Empowering nurses, frontline staff, patients and relatives
For several years now I have become increasingly dismayed about what has happened to our profession and the NHS.
I am a retired Director of Nursing who has worked in both General and Psychiatric Nursing. Over a period of 10 years I also worked in the Health Advisory Services and since retirement I have worked for 15 years in the Mental Health Act Commission/ CQC.
For several years now I have become increasingly dismayed about what has happened to our profession and the NHS. For many years now there has been increasing political interference in the NHS from both the socialist and conservative parties. Despite rhetoric to the contrary, the decline of the NHS has been brought about by politician’s constantly changing direction and priorities. In future years how many more times are politicians going to continue to “reform their previous reform”?
Don’t you think that it’s almost delusional that politicians and others working with them in the stratosphere are convinced that they know more about what is going on in the NHS than you and your colleagues who are working day and night in the front line?
The reputation of the hospital or service you work in does not depend on Politicians, Department of Health Mandarins, Board members, Chief Executives or Managers. It depends on the skill and caring attitude of all good front line staff.
Reprehensively front line staff numbers and grades have been steadily and deliberately reduced at a time when patient admissions and dependency levels are significantly increasing. This makes it extremely difficult for conscientious nurses and other frontline staff to provide the level of care they know is required.
You will know about the Stafford Hospital situation where over a 1000 patients died unnecessarily, many in dreadful circumstances. You will also be aware that other hospital and services have had their own scandals and that there will certainly be many more to follow. The deplorable situation at Stafford will have raised two very important questions in your mind. (a) How can these dreadful situations occur? and (b) why did the good nurses who were aware of the situations feel unable to speak out?
There is no escaping the fact that front line nurses and support workers are the staff that attend to almost all of a patient’s basic needs. The very same basic needs that were so woefully neglected at Stafford.
As a front line nurse you will almost certainly be the first to know if patients are not being fed properly or not being given sufficient fluids. You will know if patients are left in wet or soiled beds. You will also know if medication is not being given on time or being misused or missed. Further you will know if a patient’s pain control is inadequate. You will most likely be the first to know if patients and their relatives are unhappy. You are also in a unique position to observe doctors and other front line staff and to be able to assess the treatment and care they are delivering. Most importantly you will most likely know or have heard of individual staff that are uncaring, abusive or neglectful.
It therefore follows that if we are to stop the abuse and neglect of patients in the future that an effective early warning system must be introduced and sustained. To achieve this, the system will have to truly empower good nurses and front line staff and be capable of eradicating the fears that inhibit them. It will also be of paramount importance that the real fears of patients and their relatives are eradicated as well.
You, as a trained nurse, must know that you are accountable as an independent practitioner to the Nursing and Midwifery Council and that your Code of Professional Conduct clearly states that “As a professional you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” It also states that “you must make the care of people your first concern, treating them as individuals and respecting their dignity.” Finally it says that you must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk and that you must inform someone in authority if you experience problems that prevent you working within this code or other nationally agreed standards.
It is therefore very clear what the responsibilities of trained nurses are. So why didn’t the good nurses at Stafford Hospital come forward at the start when care was dropping well below acceptable standards and why generally are good nurses unwilling to put their heads above the parapet?
The answer is not rocket science. It is simply this. Fear, fully justifiable fear.
The 20 powerful reasons that will inhibit you and other front line staff are as follows.:
- The staff witness may be junior in status or recently employed.
- They may be lacking in confidence or be of a quiet disposition.
- They prefer to keep quiet to avoid confrontation in the hope that what they witnessed may not happen again.
- They might have skeletons in their own cupboard that they fear may come to light during an investigation.
- They are a friend or a close working colleague of the perpetrator.
- The person they are accusing is a respected senior member of staff.
- There are other witnesses who they may know will not or don’t want to support them.
- They have little or no firm evidence regarding what they have witnessed.
- They may have reasons to be fearful of their mangers and may not trust them. If that is so they will expect that their manager will react adversely.
- They may fear consequences of professional or social isolation.
- They may be concerned about their future employment particularly at times of reconfiguration or downsizing.
- They may feel it will adversely affect their chances of future promotion.
- The may be worried that no one will believe them.
- If they have witnessed previous incidents and not reported them they will worry that they could be implicated for breaking the nurses code of conduct
- They may have considerable anxiety about making a written statement and being involved in an internal enquiry.
- They will worry about appearing at a possible disciplinary hearing.
- They will also worry about a possible police enquiry or having to appear in a court of law.
- They will worry about having to appear at a hospital Disciplinary Hearing or ENB Disciplinary Hearing.
- They may worry that their union or staff organisation will strongly support the accused in preference to them.
- They will worry about the final outcome regardless of whether their case is proven or not proven.
It is no wonder I have heard it said many times that to be a whistle blower you have either to be very brave or very stupid or a combination of both. This of course is not always the case but certainly the history of whistle blowers in the NHS and in other organisations in many instances fully justifies this conclusion.
In Mid Staffordshire NHS Foundation Trust Public Enquiry conducted by Robert Francis QC one of his conclusions was that a witch hunt should be avoided. Why? Shouldn’t all people who have been complicit in so much suffering and so many untimely deaths suffer the full consequences of their failures and cover-ups? We have seen two of the key players at Staffordshire Strategic Health Authority level being promoted. Cynthia Bower to become the first CEO of the Care Quality Commission and Sir David Nicholson promoted to become CEO of the entire NHS. What sort of message does this send out? Its certainly is not one that will encourage future whistle blowers.
Since the Enquiry Report we have had politicians and members of other august bodies talking on TV and in the papers about the need for transparency. How often have we heard this sound bite bandied about in the past without any detail of how this will be achieved or sustained? Another idea is making it a legal requirement for staff to identify abuse and neglect. Further frightening nurses and other front line staff may only increase their fears and potentially make matters worse. Another nonsense idea is that all student nurses should work for a number of years as support workers. Then there is the proposal to increase and strengthen the CQC inspections. This will not solve the basic problem as at best they may increase their visits to 4 to 6 times per year. How will this square with the fact that each individual hospital ward has about a 1000 shifts per year and possibly the hospital may have twenty or more wards. 6 visits will not even scratch the surface and certainly will not remove the real fears of the front line staff. The CQC also belatedly intend to move from generic to specialist inspections. This will be helpful. However most importantly the CQC has neither the structure, the systems nor the expertise to provide an instant national early warning system. (NEWS)
At last the new Chief Inspector of Hospitals Sir Mike Richards has identified those people best placed to provide an accurate assessment of a hospital and its services. Again it’s not rocket science, its just using front line staff, patients and relatives. However the proposals as good as they are have a major failing. That is recruiting assessors from these groups of people. Why go through the laborious process of recruitment, screening, selection and appointment when there are dozens of good staff, patients and relatives already available every minute of the day and night on every ward and department?
The system I propose will render recruitment and selection totally unnecessary. It will free current front line staff, patients and relatives from the worry of reprisals. It will provide dozens of eyes and ears in every ward and department not retrospectively like other inspection systems but in real time at the point when things start to go wrong. It will in a similar way immediately identify good standards of practice and good care.
All external systems cause delays in taking appropriate action. Death rate statistics, the CQC and Monitor inspections, whistle blowers, TV and newspaper undercover investigations all inevitably involve delays during which patients suffer and some die.
We now know that another 14 failing hospital are under review and that teams of “experts” are being parachuted in to sort them out. When they leave how will the “improvements” they achieve be sustainedand what about all the other failing hospitals and services as yet unidentified? How will they be detected and improved?
I have listened to all the high flyers on TV each giving their version of what needs to be done. They are articulate, persuasive and apparently sincere in their views but all have missed the obvious solution by a mile.
So what is the solution to ongoing poor care, abuse and neglect in the NHS?
It is simply this. There needs to be strong checks and balances introduced into the NHS and others services. To achieve this will require a system and structure that will fully and consistently empower front line staff, patients and relatives. A system that will allow them regularly to fully assess the services provided.
This system can be introduced quickly and well within current resources by diverting finance from the hugely expensive CQC and using some of their current inspectors and resources to better advantage (see below).
Schedule for introducing a National Early Warning System. (N.E.W.S.)
Step 1. Appoint three people in each hospital to form an Early Warning Team (nurse, layperson and doctor)
Step 2. Issue details of the system via email to all front line staff and managers and distribute paper copies to patients and relatives.
Step 3. Members of the team visit each ward and department to establish an open relationship with staff and to gather information and answer questions.
Step 4. Issue first confidential questionnaire to all front line staff via email with paper copies to patients and relatives..
Step 5. Summarise all returned questionnaires together with verbal information.
Step 6. Present initial findings direct to the Board and the CQC within six months or earlier if the team consider it necessary.
Step 7. Repeat steps 3 to 6.
To be share between the hospital and CQC.
Team Selection and Appointment
The interview panel would be comprised of an independent chairperson. A non executive member of the Board and a local CQC inspector. The appointments will be time limited with a possibility of re-appointment if the team or a number of its members have demonstrated that they have significantly improved patient care or have identified poor practice or neglect and abuse.
Fundamental Selection Criteria
- Good clinical knowledge and experience in front line care.
- A proven record and commitment to caring for patients.
- The ability to inspire confidence and trust.
- A pleasant personality with an ability to clearly communicate their finding to the Board and CQC.
Setting the Scene
The initial introduction of the early warning concept and the team must be given a very high profile, with emphasis on the teams independence and the confidential nature of its information gathering.
A statement of intent should also be published clearly indicating the Board and CQC’s full and unequivocal support for the team and a further clear commitment to acting quickly to deal with all untoward reports provided by the team.
Information gathering and reporting
Letter of Introduction (Example)
The Board and the Care Quality Commission (CQC) are fully committed to providing and maintaining the highest level of patient care in the most suitable environment.
However both the Board and the CQC are aware of how difficult it is for front line staff to feel safe in expressing their concerns about standards of patient care and treatment.
To enable you to quickly express your concerns the Board and the CQC have jointly introduced the National Early Warning System. (N.E.W.S.) to this hospital
The early warning team have now been appointed and they are: Nurse_________________________Doctor______________________ and Lay person___________________________
Their telephone number is_____________the email address is______________
The members of the team are independent from hospital management and CQC and will report directly to the Board and the CQC every six months or earlier if necessary. All team member have the authority to submit a “minority report” if they feel that an essential element is missing from the report or has not been sufficiently emphasised. The reports will not be altered in anyway by anyone outside the team.
CONFIDENTIAL EARLY WARNING QUESTIONNAIRE (Example)
Members of the Board and the CQC would ask you to state fully and frankly your opinion of the service and any concerns that you may have. Please give as much information as possible.
You should not identify yourself in any way but the ward or department is indentified by the code in the top right corner of this questionnaire. This code is only known to the three members of the N.E.W.S. team but may be used in their direct report to the Board and CQC.
The early warning team will in addition regularly visit all wards and departments and be available for confidential conversations with staff, patients and relatives.
1. Is the ward environment and equipment suitable for the type of patients you care for? If not state why.
2. Is the mix and dependency levels of patients appropriate? If not why.
3. Does the number of staff and the skill mix during night and day shifts enable you to provide a good standard of care to patients?
4. Does the ward have a long day shift system and or rotate its day and night staff? If yes what are your views on this.
5. Does the ward have staff from NHS Professionals or other Agencies? If yes please comment.
6. Is there a ward sister/charge nurse based permanently within the ward who is fully responsible for directing and supervising patient care and treatment or are they responsible for more than one ward? Please comment.
7. Are there sufficient single rooms to nurse very ill patients?
8. Is there a room for relatives to stay in and is it comfortable, clean, tidy and well equipped?
9. Do patients receive adequate food and fluids?
10. Are patients who are unable to feed or take fluids themselves always helped by a member of staff and is sufficient time available?
11. Is there a good selection of food and drinks to suit most tastes and cultures?
12. Are you able to change wet or soiled beds immediately?
13. Do you have sufficient time to talk to patients and their relatives?
14. Is there an efficient and effective pain control system on the ward and is it sufficiently flexible?
15. If required, can you get a consultant or doctor to attend quickly during the day and night?
16. Is the wards overall cleanliness and hygiene satisfactory?
17. What are the daily visiting times and are they flexible?
18. Can very ill patients be visited at any time and do relatives who have difficult journeys have open access to visiting?
19. Do you have to “cut corners” to be able to cope with the work load? If yes, give examples.
20. Have you personally witnessed any poor care or abuse and neglect? Please state when and give details.
21. Have you heard of any cases of poor care or abuse and neglect within this hospital? If yes please give details.
22. Have you or any other staff been subjected to bulling or harassment?
23. Do you have any worries or fears about completing this questionnaire in a full and frank manner? If yes say why.
24. What innovation and good practice would you recommend to others?
25. What are the priorities for improving patient care and treatment?
26. What important questions are not asked on this questionnaire?
27. Is there anything else you would like to add?
THANK YOU FOR TAKING TIME TO COMPLETE THIS QUESTIONNAIRE
PLEASE EMAIL YOUR COMPLETED QUESTIONAIRE TO_______________
NATIONAL EARLY WARNING SYSTEM (N.E.W.S.) (Example)
Members of the Hospital Board and the Care Quality Commission (CQC) are fully committed to providing a high standard of care for all patients.
To achieve this they are taking part the new National Early Warning System (N.E.W.S.) In accord with this new system a independent three person early warning team has been put in place. Its job is to quickly detect any failings in the provision of treatment and care for all patients.
The Board and the CQC are very aware that patients, relatives and visitors may be very cautious about making complaints as they may worry about getting adverse reactions from the staff. This new system is designed to prevent this happening.
The Early Warning Team will circulate a confidential questionnaire every six month but it will also record information from all other sources.
Members of the team will also visit wards and departments to talk to staff and visitors. A member of the team will also be available for private confidential conversations.
The team will report directly to the Board and the CQC at six monthly intervals but earlier if necessary.
The team members are
PATIENTS, RELATIVES AND VISITORS QUESTIONNAIRE (EXAMPLE)
The Hospital Board and the Care Quality Commission (CQC) ask you to state fully and frankly you opinion of the treatment and care you have received in this hospital. In particular we would like to hear where you have experienced poor care and treatment. You do not have to identify yourself in any way but the code printed on the top of the form will identify which ward and department the form has come from. The code is only known to the three members of the early warning team but it may be used in their report to the hospital Board and CQC.
To be completed by the patient
1. Is your ward or room kept warm, clean and tidy?
2. Do you have a comfortable chair to sit on and is there at least one other for visitors?
3. Have you sufficient space in a locker for your personal belongings?
4. Have you TV or radio in your room?
5. Is your bed warm and comfortable and do you have enough pillows?
6. Is there a call system within easy reach of your bed and when you call does someone come quickly?
7. Can you keep contact with people from your bed by mobile or pay phone?
8. Are your toilet and washing facilities within easy reach?
9. If you are confined to bed are you helped with your bodily hygiene and hair washing?
10. Is your room reasonably quiet during the day and night?
11. Has a doctor or nurse explained your health problem, treatment and possible length of stay in the hospital?
12. Have all the staff been helpful, caring and polite?
13. What would you say about the food?
14. Do you get sufficient hot and cold drinks?
15. If you have difficulty eating and drinking are you always helped by a member of staff?
16. Do you always get the correct day and night medication on time?
17. Is any pain you have well controlled?
18. Is your bed changed quickly as required?
19. Have you developed a bedsore? If yes, is it being regularly treated.
20. Do you have concerns or complaints about your treatment and care?
21. Are there any important questions missing from this questionnaire?
22. What would you recommend about your stay in the hospital?
23. Is there anything else you would like to say about your stay in hospital?
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
PLEASE PLACE YOUR COMPLETED QUESTIONAIRE IN THE SEALED ENVELOPE PROVIDED
QUESTIONNAIRE FOR RELATIVES AND VISITORS (EXAMPLE)
The Hospital Board and the Care Quality Commission would like you to express your opinion about the care and treatment given to patient in this hospital. Your opinion is particularly important if the patient is too ill to give their account of their treatment and care.
1. Are you provided with sufficient regular visiting time?
2. Have you been informed that you may be eligible to reclaim some of your travelling costs? If yes have you been given help regarding your claim?
3. Do you receive a friendly welcome when you visit?
4. During visiting are nurses readily available to answer your questions or deal with your concerns?
5. When you visit can you see the consultant or a doctor?
6. Is it easy to get through to the ward by phone?
7. If you are the next of kin or a close relative are you kept well informed about the patient’s condition?
8. Is there a comfortable well equipped relatives room for a long stay during the day and night?
9. Have you any concerns or criticisms about the patients care and treatment? If yes please provide information.
10. Are there any important questions missing from this questionnaire?
THANK YOU FOR COMPLETING THE QUESTIONAIRE
PLEASE PLACE THE COMPLETED QUESTIONNAIRE IN THESEALED ENVELOPE PROVIDED
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