Act now to reduce impact of staffing crisisPractice blog
How do you get hospital staff to walk in the shoes of people with dementia?
Yesterday I went to see a play Inside out of Mind. Based on a dementia admissions ward it told the story of staff and patients. It captured the chaos, noise and unpredictability of the ward as well as the emotional and physical demands of caring for people with dementia.
We saw how staff formed close bonds with patients and cared deeply about them but were challenged by some of their behaviour which clearly upset and confused patients. I was upset by one scene where staff and patients sat together wearing witches hast for a ward Halloween party – well-intentioned, but please don’t do it to me if I end up on your ward!
It was evident in the performance that not only patients but staff become institutionalised. In response to a question “Where do you go for help?” one of the characters - a ward sister- says “We keep it all inside”.
But this play is not fictional, it is based on research conducted on dementia wards. Justine Schneider was commissioned by the UK National Institute for Health Research to carry out an overt participant observation study of health care assistants caring for people with dementia.
The researchers worked as supernumerary HCAs in three wards for people with dementia and behavioural problems.
Commissioned to inform policy and workforce planning, I expect the final report could, like countless others, have sat on a shelf gathering dust. Justine tried to organise feedback sessions for staff once the report was completed but the attendance was poor.
She wanted to find a different way to communicate what she had observed to others. So she approached a theatre company to write a play based on the transcripts. Her hope is that Inside Out of Mind “will help people to understand that dementia care is not easy, wherever it is provided, and that the people who do it well deserve our admiration and respect”.
I watched the play with an audience of HCAs from three trusts in Nottinghamshire who were visibly moved by the performance. The trusts had arranged for staff to see the play and attend workshops to discuss the issues that arise.
I am not claiming this one play could change the face of dementia care but as part of a strategy to educate staff across large organisations it appears to be a refreshing and exciting approach.
I am fascinated by the collaboration between researchers, NHS trusts and the arts working together as a way of helping staff to walk in the shoes of people with dementia. It has also helped outsiders like me walk in the shoes of healthcare assistants.
For more information about “Inside Out of Mind” visit www.lakesidearts.org.uk.
'Let’s stop pointing the finger of blame and address the real problems'
Since the government aimed its Francis report response firmly at nurses, with many of its promises focusing on “improving” nursing care, I have felt a sense of injustice that the wrong group is being targeted.
The assumption that nurses somehow lack compassion is completely unfounded. As someone recently tweeted to NT “No one goes in to nursing for the pension, we do it BECAUSE we’re compassionate.”
But the unfairness of it only really hit home when I received a phone call from my Mum at 11pm one evening last week.
She was on her third day on an acute surgical ward with advanced appendicitis.
Having not eaten for 38 hours due to her surgery being pushed back, and then pushed back some more, she was already distressed and disorientated. She had then been told that her surgery would not be going ahead that evening as planned and no one could tell her when it would be.
What’s more, she was being moved to another ward. She didn’t know why and she didn’t know where.
I later found out that the people making these decisions were on the ward at this time but instead of having the common courtesy to explain their rationale to patients face-to-face, it was left to the nursing staff who had just come on duty to deliver the bad news.
My Mum was angry, upset and in pain having refused her morphine because she wanted to be “with it” enough to find out what was going on. She’d barely slept and was clearly frightened about having surgery.
Throughout the entire phone call I could hear a call bell going off unanswered, eventually attended to by another patient.
And yet, through all this chaos, my Mum’s unrelenting praise for the nursing staff shone through.
Having never even heard of the 6Cs, and entirely unprompted, she used the word “compassionate” to describe her nurse, Vicky*.
I find it insulting and downright patronising that the suggestion is even being made that Vicky and her colleagues somehow lack compassion.
I met Vicky on my next visit and we discussed how her concerns for patient safety have increased as clearing beds has been prioritised. She told me the story we’ve heard time and time again about how her attempts to raise concerns have been ignored or dismissed with no changes being made.
The very fact that Vicky wishes to remain anonymous highlights that staff feel they aren’t safe to raise concerns. But for things to change, they need to not only be able to speak out, but to shout out when they are left in situations where they simply cannot do their jobs safely.
Vicky is the perfect example of why our Speak out Safely campaign is so important. Following Robert Francis’s recommendation, we want to make it a legal requirement for management to act on your concerns if patients are being put at risk.
Let’s stop pointing the finger of blame and address the real problems here. Show your trust that you are behind us, behind nurses like Vicky and behind a safer, more transparent NHS. Sign the SOS petition.
*pseudonym
‘Why treat a problem when you can throw a pad at it?’
In the NHS some patients are more equal than others.
That was a message I got from delegates at the Association for Continence Advice conference last week.
Why?
Because some commissioners think bowel and bladder care is important and others don’t.
We have discussed the outcome of rationing care on this website before. Remember the case of Elaine McDonald? Ms McDonald lost a supreme court appeal against the London Borough of Kensington and Chelsea’s decision to withdraw the night-time care that enabled her to use the toilet. Instead Ms McDonald was told to use incontinence pads – even though she has mobility problems rather than incontinence.
The indignity of passing urine into a pad when you know you could go to the toilet is unacceptable. Yet our continence services are under immense pressure and in some areas commissioners, looking to save money, may see continence as an easy target.
Why treat a problem when you can throw a pad at it – and, while you’re at, it ration the number of pads?
Those who have the money can top up their supplies, while everyone else has to make do. In a #NTtwitchat last week people talked about the human cost of rationing: drying pads so they can be used again or providing a pad that lasts 12 hours so less care is required for toileting.
It is nurses who inevitably have to deal with the consequences of offering different levels of service to their patients depending on who is commissioning care.
How do you explain to Mrs Smith at number 46 why she gets one service while Mr Green at number 72 – with a different GP – gets another?
How do we reconcile the compromise this inevitably entails? Is it just the new economic landscape of healthcare that we have to get used to?
The uncomfortable realities of competition care are beginning to bite. What is your experience?
'Older people aren't to blame for NHS problems'
The Telegraph’s website the other day carried the headline “Minister: NHS will collapse if elderly bed-blocking continues”.
The story itself was a reasonable discussion about the need for better integration of health and social care to ease pressure on hospitals and ease the crisis in A&E, but the headline implied older people were to blame for all problems in the NHS. It conjured up images of stubborn older people refusing to give up hospital beds they no longer need, selfishly forcing younger people to wait for urgently needed care.
My 85-year-old mum recently spent two weeks in hospital, and the nursing care she received was faultless – every one of the 6Cs shone through in all the nurses on her ward. Nevertheless, the experience was distressing and confusing and all she wanted was to go home. And that’s exactly how most hospital patients feel, whatever their age.
The casually insulting tone of The Telegraph’s headline reminded me what a shame it is that the government has not accepted Robert Francis QC’s recommendation to create a new older person’s nurse specialty. These nurses could have expert knowledge of the ageing process and age-related conditions, and an understanding of the particular needs that ageing brings.
Older people’s nurses could help non-specialist colleagues across multiple wards or teams, and take a lead in caring for patients with particularly complex needs. And like cancer nurse specialists, they could smooth their patients’ path through health and social care, chasing test results, co-ordinating discharge plans, and ensuring all relevant professionals, family members and carers are involved and informed as appropriate.
I hope that when it makes its more considered response to the Francis report later this year the government will announce that it will, after all, create an older people’s nurse qualification with registered status. These nurses could do much to improve the experiences of older patients, and may also help to reduce the pressure on hospitals by reducing inappropriate A&E attendance and speeding up discharge by coordinating all care providers. Maybe they could also teach lazy headline writers that older people aren’t to blame for NHS problems – in fact they have spent a lifetime paying for it.
Every week needs to be dementia aware for nurses
This is Dementia Awareness week which is a good way to call attention to this common condition. But in reality every week needs to be dementia aware for nurses. And it’s not just for nurses working in care of the older persons and in nursing homes. All nurses will come into contact with patients with dementia – on surgical wards, in A&E, outpatients, GP surgeries and out in the community.
Simple strategies can really help to make communication easier. Take a look at an article we published recently which gives some useful tips. It sounds simple but it will make a difference. For example, avoid asking open-ended questions such as “What would you like to drink?” but ask instead “Would you like a drink of water?”
And think about the environment where you work. With the increasing number of people who have dementia, and will have it in the future, it is time to think about how you can make the space where you see patients more dementia-friendly.
Take a look at our excellent article written by June Andrews at the Dementia Services Development Centre at the University of Stirling. Even small adjustments can make a difference. For example, having doors in contrasting colours to the walls makes it easier for the person to navigate their way around.
We are having a twitchat at 1pm on Wednesday 22nd May. If you have strategies that you would like to share please join us for the chat. It is an important subject – this and every week.
Are nurses too quick to use rapid tranquillisation?
Rapid tranquillisation on mental health wards is much-debated.
On the one hand, rapid tranquillisation is sometimes needed to maintain the safety of the ward, on the other hand it carries with it extreme risks to the patient, can be addictive and arguably should be the last resort when all other methods of de-escalation have failed.
Patients are often subscribed tranquillising and antipsychotic drugs PRN so they can approach staff if they feel they need additional medication. In my experience, this can work well with patients being afforded the opportunity to take responsibility of controlling their symptoms before escalating.
However, as a staff nurse what do you do if a patient asks for medication they do not appear to need?
As you can’t tell what’s happening in someone’s mind, should you take their word for it that they know what they need?
What if they have been sitting watching TV, appearing calm for the past hour, and strolled to the nursing station to request highly-addictive benzodiazepines?
Giving medication without clinical need is not in the patient’s best interest and may in fact be feeding an addiction.
But, what if saying “no” leads to aggressive behaviour, putting patients, staff, visitors and the hospital environment at risk?
I have witnessed patients requesting lorazepam without clinical need only to be, rightly, refused this by nursing staff. In order to ensure they got the medication they wanted, I’ve seen patients then damage hospital property, threaten staff and other patients and escalate to the point that staff have no choice but to medicate in order to maintain the safety of the ward.
This positive reinforcement of disruptive behaviour only leads to the same happening again.
Benzodiazepines are all too often given without consideration to the long-term consequences. The MDT must look at ways to balance the short-term benefits of using these drugs with the long-term affect they may have on the patient and the nature of their care.
What do you think? Do we give out too many benzodiazepines without considering the consequences of long-term addiction? Are we too quick to use rapid tranquillisation to de-escalate?
'How do we close the research-practice gap?'
There is an old man who occasionally catches the same bus as me to the station. When he arrives at the bus stop there is an odour which in the confined space of the bus gets worse.
It took me a while to work out that the smell was from compression bandages on his legs which are usually heavily stained with exudate. Month after month the smell hasn’t improved and I would assume neither have his ulcers.
How does he feel when people instinctively move away from him, look the other way or fan themselves with a copy of the Metro?
I can’t make a judgement on his care or whether he is compliant but I do wonder whether his wound management is based on the best available evidence.
Management of leg ulcers, unlike other nursing activities, has a fairly robust evidence base. A well-managed venous ulcer can heal and we have a host of products for management of odour and exudate.
Sadly, the evidence has also highlighted the profound psychological effect ulceration has on people’s lives leading to social isolation, depression and anxiety.
So when I look at my fellow bus companions bandages I am left wondering about the research-practice gap.
Who is removing this gentleman bandages and assessing his symptoms?
Is anyone talking to him about how he is managing is hygiene and washing is clothes?
Has anyone talked to him about his shoes that don’t fit comfortably over the bandages?
Has anyone asked him how he feels?
The application of compression bandaging is a specialist skill and the Leg Ulcer Forum is clear that it should be undertaken by nurses with specialist training.
However not all patients have access to specialist services and the net results is on-going, expensive and ineffective care that has a negative impact on patients.
We all have a responsibility to use evidence based practice but practitioners need to have access to it. While practitioners should ensure they are up to date, researchers must ensure that their work is disseminated as widely as possible.
The problem is academic institutions usually measure the value of its researcher by their publications in academic journals with impact factors. This measure is not based on the impact on patient care but on the number of citations to the journal - those with higher impact factors are deemed to be more important than those with lower ones.
Perhaps it is time for researchers’ success to also be measured by their impact on patient care.
Futher reading:
Resources for community clinics must match those of the hospital
A friend recently tried to have a Doppler scan and tissue viability assessment in the community rather than in the hospital.
Sounded sensible – just around the corner.
But the saying is there is no such thing as a free lunch. And in this case it seemed there was no such thing as accessible care.
A trip to the hospital is only another 30 minutes on the bus and as it turns out this would have been time well spent.
Appointment number one failed as the staff member who could work the Doppler machine was not in until later. Appointment number two failed as the nurse using the Doppler machine could not get it to work properly – no back-up support available to assist. Appointment three failed because the wrong type of gel was available to get a reading.
Three weeks have now passed as the clinic only runs once a week. And the venous ulcer in question continues to exist but fortunately not to expand.
Running outpatient clinics and other services out in the community is good for the patient as it makes services more accessible and can be cost-effective.
The plan is that services for long-term conditions such as venous ulcers will be looked after by outreach and community services. But for this to work they must be properly resourced in terms of staff and equipment.
Community care is not supposed to be care on the cheap.
My friend did not feel the failure of each appointment was down to the willingness of the staff as each time the staff did their best to rectify the problems that occurred at each consultation. But that there was not the human and equipment resources to offer the service that deserved the commitment of the staff.
Challenging behaviour is often a symptom, not a personal attack
Throughout university we’d been taught that patients with this diagnosis can exhibit “challenging” behaviour, that they can divide teams and we should reflect on how we feel to avoid burnout.
Although we spent a great deal of time analysing how best to nurse patients with a personality disorder (PD), this was approached in a clinical manner. We barely covered the reasons why someone might choose to behave in these ways and want to spend their time in hospital.
So, what is it about this diagnosis that worries nurses before they’ve even met the patient?
Although those with PD can often put a strain on nurse time, I don’t believe reluctance to engage is the result of laziness.
Nurses join the profession wanting to help people. But trying to care for someone who appears to be thwarting attempts to be helped can leave health professionals feeling hopeless. It can be difficult to empathise with someone whose behaviour doesn’t always appear to fit with what they are saying. And even harder to put yourself in someone’s shoes when they are doing everything they can to avoid discharge, a situation that can often come up when nursing this patient group.
Let’s face it, mental health wards are a far cry from the Hilton so why do they want to stay?
It can be easy to forget thatBPD is an illness in itself and the challenging behaviour that can come with it is a symptom, not a personal attack. Understanding this behaviour makes it easier to get a grip on what is actually happening.
In my experience, this is where compassion can often fall down.
And, in these situations, maintaining unconditional positive regard can be difficult.
I agree with the Willis Commission that nurse education is of a high standard, but I feel that training is focused solely on helping and supporting people who want to get better. Little time is spent exploring the reasons why someone might rely heavily on services, often without any apparent reason.
Learning why someone may want to stay in hospital and go to extremes to resist discharge may help nurses, particularly those newly qualified, to remain compassionate when faced with challenging behaviour.
For this reason, it is essential that education on personality disorders centres on the reasons behind the presentation, rather than simply how to manage challenging behaviour.
After all, not everyone can learn compassion, but everyone can learn understanding.
Would you accept payment from the drugs industry?
Last week the ABPI released figures suggesting that doctors, nurses and other health professionals in the UK received £40m last year from pharmaceutical companies. The money pays for medical education events, training and development, and fees for services such as speaking engagements and participation in advisory boards.
I know many nurses, particularly those with specialist roles, benefit from the educational events and sponsorship offer by drug and appliance companies. But should professionals, who make objective decisions about purchasing products and drugs, rely on this financial support. Is it naïve to think there is no undue influence?
We all like to assume we would not be open to influence of the drugs industry but we have to question why spends such large amounts of money on us – after all their job is to ultimately to generate sales.
I have attended sponsored educational events and seen the benefits that could be gained from amassing potential customers in one place at the same time. If you have a new product to sell this is the ideal way to market it. Yet it is clear these events also provide valuable information and a chance from nurses to network and share experiences.
Many nurses are struggling to find funding for education and training and there is a growing dependence on industry financial support. Nurses who receive such support need to be clear about their relationship with industry, and this must be open and transparent. This is vital to ensure that we continue to serve the needs of the patient not the company who funds training.
But an additional concern is how we meet the training needs of nurses whose jobs do not fall into the target groups for drug industry investment. Post Francis there is clear evidence that all nurses need time out to reflect on care; to have supervision and regular updating. Who is looking out for all their training and networking needs?
