OPINION

'Dignity spot checks are vital to help drive out poor practice'

25 October, 2011

Dignity in care has been made one of the top priorities for NHS Wales, says Jean White

I am writing this article on the day the media was discussing the findings of the dignity inspections for older people carried out in 100 English hospitals by the Care Quality Commission. It was depressing hearing the case studies described and I was concerned that some professional colleagues were failing their patients so badly. It is the nurse’s primary role to provide safe, effective and compassionate nursing to each and every individual in their care. Abuse and neglect should not be tolerated and a bright light shone on areas of failure.

One point that struck me as important from the reports was that sensitive, considerate care was delivered in areas where there were resource issues. Lack of time and staff are often the reasons given for lapses in the standards of care. In some cases that would be fair but it is equally fair to say it costs nothing to deal with patients in a caring and compassionate way in every interaction. Nursing is more than just a collection of tasks to be done.

“It costs nothing to deal with patients in a caring and compassionate way in every interaction”

But I did gain something positive from this episode. The stories of organisations’ reactions to the negative reports showed how the results being publicised acted as a wake-up call to organisations about the quality of care being given. I am convinced unannounced spot checks are a key tool to help drive out poor practice and to highlight good care.

In March 2011, the Older People’s Commissioner for Wales published her first review, which looked at the dignity and respect shown to older people in acute hospitals in Wales. Good and bad practice was found, and the report identified 12 recommendations for action by the Welsh government, NHS Wales organisations and their partner local authorities. One consequence of the review was to make dignity in care one of the top priorities in the NHS Wales Delivery Framework for 2011/2012, on which NHS Wales must deliver.

In addition to the action plans that the Welsh government and NHS organisations have in place, Healthcare Inspectorate Wales (HIW) will be conducting unannounced dignity spot checks from November 2011. Conducted by small teams, including a senior nurse and a lay reviewer, they will focus on the experience of the individual, particularly in terms of dignity and respect, and whether their essential care needs were met in a timely manner.

HIW’s analysis of its previous inspections and other published reports has identified the following themes that will form the backbone of the spot checks: staff attitudes; discharge planning; fluid and nutrition; communication; toileting; personal care and hygiene; care planning; medicines management and prescribing; physical care environment; activities and stimulation; and management of patients with confusion and cognitive impairment.

The reviewers will also look at the individual’s pathway, specifically asking: should the person have been admitted? How long have they been in hospital? Should they still be in hospital? Are there appropriate plans for discharge?

There is clear evidence that it takes a very short time in hospital for older people to lose their independence and their confidence - a benchmark of 20 days is often referred to as the turning point. If older people get stuck in the hospital system for any length of time, their chances of being discharged home with a similar degree of independence to that enjoyed before admission can be severely affected. Providing effective reablement/rehabilitation and active discharge planning with all relevant agencies is vital if we want to reduce the number of people going from hospital care straight into residential or nursing care homes.

Jean White is chief nursing officer for Wales

Readers' comments (20)

DH Agent - as if ! | 25-Oct-2011 11:08 am
'One point that struck me as important from the reports was that sensitive, considerate care was delivered in areas where there were resource issues'

I fear, Jean, that you will find very little discussion of the reasons why that might be true in some but not all cases, on this site - but I hope I am wrong about that.
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Jodie's mate | 25-Oct-2011 2:57 pm
That's a really interesting point. Having actually read the CQC report too I am pleased to say that it wasn't the slagging off of nurses that everyone was led to believe. Indeed it went to lengths to point out poor staffing and poor managment cased a lot of problems.

However, as you both (Michael and Jean) say, the CQC did comment that in some cases good nursing happened where staffing levels were low and did not happen where they were higher.

So, staffing levels can't be the only problem here and we owe it to ourselves and our patients to have a mature and calm discussion about why these problems might be happening.

I wonder whether apathy attracts apathy, so a ward with a poor attitude attracts nurses who feel the same, and good nurses get attracted to more dynamic and caring wards no matter how busy they are.

Oh, and one more point to make that no body ever does- the CQC also listed around 180 hospitals that they'd visited and had no concerns about
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Anonymous | 25-Oct-2011 3:15 pm
from page ten of the cqc report, "We carried out each inspection on a single day (from Monday to Friday)"

staff levels can be compromisd in the short term due to sickness, recruitment delays, etc. and for a period of weeks or months a team can pull together and make up the slack, but will not be able to maintain standards in the long term. staffing levels and the effect these can have on patient care cannot be adequately assessed in a single day. high standards from a team with a low nurse/patient ratio might not be fairly compared with a team with a higher ratio if the length of time the low ratio has been in effect is not taken into account.
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DH Agent - as if ! | 27-Oct-2011 10:26 am
Geeze | 25-Oct-2011 2:57 pm

'Oh, and one more point to make that no body ever does- the CQC also listed around 180 hospitals that they'd visited and had no concerns about'

One of my 'email discussion partners' is the Head of End-of-Life Care at the DH, and she also gets irritated by the lack of good news stories, and praise. She recently described it as something like ' the lack of praise for the usually good care , and constant carping on about the bad care'

But isn't that, a combination of things like Lansley saying 'People should expect NHS care to be excellent' and the way of the world ? After all, you EXPECT pilots to land an airliner in such a way that it gets to ground safely - the newsworthy landings are the bad ones !

And, it does not necessarily mean that people are implying that no NHS care is good, just because the bad examples are the ones being talked about - I think there is a sort of 'professional over-sensitivity' here, which although understandable, is also not 'objectively neutral'.
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DH Agent - as if ! | 27-Oct-2011 10:32 am
Geeze, I had not considered your:

'I wonder whether apathy attracts apathy, so a ward with a poor attitude attracts nurses who feel the same, and good nurses get attracted to more dynamic and caring wards no matter how busy they are.'

which is a bit different from the 'bad ward leadership' effect the CQC mentioned.

Do nurses and other staff, in practice make these migrations - do staff commonly make elective moves between wards, and types of care setting, regularly ? If they do, your suggestion is plausible - but if they do not, or are not empowered to make such moves, I can't see how it can be a contributing factor ?
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Anonymous | 27-Oct-2011 11:12 am
michael stone | 27-Oct-2011 10:26 am

'And, it does not necessarily mean that people are implying that no NHS care is good, just because the bad examples are the ones being talked about - I think there is a sort of 'professional over-sensitivity' here, which although understandable, is also not 'objectively neutral'.'

One can only assume that you don't read newspapers or watch/listen to the news, sir. Or have any idea of the impact of, in particular, 24 rolling news. Well, the vast majority of the country do and, as a result, actually believe what they see and hear to be, on the whole true. It does not matter how much evidence of good practice is recorded in any report or stat, the bad practice has exclusivity in the headlines. That has enormous consequencies for our profession in terms of conditions of employment, pay, etc. People don't want to give money to something which they don't believe is value for money. When the fact that the NHS functions at all, is due to the sheer hard work of the vast majority of Health professionals who go above and beyond daily.

Many of us work our backsides off for 12 hours (plus) a day, providing the very best care we can in extremely difficult circumstances, of which you have no idea. No, you really don't. To say that, in your opinion,
' there is a sort of 'professional over-sensitivity' here'
demonstrates utter ignorance of reality.

Try aiming the 'not 'objectively neutral'.' statement where it belongs.i.e. at the media and others
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Jodie's mate | 28-Oct-2011 8:34 am
Michael:

"After all, you EXPECT pilots to land an airliner in such a way that it gets to ground safely - the newsworthy landings are the bad ones !"

That's an interesting point, However I would say that whenever there are plane or train crashes, every media report I've ever seen has ensured that they've balanced up the story by stating how rare it is, and how many times these things don't crash, which was really my point.

Anyway, as your regards your comments about apathy attracting apathy, I don't know. I was wondering aloud really as I want to know why these problems are occurring too.

I don't think it's all down to staffing levels and neither do I think it's because nurses are rubbish/ not caring

However I must say your comment:

"I think there is a sort of 'professional over-sensitivity' here....."

really cheered me up as I usually get slated for not being pro- nursing enough on this forum!
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DH Agent - as if ! | 28-Oct-2011 3:15 pm
Anonymous | 27-Oct-2011 11:12 am

I am not suggesting that some people do not believe the media - I mean, some people read The Mail ! Nor am I claiming that nurses are not typically very hard-working, stressed, etc - I happen to beleive that is true.

But it is noticeable, that many nurses on this 'site take offence at my posts, apparently simply because I am not a nurse, claiming that my 'lay' perspective is 'de facto' less valid than theirs (as nurses) is. Well, EVERYONE (me included) probably exhibits this 'over-sensitive' thing: I get very heated as soon as I come across across clinical guidance which suggests that relatives need to prove they are telling the truth ! And when guidance incorporates 'professional back-covering', with consequences which all fall on the shoulders of relatives.

But ENORMOUS numbers of people use the NHS, and if most of them have good experiences, that alone will mean that most people do not assume that bad media stories are typical. And if most people are having bad experiences, then I see that as a problem !

But most of all, and in almost ever problem I come across, I have concluded that what would really help, is if staff would talk to patients and their relatives in pretty-much the way staff talk to each other (openly, basically), without introducing any 'us and them' 'attitude': talking to each other properly, is almost always helpful, and not talking, is potentially very unhelpful !
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DH Agent - as if ! | 28-Oct-2011 3:22 pm
Geeze | 28-Oct-2011 8:34 am

Geeze, I agree with you (except that there probably are rare 'rogue and uncaring' clinicians) about:

'I want to know why these problems are occurring too.

I don't think it's all down to staffing levels and neither do I think it's because nurses are rubbish/ not caring'

As usual, it is complicated - but for this one, I don't really understand the problem well enough to be very sure of much at all ! I am on firmer ground in my argument with the BMA, etc, over the meaning of the MCA - at least there is some law to read, there ! Here, there is no law to quote - this is an empirical and logical problem, which must be addressed in those terms, and 'answers' can only be suggestions, which appear to make sense, combined with measurements of the effects of any implimented changes to behaviour, etc.

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Anonymous | 28-Oct-2011 10:07 pm
michael stone | 28-Oct-2011 3:15 pm

Of course some your posts are less valid!! Many of your comments are not well-founded and do not correspond accurately to the experience of nurses. Do you know why? Because you are not a nurse! If I presented myself as an authority on Law, when I have neither studied it nor had the experience of being a lawyer, my comments would lack validity. Don't flatter yourself that people on this site often treat your comments in such an unwelcome manner, " simply because I am not a nurse". It's because you speak out of ignorance. Simples.

Anonymous | 25-Oct-2011 3:15 pm

It would appear that Jean White missed the point. It doesn't look like she's the only one.

Anonymous | 27-Oct-2011 11:12 am

Well said!

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DH Agent - as if ! | 29-Oct-2011 11:12 am
Anonymous | 28-Oct-2011 10:07 pm

Yopu write;

'Many of your comments are not well-founded and do not correspond accurately to the experience of nurses. Do you know why? Because you are not a nurse!'

Well, it is equally true that many comments on NT do not correspond accurately to the experience of patients and relatives, because they are made by nurses and not by patients and relatives.

Actually, I find some of your comments amusing.
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Anonymous | 29-Oct-2011 1:04 pm
michael stone | 29-Oct-2011 11:12 am

Many of the comments here are made by patients and relatives!! Another mistake that you frequently make.
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Jodie's mate | 31-Oct-2011 12:10 pm
Michael's coments ARE valid. Everyone is entitled to their opinion. I find the fact that we have a patient and relative's perspective here is excellent and if we stopped being so defensive about it all the time, is something we can learn from.

Now I come to think of it, it's not whether or not I'm pro-nursing that gets me slagged so much on this site, it's the fact that I support Michael...
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Anonymous | 31-Oct-2011 2:36 pm
Geeze | 31-Oct-2011 12:10 pm

Who are you?!
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DH Agent - as if ! | 31-Oct-2011 3:12 pm
Anonymous | 29-Oct-2011 1:04 pm

I know some comments are made by patients and relatives (who are not ALSO nurses).

But I honestly wish, that people would either post with their own name, or with a nom-de-plume: a long chain of anonymous comments, makes working out who is saying what, effectively impossible ! Very annoying, if you actually want to understand the development of a 'line of argument'.

Thank you Geeze - all support accepted, all contrary views which are backed up by explanation thought about, all 'trolling' ignored ! I'm pleased with myself, having learnt (from Mags, I think it was) what 'trolling' means - I can kid myself, I am up-to-date with social media !
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DH Agent - as if ! | 31-Oct-2011 3:21 pm
Actually, it is definitley true that I do not have any experience of front-line nursing: that perspective, is what I am trying to understand from this 'site.

I also want to understand other people's perspectives, about certain things. Such as the position of GPs, for a problem I am grappling with 'the NHS' over. A couple of days ago, I got an answer by e-mail to a couple of my questions, from a GP:

'I am very sorry that has taken so long to reply to your query which has only recently been passed to me. You seem to me to be expressing very reasonable concerns and, indeed, I have recently written about this issue in the British Medical Journal. I enclose the text of that article in case it might be helpful.

My understanding is that it is the capable patient who should be in control of the refusal of treatment decisions and choices and that the GP should seek to support that decision. However, current protocols - especially for paramedics - mean that patient preferences are too often not even elicited let alone implemented.'

I will 'work with' that answer - it came from the President of the Royal College of GPs.

Ignorant I may be - but I try to fill in the gaps in my experience, by asking the 'right people' !

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Jodie's mate | 1-Nov-2011 8:23 am
Anon 31 Oct 2.36 pm

In answer to your question:

Who are you?!

I am a hard working nurse, passionate about my job and concerned about the future, exactly the same as every other nurse that posts on here I imagine.

I am also someone who thinks that Michael gets not only a raw deal here but sometimes, to my horror, extremely unprofessional and bullying treatment too.

I am interested in what he has to say. the perspective of a relative and member of the public is important, and actually although I don't always agree with him I find his approach calm, measured and enquiring. The exact opposite of what he gets in return quite a lot I'm afraid.

Seeing's as you asked!
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DH Agent - as if ! | 1-Nov-2011 10:55 am
Geeze | 1-Nov-2011 8:23 am

Thank you Geeze, I do try to remain calm in my posts (calmer than mike, at any rate). I don't really mind being bullied - but I agree that some of the responses I provoke appear to be unprofessional, and I 'file them away/potentially use them' in the context of their being unprofessional, as opposed to bullying.

But I am personally fairly low on 'empathic', but very 'analytical' - really my natural 'home', for debates, would be inside ethics committees, and I think that sometimes causes me a few problems in debates with nurses.

I'm pleased you find some of my points interesting - all anybody can hope for, or indeed do, is to think about the perspective of other people, in the hope it might lead to 'better overall understanding' of problems.

As an 'unwanted' comment - there is, in my opinion, a level of 'bickering or even abuse' in some NT debates, which seems higher than I would have expected. And I don't mean at me, personally - I mean that for some reason contrary opinions, instead of leading to a debate about why the different opinions exist, often seem to rapidly degenerate into abuse.
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Jodie's mate | 1-Nov-2011 11:55 am
Michael

"I mean that for some reason contrary opinions, instead of leading to a debate about why the different opinions exist, often seem to rapidly degenerate into abuse."

I couldn't agree more, and I think it's really sad as it's quite hard to argue that one should be treated as a professional in one breath then dissolve into childish bickering in the next
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Anonymous | 1-Nov-2011 6:26 pm
Geeze | 1-Nov-2011 11:55 am

Think you need a shovel mate!
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