Practice team blog
All posts from: July 2011
“What’s the matter with nursing?” cried a BMJ editorial a few weeks ago. Just about everyone seems to have a view, with many commentators looking for a scapegoat or a quick fix. Many of my friends know exactly what’s wrong. They don’t make nurses like they used to. In our day…
Well, it’s easy to hark back to a golden age, but I would challenge anyone who does to think carefully about the workload, staffing and challenges of modern healthcare. Most wards have significant numbers of chronically sick, frail and vulnerable patients. Many nurses work on wards that are not fit for purpose, with staffing levels that have not changed in years. Many of you describe your working life as a war zone. And this week we learnt that ward sisters in some hospitals spent 40% of their time on bureaucracy.
Most of the criticism levelled at nurses relates the essential care given to dependent older people.
So let’s be honest about how we care for older people. Although there are many individual examples of excellent care, there has never been a golden age. I remember the warehouse-like Nightingale geriatric wards during my training in the early 1980s. In the 1990s, I took over management of a rehabilitation hospital where communal toileting, communal clothing and milk and sugar in the tea pot were standard practices. When I asked staff why they did this they were happy to explain. The toilets were difficult to access with a wheelchair; patients’ clothes got lost so it was better to use the hospital ones; and it was quicker to put everything in one pot than ask patients’ preferences since most had dementia.
Scary stuff for a newly appointed senior nurse.
I learnt how easily staff lose sight of what they were doing and why. If we put nurses in silos, give them little education, no feedback, and an inappropriate skill mix they will cut corners. Deidre Wild, a nurse researcher with a passion for care of older people describes it as caring for, rather than about, patients. Getting the job done, rather than thinking about how best to do it, becomes the priority.
My staff worked in a vacuum. What was missing was a crucial element - strong clinical leadership provided by empowered, skilled and enthusiastic ward sisters.
The ward sisters who inspired me to be the best nurse I could be weren’t in the office doing the paperwork but equally they weren’t mucking in. They worked as role models alongside staff, facilitating, challenging, managing and developing every member of the team. This role is for nurses at the top of their game, who can teach, inspire and develop our next generation.
Everyone knows ward sisters hold the key, but is there a will to make the organisational change and investment to ensure we keep our best nurses close to the bedside? If we don’t do this what is the alternative?
Being a health visitor has characteristics that makes it different from many other nursing roles. You don’t wear a uniform, you manage your own caseload, you visit clients in their own homes and rarely carry out a nursing procedure.
It can be difficult for nurses to contemplate so much change to the way they work.
So the lack of certainty about health visitor jobs highlighted last week in Nursing Times’ exclusive report will not help nurses to make that move into health visitor training. Few nurses will be interested in training for a year if they think there will not be a job at the end of it.
What a lost opportunity, because health visiting is an interesting and fulfilling role that offers nurses a different way of working.
When I cycle through my old patch in North London I vividly remember families in my caseload, including the large family I visited who were told their baby with a physical disability would not walk. The day she took her first steps at the age of two years her father rang me to come immediately to see and celebrate this momentous moment in their family life.
These relationships are what makes health visiting so rewarding.
If the government wants to carry out its strategy to increase the number of health visitors by 4,200 over the next four years it will need to find a way to ensure that the jobs are there for the new health visitor trainees.
Like Eileen Shepherd, I was appalled at the story of Elaine McDonald, who 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 has been told to use incontinence pads – even though she has mobility problems rather than incontinence.
Of course it is dreadful that a woman who is not incontinent should be condemned to lying in her own waste throughout the night. Where is the dignity in that? But something else also angered me about the story.
Ms McDonald is a celebrated former ballerina with the Scottish Ballet, and received an OBE in 1983.
I know this, and a whole lot more, about her because her case was covered extensively across the media. From the BBC and the Guardian to the Daily Mirror and Daily Mail, the story was given huge prominence, particularly online. But the stories focused on Ms McDonald alone, and made much of her distinguished career and honour.
What about the many other people who may be affected by this decision? Councils are desperately looking for ways to save money and have just been given a clear message. It’s OK to stop funding night-time visits to people who need help to use the toilet.
Charities commenting on the case pointed out that the court decision had wider implications for some of society’s most vulnerable people. Michelle Mitchell from Age UK called the decision shameful and said it “opens the door to warehousing older people in their own homes without regard to their quality of life”. However, her comments and those from other charities came towards the end of the BBC’s and Guardian’s stories and were ignored by the Mirror and the Mail.
As far as the media are concerned the story is interesting primarily because Ms McDonald is, to quote the Mail “a once beautiful and gifted former ballerina”. Surely the real story is that tens, if not hundred, of thousands of older and disabled people may now be expected to lie in urine and faeces until their daytime carers arrive?
You don’t have to be a prima ballerina to deserve a little dignity.
I was driving on the motorway a couple of days ago counting the miles to the next services and regretting the second cup of tea I had before I set off.
Predictably the traffic ground to a halt. As minutes passed I went from mild discomfort, to anxiety, then panic as I held onto a full bladder.
So why share this with you?
This week, the supreme court was asked to rule on a case in which 68-year-old Elaine McDonald, who had had a stroke, wanted the council to provide a night-time carer to help her use a commode rather than supply her with incontinence pads.
Sadly this is not an isolated situation. Everyday, people in their own homes, care homes and hospital are required to use incontinence pads when they could be continent. They do this because of lack of time, lack of care or lack of knowledge on the part of those caring for them. This ruling is not the start of something new, but more worrying, it legitimises a system of care already in place.
Being allowed to defecate and urinate in a dignified way is a basic human right. It is difficult to imagine what it is like to sit in bed and have to make a decision to pass urine into a pad, when you know you are continent.
Rationing of continence products is already common in England.
Many nurses involved in assessing continence are concerned that their ability to provide care is hampered by restrictions on resources. In parts of the country cuts to pad budgets mean patients may not get the number or type of product they need. They either do without or top up themselves. Many do not have the financial resources to do this.
Functional incontinence should be carefully managed to maintain patient dignity and promote independence. But in so many cases it is easy to ignore the problem because patients have no voice and no one to speak out for them. This is truly shameful.
If you have problems accessing appropriate continence care for your patients I would be interested to hear about your experiences.
I have been really interested in your debate about the effectiveness of 30 degree tilts to reduce pressure ulcers.
I have two thoughts, one professional and the other personal.
My first thought is if we know how to prevent skin breakdown, why is pressure ulceration still a major problem?
Several weeks ago, Judy Harker, a tissue viability nurse consultant, talked about the challenges of pressure ulcer prevention and the work underway to improve care. The problem is that although we have guidelines, the supporting evidence is surprisingly poor.
I agree research into essential care can sometimes feel like “teaching your grandmother to suck eggs”. But looking forward we are facing very different challenges of caring for older, sicker and more dependent patients, and this must demand systemic investigation. We need to know more about individual risk factors and how interventions can be used efficiently and effectively.
On a personal note, both my parents died in recent years.
My father died with a grade 4 pressure ulcer and my mother with ulcers on both heels.
I wish the staff had known about 30 degree tilts, turning and mattresses. They both died with infected, painful wounds which could have been prevented if every nurse involved in their care had thought about their complex health problems and understood their risk factors, hypoxia, neuropathy etc etc..
This shouldn’t happen and any research that improves nurses’ knowledge has to be a step in the right direction.
Judy Harker noted a possible link between the value a nurse places on pressure ulcer prevention and the patient care that they deliver. Discussing ways to improve care is essential and we have to work together as a nursing community to find solutions.
Looking at your debate about 30 degree tilts, I note one brave contributor who put his hand up and said “I didn’t know that”.
I am absolutely sure he is not the only one.