In the 1980s, in response to demographic changes, older people were moved from the acute setting into an expanding private care home sector.
Now in 2011, care homes reportedly have “patchy and fragmented” access to NHS services – but social care alone is unable to meet residents’ complex health needs (Martin et al, 2011).
Of the 440,000 older people in care homes, six out of ten are in residential homes with no onsite nursing, even though nursing needs are reported to be as high as those in nursing homes. These needs, arising from the disabling effects of late life – including incontinence, immobility, instability and falls – are often met by support social care workers. Although trained in social care, they lack nursing knowledge.
In England in 2011, twice as many ombudsman-investigated complaints were related to older patients than for all other age groups combined. Those involving nursing were largely failures in meeting older people’s fundamental needs.
Also, a survey of specialist and advanced roles has shown that no titles are specific to the care of older people, and few were given in rehabilitation or community care. Of these “expert” roles, clinical activity far outweighed that spent educating others (Royal College of Nursing, 2005).
Does such evidence suggest as nurses have moved towards greater specialisation, “the lamp” burns dimly for older residents, because despite their NHS rights, theyappear to be someone else’s responsibility?
In a downturned economy, improving quality requires people to use existing resources in a different way. For example, if it takes 20 minutes to change a person who is wet, but 10 minutes to pre-empt this by taking them to the toilet, it is obvious which is the more resource efficient. But changes to ways of working are not always organisationally obvious.
Dedicated community nurse support for upskilling care staff in fundamental nursing has been shown to save on costs through reducing hospital admissions and nurse input (Szczepura et al, 2008). So a strategy to upskill support workers, as a new tier of practice-oriented “support nurses” must be introduced. Older people’s nursing needs should be met by those qualified in, and accountable for, nursing activities, and by definition, be named as nurses.
The National Skills Academy and the Nursing and midwifery Council could offer a remedial nursing qualification. Teaching and competency supervision would be carried out by nurses, which could over time be undertaken in lieu of tasks safely delegated to the profession’s newcomers.
Nurses may no longer be the hands-on providers of fundamental care, but their leadership in shaping and sustaining the empathetic and remedial qualities of others filling the vacuum will be crucial.
Deirdre Wild is senior research fellow (visiting), University of the West of England, Bristol
Martin F et al (2011) Quest for Quality. London: British Geriatrics Society.
Royal College of Nursing (2005) Maxi Nurses. Advanced and Specialist Nursing Roles. London: RCN.
Szczepura A et al (2008) In-reach specialist nursing teams for residential care homes: uptake of services, impact on care provision and cost-effectiveness. BMC: Health Services Research; 8: 269.