'The changed demands of healthcare require organisational commitment'

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31 October, 2011

The media storm following publication of the latest CQC report on hospital care of older people has abated has left health professionals – and particularly nurses – feeling bruised and battered.

Of course some extreme examples described in the report were simply unacceptable. No one should have to lie in excrement for two hours, and it is hardly something staff could have been unaware of.

However, the commentary once again got hijacked by the people who think nurse education shouldn’t extend far beyond wiping bottoms, making perfect hospital corners and mopping fevered brows. What these people fail to realise is that healthcare is a totally different landscape from the time when nurses’ responsibilities were primarily what we now variously call basic, fundamental or essential care.

Nurses have moved into territory once occupied by medics, not in a power-hungry land grab, but because their education has equipped them for this - and because there simply aren’t enough doctors to take on the increasingly complex tasks and responsibilities modern healthcare demands. Would those who want nurses to return to what they see as a golden age that probably looks like 1950 also be prepared to accept the technology and medical interventions available at that time?

But however much the nursing role has changed, the fact remains increasingly vulnerable patients, with increasingly complex healthcare needs, don’t always get the care and compassion they need. So how can healthcare providers address this?

Of course there’s no single answer, but giving clinical staff the right support and leadership would go a long way. And this needs organisational commitment rather than expecting hard-pressed ward managers and team leaders to carry the entire burden. So here’s one option: originating in the US and brought to the UK by TheKings Fund, Schwartz Centre Rounds give staff from across a hospital a forum to discuss non-clinical aspects of patient care - the emotional and social aspects of their jobs. Typically taking place once a month, with lunch provided, the one-hour meetings take a single patient story, presented by the team who provided care, and discuss emerging issues.

A Kings Fund evaluation revealed that staff value the Rounds enormously for providing space to reflect on their work and support in dealing with the emotional challenges associated with caring for increasingly frail patients. It’s probably too much to ask that the mass media acknowledge the changed demands of healthcare, but the organisations employing nurses and other professionals in their increasingly demanding roles must do so - and offer them real leadership and support in fulfilling their responsibilities.

Readers' comments (17)

Rowena Myles | 1-Nov-2011 1:19 pm
I agree that the provision of
healthcare has become increasingly complex as a result of increased technology, also the throughput in acute hospitals is more frenetic than it once was. I would wholeheartedly support the need for nurses to be well educated in order to meet the demands of the modern healthcare environment ,ut would make a plea that what are ofton termed basic, fundamental or essential needs are afforded the same status as those high tech skills. the delivery/supervison of dignified and compassionate care by knowledgable and skilled professionals can mean the difference between suffering and the relief of suffering, the difference between deterioration and well-being and recovery and the difference between a dignified and hopefully pain-free death and spending one's last hours in physical and mental pain and distress. healthcare organisations need to look critically at what their priorities are and question do the expect encourage and provide nurses with the support to provide the sort of care that we would all want for ourselves and our loved ones.
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Jane | 2-Nov-2011 9:36 am
I totally agree withg the comment above
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DH Agent - as if ! | 3-Nov-2011 3:09 pm
Rowena Myles | 1-Nov-2011 1:19 pm

I am 100% with Rowena Myles as well. This sort of thing, from the Mid Staffs story, is something which shows values have been misplaced, somewhere:

'Patients and relatives may tolerate drab surroundings, poor food and staff shortages - but not unkind, discourteous and uncommitted nursing staff.
The most heartfelt and penetrating insights were delivered on the final day of the inquiry (day 133), when the last of the 161 witnesses gave oral evidence.
Helene Donnelly spoke with dignity and courage and her message should reverberate throughout the profession. In a controlled and courteous manner, she told the inquiry that she had worked as a staff nurse in accident and emergency at Mid Staffs hospital between 2004 and 2008. The atmosphere was one of fear; there was a lack of professional leadership, and a chronic shortage of staff and basic equipment. Two senior sisters ruled with a heavy hand, regularly using physical threats and verbal abuse to intimidate staff.
Helene was appalled at the standards of treatment and care, especially where older people were concerned, and at the number of patients who died needlessly in undignified circumstances. Patients endured “unimaginable” suffering and were left “sobbing and humiliated” by staff. Fabricating waiting times was common practice and, when Ms Donnelly refused to falsify records, she was threatened by her managers. Her workload increased and she was expected to stay long after her shift was finished. She became so frightened as a result of threats of physical harm that her husband or her father would collect her after work.
Codes of practice, professional values and ethical standards were all sacrificed, as long as the trust did not incur financial penalties for missing targets. Making a formal complaint to managers or supervisors was futile - it was they who were the problem.
Target-chasing attacked the professionalism of nurses and turned nurse against nurse. Ms Donnelly concluded by making a recommendation that nurses should have access to independent supervisors and confidants who were not part of the organisation.
Ms Donnelly left her post at Mid Staffs fully aware that a culture of neglect may exist in other hospitals and that nurses are frightened to speak out.
After her evidence, people rose to their feet, some in tears, others in stunned silence. The audience at the inquiry, mostly relatives of deceased loved ones, applauded her. They did not applaud what she had to say - they knew that already. What they applauded was her honesty and courage in saying it. '
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mike | 4-Nov-2011 9:05 am
Rowena, whilst I absolutely agree with you, I would say who says that those fundamental aspects AREN'T given the same status as 'high tech skills'? The argument that somehow education erodes the caring aspect of our profession is such a ridiculous and insulting one I am surprised anyone gives it any credence whatsoever; and speaking as one of those degree educated Nurses, my care, my passion for caring for my patients, has been enhanced by my education and clinical skill, not eroded because of it.

When are people going to stop blaming a 'lack of care' from Nurses themselves, and see what is really happening. Many patients are being failed by the NHS, not because of any lack of care by its Nurses, Doctors or any other HCP, but because the CULTURE of the NHS, imposed on us by a top layer of beauracrats, politicians and executives who are focused on a business/profit model, has absolutely no time for little things like care, compassion or ethical treatment of patients or staff. Targets, waiting times, profits and savings, these are the priorities of the modern NHS, not patient care or treatment, not staff well being, not staffing levels or providing the correct, necessary equipment.

When will people start focusing their anger on who and what is truly to blame for many of the ills within the NHS? Things will never change until they do, and until they do, the next mid staffs is only round the corner.
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DH Agent - as if ! | 4-Nov-2011 11:59 am
mike | 4-Nov-2011 9:05 am

'Many patients are being failed by the NHS, not because of any lack of care by its Nurses, Doctors or any other HCP, but because the CULTURE of the NHS, imposed on us by a top layer of beauracrats, politicians and executives who are focused on a business/profit model, has absolutely no time for little things like care, compassion or ethical treatment of patients or staff. Targets, waiting times, profits and savings, these are the priorities of the modern NHS, not patient care or treatment, not staff well being, not staffing levels or providing the correct, necessary equipment.'

I posted a shortened version of exactly that, somewhere, yesterday.

And nobody has ever claimed that being clever means a person need not be caring (although those people who are strong on caring but less clever are being excluded from becoming nurses - probably correctly). All 'we idiots' ever suggest, is that it seems possible that some people who are 'clever enough' to be a nurse, lack as much 'caring' as nurses of yonder years did.
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DH Agent - as if ! | 4-Nov-2011 12:08 pm
mike, this is my post from yesterday, where it related to the above point:

'But you are right - and so is 'Anonymous | 2-Nov-2011 9:38 pm' to an extent. You work within an NHS which has high-level guidance and objectives 'imposed from above' and if they are flawed, those things impede your ability to 'change things for the better' acting as an individual nurse. But 9:38 pm is also correct, in that as an individual you should be trying to change things for the better.

The NHS needs both - good high-level guidance, and good individual behaviour.'

I think we agree about this point, at least !
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mike | 4-Nov-2011 12:44 pm
Michael, "And nobody has ever claimed that being clever means a person need not be caring", actually they have, many times. It is an old argument that has existed since the introduction of the degree into the profession (and also, ironically project 200 before that which wasn't even a degree). The call for 'basic care' to be given equal weight alongside technical skill/education is a symptom of that erroneous thinking. Care AND intelligence CAN go hand in hand. But anyway, slightly off point.

You are right that the NHS does indeed need both of those things you suggest, good high-level guidance, and good individual behaviour. I totally agree.

However, I think that the vast, vast majority of all health care professionals across the spectrum do exhibit this 'good behaviour' (as a rather large umbrella term), and of course there will always be exceptions as there will be in every profession, but these should never be taken as the norm. What is much, much more important is that the 'culture' within the NHS is set right on a lot of different levels.

For example, I would argue that starting right at the top, the business/profit model HAS to go. It has absolutely no place in this environment. From a fundamental ethical paradigm, healthcare should not be a profit making venture. Health care is a fundamental aspect of any civilised society. For a government NOT to provide that simply because they think they have better things to spend the money on (usually the banks) then that is tantamount to criminality in my opinion.
Leading from that, the culture of business that is awkwardly imposed onto health care professionals does not work, it does not fit at all, and causes a LOT of problems. The basic principle of management, directives or policies calling the public 'customers' or 'service users' whilst we tenaciously call them patients, for example. There was a post in a different thread (apologies I can't remember which one) where there was a non clinical manager or trainer or whatever title they gave themselves, denigrating Nurses for criticising her training when she was attempting to utilise customer services protocol within a HC environment, which clearly did not work.

We need to get back to a basic culture which sees the public as patients, not as service users who cost money. They are patients who need care and treatment, and who will GET that care and treatment with dignity and respect to the best of our ability. If that means hiring the correct amount of staff, and the correct amount of QUALIFIED staff, then that is what will be done. If that means ensuring the right equipment, drugs and treatment is available uniformly across the UK, or enough hospital wards and beds are available, etc, then that is what will be done. If that means spending a significant amount of money (which the government DO have) to fund the nations health care without god forbid making a profit, then that is what SHOULD be done.

Of course, I could write a lot more on this issue, but it is THIS fundamental cultural commitment that is needed, I think.
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mike | 4-Nov-2011 12:45 pm
Sorry, should have been project 2000, not 200, typo.
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DH Agent - as if ! | 5-Nov-2011 11:31 am
mike | 4-Nov-2011 12:44 pm

Yes, I should indeed have typed 'nobody rational has ever claimed'.

'Care AND intelligence CAN go hand in hand.' Yes - but a 'PERFECT' nurse, does need the 'care' bit: this isn't 'either or', however you weigh the 2 factors.

'What is much, much more important is that the 'culture' within the NHS is set right on a lot of different levels.' - with you 100%

I also think that most staff behave pretty well, or at least try to. And I think that most patients and relatives behave pretty well - the percentage could be a bit lower, because nurses are a selected group. But nobody who is behaving well, likes being tarred with the wrong brush: so I don't like 'some relatives behave badly, so we plan around that' any more than you like 'some nurses are uncaring, so we assume that for all'.

I also agree with the rest of your post, but you are a nurse and as such can legitimately try to improve the pay, etc, of nurses relative to other groups in society. I won't simply say 'nurses should be paid more' because I need to see 'so who gets paid less' as well, to give an opinion at all. Is it more pay for nurses, and a lower state pension ? More pay for nurses, and lower pay for teachers ? More pay for nurses, and higher corporation taxes ? That is more your question, than mine.

But, as a potential patient, I can legitimately be interested in whether the NHS could perform better, without having any more resources. So the CQC's observation that some wards 'did much better than others, with comparable resources' is, for example, something of interest to me. If those wards were different because of the levels of effort being input by nurses, then it is 'useless' information: I cannot suggest that everyone works harder !. And I wouldn't suggest working harder as a solution, because it leads to stress and problems. But if the organisational and working practices, mean that in some hospitals 6 nurses 'provide as much care' as 8 in other hospitals, then I would want the better practice to spread. The Goverment, of course, might use that as an excuse to try and reduce the number of nurses: again, not quite my issue; I am interested in maximum 'return', for whatever level of resources can be arm-twisted out of the Goverment.

So I do agree with you, but we are both validly more interested in different issues.
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mike | 5-Nov-2011 4:07 pm
Fair enough Michael. But the statement by the CQC that some wards 'did much better than others, with comparable resources' I am very suspect about to be honest.

I think as a very basic starting point, the way wards are run should have a basic tenet instilled of 'look after your staff, the staff will be able to look after the patients'. It isn't as if we are asking for much, basic staffing levels based on clinical evidence, enough resources and equipment to do our jobs, regular and embedded training and updates for staff, good working conditions that take work/life balance and stress and health into account, etc. Support and back up from predominantly clinical managers. This would be the basic starting point for me if I could wave a magic wand and would lead to a real starting point for organisational commitment.

If you want to bring resources and 'maximum return' into the mix, which is a fair point, are you aware of the sheer amount of money that swims around the top layers of the NHS and is wasted before it even gets to the 'front line (ie clinical staff and patient care)? The army of non clinical managers, middle manager, executives and their personal budgets, the non clinical consultants and trainers, generally on band 8a pay or above, moronic decisions made by government such as PPI which waste billions of the NHS' overall budget. etc etc etc. If I mentioned all of the waste I would be here all day. ALL of this, and I mean ALL of it could be swept away without ANY denigration to patient care or services, and the billions could then be spent creating a real NHS from the ground up again, one that has values such as those I mentioned above, one that has true organisational commitment to it's staff, and one that would allow for true cultural and organisational change.
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DH Agent - as if ! | 6-Nov-2011 12:58 pm
mike | 5-Nov-2011 4:07 pm

I have only 2 minutes of online time today - I will read that post, and comment, but not until tomorrow or Tuesday. I am INTERESTED in this 'despite the resources issue' - not saying how clear it is, yet !
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DH Agent - as if ! | 7-Nov-2011 11:27 am
mike | 5-Nov-2011 4:07 pm

mike, I am not saying that the CQC PROVED that '8 staff can do better than 10' but it seems to have raised that possibility. And it looks like 'magic', but it might be true. There are 2 obvious possibilities.

One, is that there is a 'magic' ratio for the skill mix - some particular HCA:nurse(s) ratios, which are opimum.

But the second, is the possibility which intrigues me - and this is related to the second part of your post, and also to the way 'principle-based behaviour' invariably turns into 'tick-box rules'.
Have the 'over-performing' wards, managed to find a way of 'leaving the clinicians to do their job' better than most ? Within all large hierarchical organisations, 'blame flows vertically'. So people nearer the top of the hierarchy, have a tendency to try and micro-manage, or over-manage, people below them. This is why front-line staff claim that 'masses of pointless paperwork, are stopping me from doing my job !'. The basic problem, works out as 'is it better to assume that staff are competent, set objectives, and leave them to get on with it' or 'because I myself (manager) will get blamed if the wards I am responsible for fail, is it safer (for me) to set out detailed rules for their behaviour, and to use 'tick-box' confirmation ?'.

The magic bullet, would be if the hierarchies in those over-performing places had discovered:

a) That by allowing staff to use their discretion more, and fill-in less paperwork, the patients end up with better outcomes, AND ALSO

b) And I myself (the manager, higher up) then end up getting 'blamed less'.

IF that is what the CQC discovered, then a) would suit nurses, and b) would suit managers - so it ought, logically, 'roll out'.

Of course - because I think so far you will agree with me - I will add, that the PATIENTS need to judge if 'patients end up with better outcomes'.

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mike | 7-Nov-2011 6:51 pm
Michael, as for the staffing ratio, the 'magic number' as you put it is 1 qualified Staff Nurse plus at least 1 health care assistant per 4 patients. There is a wealth of clinical evidence on it and Australia have adopted a system based on it.

As for wards performing better than others, the first question I would ask is what criteria did they use? How long did they view the wards for? I have worked on various wards, some better than others, and have seen CQC inspectors come in, sign a few sheets behind their clipboards and then disappear. There is no mention of the fact that some wards were great on one day and horrendous the next, you cannot predict what patients comes through your door, and levels of dependency, critical care, emergencies etc all have to be taken into account, which is something that you cannot realistically quantify, so to make a statement like one ward is better or more productive than another with comparable or even less resources is in my opinion just nonsense.

I do see what you are saying about 'pointless paperwork' and too much management interference, and you are right in the extent that the non clinical paperwork and rubbish sent down from the higher echelons is a nightmare, and yes they should just leave us alone to get on with the job of looking after the patients. The NHS would do well to have a 'cultural and organisational change' and sweep away this army of non clinical staff. But I don't think either that under this current climate, any individual wards may have found a way of 'leaving the clinicians to do their job' better than most', in the terms of one performing better than another, as in my opinion this is a culture that exists right across the NHS as a whole, and I just do not think that finding one trust that does this a little better or worse than the next one is possible really. There is also the point that clinical paperwork/admin tasks etc are also a general constant on top of all this. I do agree that micromanagement is often counter productive and that delegation of responsibility can help, but I do not think that this is something that should be focused on as an 'answer', as the clinical paperwork would still be there regardless. Care plans, waterlow scores, risk assessments, obs charts and MEWS scores, fluid balance, nutrition charts, daily records, updates, etc etc etc etc etc. They all need to be done, regardless of how good or bad the management is. The answer is to have enough staff that allows us to do all of this, as well as all of our clinical work, and also have personal time with our patients. If I have patients to look after, this wouldn't be a problem, but when I have 44, it becomes impossible. The best wards I have worked on are the ones that focus on safe staffing levels and staff health/well being. THAT is something that needs looking at.

And I agree that patients need to judge on outcomes to a certain extent, but again, that depends on the criteria used.
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DH Agent - as if ! | 8-Nov-2011 11:55 am
mike, I am still 'with you'. We basically agree with each other.

There is paperwork 'necessary for the performance of the job' (for example records of drugs administered) but also paperwork imposed from above 'for back-covering purposes': so that a manger, somewhere, can claim 'they told me they were doing it properly - so I can't get blamed for that !'

The second type, is the 'awkward' paperwork. And it tends to expand, whenever there is 'an inquiry into a disaster'.

You might very well be correct, and some of this could be down to inaccurate measurements: although if you do listen to patients, they often agree with the 'adverse' finding of the CQC, which nurses tend to say 'must have been one-offs'. Perceptions, perhaps - but nurses and patients, are influenced by where they are standing, in what they see.

Out of interest, you missed out a crucial number in:

'If I have patients to look after, this wouldn't be a problem, but when I have 44, it becomes impossible.'

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mike | 9-Nov-2011 11:22 am
Did I? Apologies. It should have read If I have 4 patients to look after, this wouldn't be a problem, but when I have 44, it becomes impossible.' Incidentally, my record is being left alone with a number of HCAs to look after 67 patients!!!! As you can imagine, I tried my best to cope at the time, but raised holy hell when the shift was finished. I'm just glad nothing went wrong and there were no emergencies.

Again I agree with you on the paperwork. But my initial point about organisational change still stands. Until the NHS fundamentally changes it's position on providing a safe working environment for its staff rather than thinking of costs, patient care cannot improve either.
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DH Agent - as if ! | 10-Nov-2011 12:01 pm
mike | 9-Nov-2011 11:22 am

I think 1:67 is way out-of-envelope. But I'm guessing it was a 'one off'.

We agree about everything here, it seems, in as far as we can progress the analysis and bearing in mind my 'I can't be 'political' point (my 'I can't just say 'spend more money' unless you explain who/what will then get less money' point).
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Anonymous | 10-Nov-2011 2:00 pm
Mike

"Incidentally, my record is being left alone with a number of HCAs to look after 67 patients!!!!"

Don't Believe you
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