out there and evidence to support its input, but we need to be able to demonstrate the impact on patient care,” he said. “Although there are many examples of good practice, we need to address why some things are still not happening. For example, how many hospitals have put specialist outreach teams in place to help support older people?”

According to Ealing and Harrow Community Services consultant nurse for older people Linda Nazarko, the perceived image of older people’s nursing, and of those who work in this area, is partly responsible for hindering good care.

“Older people’s nursing can struggle to recruit the brightest and the best nursing students, because it is seen as a job of last resort rather then a positive choice,” said Ms Nazarko, an older people’s nurse for more than 25 years.

Like Mr Webster she also highlighted the need for more leadership and support for nurses working with older people.

“The level of acuity of older people has increased significantly, and nurses have to be highly skilled to work in this area. Nurses who do this job do not need to be run down by the rest of their profession, they need positive role models and leaders, and to feel valued and supported,” she said.

As Ms Nazarko points out, pressure on this area of care is only likely to increase. A greater proportion of the population than ever before are classed as elderly and as people live longer, so they develop a more complex range of co-morbidities.  

According to data from the charity Age Concern, the number of people aged 65 and over living in the UK is expected to rise by more than 60% in the next 25 years to almost 15.8 million by 2031.

Almost 70% of people aged 85 and over living in the UK have a disability or long term condition, and one in three people who die aged 65 and over have dementia, the charity said.

When the Department of Health published Lord Darzi’s NHS Next Stage Review in June 2008, one of the aims of the reform was to provide better care for people with long term conditions closer to home – moving care for this group of patients from the acute sector to the community to help them self-manage their condition.

However, helping older people to self-manage long term conditions will not happen overnight, and changing behaviour from dependency on acute care will take time, said Jonathan Webster.

“Older people are the largest group of service users in the NHS, and will continue to be admitted to hospital wards with multiple co-morbidities. We have to have a skilled workforce to ensure their needs are met,” he said.

“Staff need to be able to identify the real issues, who is at risk and who needs help. It is not just about feeding a patient, but observing how they swallow when they eat and drink, and promoting their ability to help themselves.

“Patient safety and quality have to be at the forefront of care, and nurses need the appropriate training and expert support to achieve this,” he added.

However, pre-registration training in the care of older people is currently variable, and depends on the educational organisation attended.

The Florence Nightingale School of Nursing and Midwifery at Kings College London runs a course for senior students specifically on the care of older people. But in many organisations it is embedded into other parts of the curriculum.

Post-registration courses in the care of older people are available to qualified nurses, but again they are often part of other relevant modules, such as continence care, rather than fully-fledged stand-alone courses.

Mr Webster has developed a six-month course designed to help nurses understand the complexities of nursing the acutely ill older person. Run at South Bank University, the six-month course focuses on the key elements that underpin practice, such as falls prevention, privacy, dignity and nutrition.

“We need to have dedicated training to promote the care of older people as a speciality in its own right, because existing training does not support this approach,” said Deborah Morris.

“The pressures placed on NHS nurses, and the immense pace they have to work at, mean it is also difficult for them to take the time out to do training. A lot of nurses struggle to even get the time to do their mandatory training,” she added.

Ms Nazarko added that where training courses do exist, they are often undersubscribed. “There needs to be a root and branch reform of nursing education, at both pre- and post- registration level,” she said.

“Around 80 per cent of service users in the NHS are older people, but there are not enough specialist training modules to reflect this. Nurses looking after older people need more resources to enable them to do their job, including specialist training in things like advanced communication and physiology,’ Ms Nazarko told Nursing Times.

Ms Nazarko added that issues around staff shortages and the number of senior nurses caring for older people also need to be addressed.

“There is huge pressure placed on nurses today, and although older people need greater levels of care, staffing levels have not been increased to reflect this. I would also like to see more nurse consultants for older people employed in the NHS,” she added.

However, improvement may be the way, with several important developments in the pipeline.

From April 2010, all health and adult social care providers will have to meet new quality standards to register with the Care Quality Commission, or face having their services suspended.

As part of this new registration system, the Care Quality Commission will focus a series of special reviews and studies on the dignity agenda, including a review of healthcare needs in the home, and the stroke pathway.

Additionally a full evaluation of seven sites involved in the RCN’s dignity campaign will also be available later this year. Pauline Ford said preliminary results have shown some very promising results.

“Organisations need to hear the messages in reports like the one from the Patients Association and start working towards improving both the patient and staff experience,” she said.

“But we need to move away from a punitive and critical approach and towards one of appreciation, focusing on value systems. Only then can we empower the workforce and deliver effective care,” she added.

Readers' comments (2)

  • I work in general medicine and care of the elderly.

    We get 3 staff for well over 20 acutely ill and elderly patients.

    The majority of our patients are cognitively impaired, resistant to care, combative, and immobile. They have multiple co-morbidities and are very complicated. In addition to this we take acute medicals who also tend to be elderly with the same problems.

    The ward upstairs is short stay surgery. Their patients are mostly young to middle aged well adults. They have no real past medical history. They are oriented and mobile and self caring throughout their hospital stay, merely in for a hernia repair. They have one nurse to 6 patients up there. We are one to 15 many days.

    When we make the claim for better staffing we are told that medical nurses only "deal with commodes" and that more staff will not be forthcoming. Yet I get called to surgical wards when the nurses are freaking out because a CCFer just went bad and they don't know what to do.

    Having worked in many areas of health care I do find that acute medical and care of the elderly is more intellectually challenging than what I experienced in short stay surgery. It is certainly more demanding and challenging than a specialist ward that has a well controlled patient population i.e. planned admission orthopaedics. Care if the elderly has changed dramatically since the old days.

    Our health care assistants are treated terribly compared to the health care assistants in surgery. They are not allowed to go past level two, yet their job is more demanding in general medicine.

    But the only the nurses realise this. Management does not want to understand any of this.

    And I would like to know when the public is going to stop expecting an RN, who has no contol over the number of patients she has, to be able to do everything for everyone at all times.

    My experience is that most of our patients probably need to have one to one care in order to get the kind of care that their families want them to have. Why the families do not push for this, is beyond me.

    Unsuitable or offensive?

  • The answer to all these problems is to abolish the geriatric ward. Geriatric wards are ageist, you are not sent there for a particular illness or procedure, you are only sent there because of your age. Geriatric doctors could see older patients on mainstream wards, where it would be far less easy to ignore patients, or abuse them.

    Unsuitable or offensive?

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