How should Francis change nursing practice?
The Francis report into failings at Mid Staffordshire includes many recommendations, some of which can be acted on immediately
In this article…
- Key nursing themes in the Francis report
- How clinical practice could change
- Overview of the recommendations
With a total of 290 recommendations, the Francis report contains much food for thought. However, while some of the recommendations require strategic or government action, there are actions that nurses can adopt or champion immediately to ensure patient care in their organisation is both safe and of high quality. Here, a selection of clinical, academic and professional experts reflect on how the report might be used to inform day-to-day nursing practice.
Julie Storr, president of Infection Prevention Society
“The Infection Prevention Society acknowledges that the report highlights unacceptable failures at all levels of the NHS. More than 100 pages focus on infection issues, including basic hygiene and cleanliness.
IPS remains steadfast in its focus: simple measures, such as hand hygiene, prevent patient harm. We welcome the recommendations that risks of infection be handled fairly and safely, including how they are communicated so, in the pursuit of infection prevention, we do not overlook the psychological wellbeing of every patient and every family.
Our contribution to developing an informed workforce, capable of delivering clean, safe care, embraces the call for enhanced education, training and support for all healthcare staff, including leaders and managers. IPS will work as a force for good to help create better, stronger systems that promote safe, clean clinical care.
A competent workforce, the right regulation, regulators who “get” infection control, all are necessary to build a strong and impenetrable defence that keeps everyone safe. IPS looks forward to working nationally and locally, and playing a key role in making these recommendations a reality.”
Deidre Wild, senior research fellow (visiting), consultant R&D older people, University of the West of England, Bristol
The report highlights the damage inflicted on older people from a misguided and uncaring NHS culture. However, if its findings are to be internalised and recommendations acted on, they will need to prevail over longstanding ageist attitudes.
Where, other than in older people’s care, has the nurse’s role been so eroded by replacement with the minimally trained care assistant, thereby falsely implying high-quality nursing is neither required for older people, nor compatible with cost effectiveness? In terms of common language, who else is accused of “blocking” beds or being a “burden” on services, both of which older people have equal rights to access? Attitude change requires professional recognition that adult care in hospital and the community involves meeting the complex needs of the ageing population, as much as meeting those of people who are younger.
The recommended registration of healthcare support workers, with a uniform code of conduct, standards and training to be maintained by the Nursing and Midwifery Council is an important step towards quality improvement, and the recommended role of a registered older person’s nurse is even more welcome. However, if it is to spearhead change towards a non-ageist culture, which enhances care and protects older adults, the role must include specialist gerontological nurse training with an emphasis on essential and remedial skills, and it must be held by sufficient numbers of nurses.
Steve Mee, senior lecturer, Faculty of Health and Wellbeing, University of Cumbria, Lancaster
“Mr Francis’ report has portrayed a vivid picture of a culture with a profound, scarcely believable, lack of care. It rightly focuses on NHS culture and suggests a host of actions to refocus on caring. These include changing recruitment and training, as well as developing leadership, appraisal by patients, transparency and clarity about the guiding principles we should all adopt.
The overall picture is that of an organisation in meltdown. Volume 2 of the first report in 2010 gives 363 pages of chilling individual stories that could lead committed nurses to despair. Yet Mr Francis’ investigation into Stafford includes positive stories such as the patient who could not speak highly enough of the care he received on several wards:
“Everyone who dealt with him was passionate and caring and the staff often worked ‘above and beyond’ the call of duty. He thinks that the constant barrage of criticism is ‘counter-productive and unnecessary’.”
In all the horror there were people going about their work - at least during that patient’s stay - in a “professional”, “courteous” and “timely” manner.
The report also refers to times when care on a ward was generally abysmal, yet an individual nurse still behaved with compassion to ensure a patient was well cared for. These individuals had an internal moral compass that ensured they would do the job properly, whatever the culture. As professionals we have a choice: to make a personal commitment to do the moral thing. I salute those at Mid Staffordshire who did just this.”
Irene Anderson, principal lecturer, tissue viability, and reader in learning and teaching in healthcare practice, University of Hertfordshire
“Sadly pressure ulcers and skin breakdown feature in the report - the detrimental effect of a target-driven culture and staff forced to comply whatever the consequences. There is a national focus on pressure-ulcer prevention; things are improving but there are still failures to record (and act on) pressure-ulcer risk, and patients waiting for equipment, lying in wet beds and experiencing poor handling. Making pressure-ulcer prevention initiatives public is recommended - and already happening in some services.
The report also points out that basic - or essential - care is not simple, and that patients are harmed when specialist nurse advice is ignored and untrained staff take roles for which they are unprepared. We must ensure patients with other types of wounds are not sidelined by pressure-ulcer targets but that we focus on tissue viability for all patients in all settings; they need and deserve skilled and compassionate care.”
Liz Lees, consultant nurse and senior research fellow, Heart of England NHS Foundation Trust, Birmingham
“Over the last 21 years I have witnessed the insidious demise of nurses routinely participating in multi-disciplinary ward rounds. Routine has been replaced by ad hoc, as and when they feel able to join. However, patient care and discharge processes have evolved over this period, resulting in increasingly frequent patient reviews and ward rounds - in some areas going from weekly to twice a day. This has increased nurses’ workloads, and it is time to recognise this through tools to measure patient dependency and acuity. We urgently need the necessary evidence to produce tools capable of measuring this often invisible nursing workload.
Ward rounds are the cornerstone of ward leadership, organisation of patient care and processes thereafter. A registered nurse is an essential member of a ward round - the sooner this standard of nurse advocacy is reinvigorated, the sooner patient care will improve.
Debbie Yarde, chair, Association for Continence Advice
It is sad day for the NHS when it requires 290 recommendations to ensure patients are treated with care and compassion. We should all know this is a fundamental ethos of looking after the sick and vulnerable, but apparently not all of us do. While I welcome much of what is recommended, I mourn the missing recommendation that would specifically endorse the need to toilet patients.
Yet again continence fails to attract attention in its own right. There is a catalogue of reported incidents involving patients being left in urine and faeces and, while responding to patient requests and hygiene have rightly been singled out, there is nothing to promote active continence assessment and promotion within care settings for older people. This is a disappointing omission.”
Ann Hemingway, senior lecturer public health, School of Health and Social Care, Bournemouth University
“This report indicates yet again that organisational culture and individual attitudes are key and that those who are not open to criticism and who don’t put patients first are giving warning signs about the standards of care they offer.
The report recommends a national entry-level requirement that student nurses spend at least three months providing direct patient care under the supervision of a registered nurse. This is welcome as it clearly focuses on ensuring those entering the profession have appropriate attitudes.
However, the report highlights that “when concerns were raised about inappropriate pressure or bullying by staff toward trainees, these were not followed up or investigated”. Once again the culture of organisations is identified as needing to change in order to focus on what is truly important:
“The patient must be first in everything: there must be no tolerance of sub-standard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations.”
Liz Evans, chair, National Nurse Nutrition Group
Nutrition and hydration are still not being recognised as essential to patients’ recovery, as the report highlights. Despite a plethora of national guidance and recommendations on the importance of good nutritional care, it is clear the message is not always getting through.
It is easy to blame nurses for not feeding patients, and the National Nurse Nutrition Group maintains they are crucial to good nutrition. However, as the report states, other health professionals must recognise the importance of nutrition and allow patients to eat and drink uninterrupted. All health professionals are capable of recognising a tray of uneaten food or a cup of tea that has not been drunk and reporting this to the nurse in charge of that patient.
There is clearly still a lot of work to be done to ensure all organisations provide good nutritional care. But we do not need more guidance - steps must be taken to embed current guidance in practice to guarantee patients in hospital receive sufficient food and drink. Nutritional care must be taken seriously and not just seen as another tick-box exercise.
Kim Holt, Patients First, campaign to improve transparency and accountability in the NHS
“Unless the pervasive bullying culture of the NHS is ended, it will remain dangerous for staff to raise concerns about patient care. The experience of Helene Donnelly, a staff nurse in Stafford who gave evidence to the Francis inquiry shows how ignoring concerns can have huge implications for safety. Her evidence exposed the hollowness of the promises in the whistleblowing policy. What powerful words.
Patients First is contacted regularly by nurses who raise concerns about serious matters affecting patient care; the problem is not the raising of concerns or lack of people to do that, but the often bullying response they receive or fear receiving.
We urge ministers to immediately strengthen the law to protect whistleblowers and arrange effective monitoring arrangements to ensure the duty of candour is discharged by all within the NHS. We need specific assurances, not warm words. We are calling for a Health Select Committee inquiry into the continued bullying and victimisation of whistleblowers.”
Baker S et al (2012) What do you do? Perceptions of nurse manager responsibilities. Nursing Management; 43:12, 24-29.