Practice team blog
All posts from: April 2012
One parent has cancer, and has been on the Liverpool Care Pathway for weeks. She and her family have received excellent care and support, which has focused on keeping her comfortable and offering emotional and practical support to her and her loved ones.
Of course they are all finding this period difficult, but my friend told me that the team caring for his Mum has enabled the family to find pleasure in their remaining time together. She is comfortable and able to satisfy herself that she is attending to things that are important to her, while her family are reassured that any distressing symptoms will be addressed promptly by professionals who understand end-of-life care.
My other friend’s Dad has advanced dementia and is now frail and declining before our eyes. He is in a nursing care home yet he has been taken to A&E twice in the past couple of months, and then admitted to hospital where he has had arterial blood gas analysis and aggressive antibiotic treatment which was distressing for him and therefore his family. After the first trip to A&E my friend asked the home not to take him in again. She understands that he is dying, and that heroic interventions simply prolong a life that is devoid of any pleasure, yet he was taken in a second time and the process was repeated causing the same levels of distress to all concerned.
These two situations reminded me of a paper at last week’s RCN Research conference, in which Karen Waters reported on a study of the end-of-life care received by patients with dementia. Like my friend’s Dad, 78% of her retrospective sample received burdensome interventions.
Like my first friend’s Mum, many people with cancer or other diseases that are recognised as being potentially terminal receive excellent end-of-life care that gives them both physical and emotional comfort and supports their family. No one tries to “save” them because it is accepted that this is both inappropriate and impossible. Shouldn’t those who are simply reaching the end of their life be able to expect the same?
Some details have been changed to protect confidentiality.
You realise what trouble we are in when policy advice is being given on whether it is best to look after patients on a trolley in A&E or on a trolley in a ward corridor. We seem to have got past the point where either of these situations are unacceptable and are now being seen as inevitable.
The advice last week from the College of Emergency Medicine is that this is the safest way of dealing with current capacity problems in some hospitals.
Maybe so but we have to careful that we are not setting up a system that will become the norm ie that every 20-bedded ward will now become 20 patients plus the one unfortunate on the trolley.
Apparently there is substantial evidence patients are harmed waiting in overcrowded emergency departments or ambulances but there is no evidence of harm to patients through waiting on wards. It may be of course that once a significant number of patients do end up on trolleys in ward corridors that we will establish that that causes harm too.
Ward corridors can be frantic and frightening places. Any patient parked in a corridor will get a ringside view of what is happening throughout the ward, much of which will appear alarming. Ringing phones, harassed staff, ringing buzzers, distressed relatives. It will all be on view and I can’t imagine it will be good for their health and recovery.
The college does specify that the patient stuck on the trolley must be “stable, orientated and not receiving active treatment or require monitoring”. However it won’t be long before that detail is lost and the trolley be treated like the 21st bed. The college may be giving useful advice — the worry is how it will be used.
Listening to recent news reports on discharge from hospital at night I wondered where were the nurses representing the needs of a 94-year-old man sent home at 1am in the morning.
The Times news story and the data it was based on was flawed, but it did make me think again about what it really means to be an advocate. Is it possible to represent your patients if you have no power to influence or change their circumstances?
I was reminded of a time - when I was working as a bank nurse at a large teaching hospital - I was asked to transfer Mr Jones, who had dementia and visual impairment, from an acute medical ward to a surgical ward at around 12.30am.
He was one of the great number of “unwanted patients” in a busy hospital pushed for beds. His medical treatment was complete and but his long-standing health problems meant he needed a bit more time to get his social situation sorted before he was discharged home. As I pushed him through the empty corridors he asked time and time again where we were going and as we got to the surgical ward his distress was tangible to the staff who greeted him.
As I told the surgical nurse about his problems I could feel her anger growing. She shared my distress about moving this frail and vulnerable person from a ward where he had become familiar with his environment and routine. Yet we were both powerless to prevent it happening.
When we were told to move Mr Jones I asked the bed manager what would happen if we refused to. She replied: “We will just get someone else to do it”. Down in A&E someone needed an acute medical bed and Mr Jones lost out.
Bed manoeuvres happen every day in hospitals and I suspect many nurses have had to push patients to other wards knowing that it will ultimately be detrimental to their wellbeing.
So where does this leave nurses as advocates? Should they think about the needs of the person waiting for the bed or focus exclusively on their patient? The NMC advises “Advocacy is concerned with promoting and protecting the interest of people in the care of nurses and midwives, many of whom may be vulnerable and incapable of protecting their own interests”.
But how do you do this in a system that is so pushed and underfunded that it demands nurses compromise the needs of patients in their care for the greater good of those elsewhere?
After all, who would ever assume the bulk of NHS care commissioning could be done effectively without the involvement of the largest group of health professionals.
Except it wasn’t a no-brainer was it? What are now CCGs were originally to be GP commissioning consortia, and there was no requirement for GPs to involve nurses - or any other health professionals for that matter. As a result of pressure from many quarters, including our own A Seat on the Board campaign, the government came up with a less contentious name for the consortia and made it mandatory to involve other professionals.
So now the NHS and Social Care Act has passed into law, and like it or not, health professionals have to make it work for the good of their patients. But it seems the battle for nurse representation on CCG boards isn’t over. As we revealed last week, CCGs will not be allowed to take on their duties unless they have a nurse on their board - but they are free to design the nurse’s role, and there are wide variations in the status of nurses on CCG boards.
Most health professionals agree that making the new NHS work is going to be difficult at best. But if nurse involvement on CCG boards is just a token gesture, it will be nigh on impossible. It took years for hospitals and trusts to accept the value of appointing directors of nursing in the first place, and even longer for them to see the value of making them board members. Surely the profession isn’t going to have to fight the same battle all over again with CCGs. If commissioning is to be led by health professionals then the ones who spend most time with patients and look at them from a holistic perspective must be fully involved in the process.
It was probably not much of a surprise to nurses out there on the frontline that their experiences are nearer to those of nurses in Greece, a country facing economic meltdown, than nurses in countries we would feel more usually feel comparable with such as Holland.
This fascinating survey published in the BMJ shows that 42% of nurses in England felt burnt out compared with 78% of nurses in Greece, 41% in Ireland and 40% in Poland. However only 10% of nurses in Holland and 15% in Switzerland felt burnt out.
Burnt out but still offering good care. A closer look at the statistics reveals that despite reporting high levels of burnout, nurses in England report lower levels than some other countries of wards that have ‘poor or fair quality of care’. For example 19% of nurses in England reported the ward they are working on to have ‘poor or fair quality of care’ compared with 35% in Holland, 27% in Sweden, 35% in Germany and 28% in Belgium.
Nurses were also asked if they would give their ward a poor or failing safety grade. The results from the nurses in England were comparable with the majority of other European countries at 7% compared with Greece at 17% and Poland at 18%.
So burnt out but still soldiering on. But for how long? The survey shows 39% of nurses in England are dissatisfied with their job and 44% intending to leave their job in the next year. Let’s hope that a good proportion of the 44% are planning to find another job in the NHS otherwise there is a phenomenal crisis brewing.
This survey of 2,900 nurses at 46 hospitals took place in 2009-10 before the details and extent of the government health reforms became clear. So it seems likely that the level of stress and pressure of English nurses will move even closer to that of Greece as they face the uncertainty of life in today’s NHS.