Nursing needs its leaders to respond to FrancisPractice blog
All posts from: February 2013
‘Two in a bed’
As a mental health nurse working on an acute ward, I found that all too frequently the handover I was given contained the dreaded words “two in a bed”. We didn’t physically have two patients sharing a bed, although a glance at the list of patients might make you think we were. This phrase referred to one patient being on leave and another patient being admitted in their absence. So a 20-bedded ward could technically be accommodating 21, 22 or more patients. Often, this meant the leave patient would return to find no bed available.
Sectioned mental health patients are given leave as part of their recovery process. As they show signs of improvement they are prescribed periods of leave either with nursing staff, with relatives or unescorted. These periods of leave become longer as they near discharge with the intention that being discharged home will be a natural progression.
However, due to bed pressures, patients would sometimes return to the ward at this critical point in their recovery to find that the support network they felt they had on the ward was no longer there. They were either asked to spend more time on leave or moved to another ward. Frequently, this led to patients being moved or discharged to “free-up” a bed, not always leaving them time to fully recover from their acute illness.
Of course the main reason for leave beds being used is the pressure being put on bed management to find a bed for an emergency admission. As many of the patients on mental health wards are so called “revolving door” patients, this raises the question that perhaps if we didn’t discharge simply to free up a bed but allowed time for a full recovery, would this reduce the number of patients requiring admission?
'Sorry, not my patient'
No patient’s care should ever be reduced to a job list. Yet nurses have resorted to task-based care in NHS organisations that have failed to put patients first.
As we all know patients can have their physical needs met efficiently, have all the tasks ticked off but may have received no care.
There is so much talk about putting patients at the centre of the NHS and this is laudable. BUT to make this happen nurses must have the resources, training and support to make patients matter most.
Every patient needs a nurse who will guide them, inform them, advocate on their behalf: someone who is knowledgeable, an expert in their specialty who they can look to for help.
So I welcome the Francis recommendation for key nurses but I am worried about how it will be implemented.
I have been, and remain, a firm advocate of the principles of primary nursing. The “my patient-my nurse” relationship is a fundamental tenet of care.
But I remember my anger when those principles were translated into a national named-nurse policy in the 1990s. A target date for implementation put the focus on the “how to” of providing personalised care rather than the “why”. As a result the system failed and the legacy was a fragmented team nursing approach to care epitomised by the catch phrase “Sorry, not my patient”.
So how can we learn from those mistakes?
The key nurse role must not be imposed on nursing teams. The mechanics of how to make it work are much less important than the philosophy that underpins the nurse-patient relationship.
Nurses need support, development, supervision and time to reflect on how they can put patients at the centre of care.
But responsibility does not rest with nurses alone. There needs to be a shift in organisational culture, that puts the nurse-patient relationship at the heart of its business and before any attempt to implement the staffing implications have to be considered.
Key nurses are not an answer to the problems facing the NHS but the recommendation offers a glimmer of hope that the value and importance of nursing care has at last been recognised.
We have an opportunity to use this and many of the other recommendations to challenge a culture that cares little about patients and even less about front-line staff.
Remember to make this work it is not “how” we do this but “why”.
'To leave the Francis report gathering dust would be an insult'
So we have finally received the much-delayed Francis report – all 1,781 pages of it, and had a few days to digest its 290 recommendations. Some people have been disappointed that the report lacks bite, thanks to Mr Francis’ decision not to apportion blame. Others are disappointed that his recommendations lack punch. Personally I would have liked to see clear recommendations to protect individuals who do raise concerns about poor practice at their place of work. That would give us a better chance of nipping similar situations in the bud in future.
But perhaps that misses the point. What Mr Francis has achieved is to gather together an enormous and complex mass of evidence. He has also placed that evidence in a clear narrative that enables anyone with an interest in any aspect of this dreadful case to find the information they need quickly and easily.
And yes, he has made recommendations, but that is all they are – recommendations. He has no power to impose his will.
What happens to this report is now up to others. The government, the NHS and everyone who works in it, the professional regulators and the police can all choose to act on his findings and his recommendations or not. They can also choose to go further than Mr Francis recommends.
One of the many shocking aspects of the Mid Staffs tragedy brought into sharp focus by the report is just how much information was available about the dreadful situation at the time it was happening, and how many people ignored it or claimed not to have seen it. Well anyone claiming not to know now needs to be able to produce evidence that they have spent the past few years in the Amazon jungle.
Everyone with the power to effect the necessary changes has the evidence they need to do so. The government can accept his recommendations as they are or give them added bite. NHS workers can decide collectively that they will not allow this to happen again, and to ensure patients are at the heart of everything they do. The professional regulators can call individuals to disciplinary hearings. And the police and Crown Prosecution Service can pursue anyone shown to have acted in a way that makes them criminally liable.
I hope all these organisations and individuals have the will to ensure the report is used in a way that does justice to the families of those who suffered – who showed such bravery and tenacity in ensuring this story was heard, to the staff who did try to raise the alarm and suffered personally and professionally as a result, and to Mr Francis’ diligence and humanity in gathering his evidence. To leave it gathering dust would be an insult to them and a travesty for the people who suffered and died. Let’s use this important publication to transform the NHS into the service we know it can be and that its patients and staff deserve.
'It is hard to hear criticism of the nursing profession'
For those of you out there who are striving every day to deliver compassionate and high-quality care to your patients within the current resource and staffing constraints of the current NHS, this is an even more difficult day than usual. It is hard to hear criticism of the profession.
Without a doubt there was poor nursing care at Mid Staffordshire and at other hospitals around the country. Some of that was the result of particular individuals but as Robert Francis makes clear the problem was more organisational factors including culture, staffing levels and staff skill mix also played a significant part.
But although this is a dark day, it is also the day that brings hope that the problems in the health service which you live everyday will start to be addressed.
In his report Robert Francis makes 290 recommendations which offer a way forward for nursing in particular. The breadth and significance of these recommendations is huge for both nursing and the delivery of healthcare.
The central tenet is that “the patients must be the first priority in all of what the NHS does”.
For nurses a key recommendation is for each patient to be allocated for each shift a key nurse responsible for their care and for this nurse should be present at every interaction between the patient and the doctor.
There are recommendations for the implementation of quality metrics and the need for evidence-based tools to establish appropriate minimum staff numbers and skill mix.
Regulation and standardised training of healthcare assistants and a strengthening of the clinical role of ward managers are important steps. As is the formalisation of the nurses’ continuing professional development with an annual appraisal and portfolio to be signed by nurse and countersigned by their manager.
For these change and improvements we need both will and resources from the government to ensure that the recommendations from the report are carried through. Nurses now have a platform to articulate their concerns and have their voices heard. We need to grasp this opportunity and ensure the appalling neglect and care at Mid Staffordshire Hospital never happens again.
'She was terrified of the very people who should have been there to care for her'
Isabella Bailey was admitted to mid Stafford hospital with a hiatus hernia. During her hospital stay her family became so concerned about standards of care on ward 11 they decided to keep watch over her 24 hours a day.
Isabella’s daughter, Julie Bailey has written about her mother’s stay in hospital and what happened to other patients on ward 11. Her book “From Ward to Whitehall” is a horrific personal account of neglect and abuse.
Reading it I found myself underlining, turning over page corners and sadly recognising some of things nurses do when they stop seeing the person in the bed.
These quotes give some insight into the scale of the problem:
On ward culture
“Each day there is unkindness because there are so many uncaring staff on this ward, the negativity feeding off itself and multiplying.”
On caring for confused patients
“Nurse Ratchet has moved Mavis, she has had a mattress placed in the corridor opposite the nurses’ station. Every time she gets out of bed she shouts at her, ‘Get back into bed!’ you can hear her hollering all the way down the corridor.”
Feeling safe
“Every time a nurse came near her, she was terrified, terrified of the very people who should have been there to care for her.. .when the staff came near her she would dig her nails into my hand in fear.”
On raising concerns
“If you contact management you’ll just get us into trouble and that won’t help anybody,” she [nurse] tells me.
Hydration
“The woman in the isolation room wasn’t the only patient I saw drinking out of the flower vases that were piled up along the main corridor.”
On nutrition
“Sitting watching them [patients] claw at their food was heartbreaking… The ward was so starved of staff it was impossible to manage a ward and care for all those patients.”
On personal care
“Without further ado the bowl is emptied and Mavis hasn’t had a wash since at least Thursday, despite being covered in faeces. I’m surprised as they must have smelt her, as we have all weekend.”
On communication
“You rarely get eye contact with any of the staff, they could just walk straight past you, without any form of acknowledgement. You can stand at the nurses’ station for minutes without any of the staff even raising their eyes.”
On good nurses
“20% of the staff are lovely, absolute gems in this uncaring environment. Their presence can light up a room… I realise that their presence calms the ward, even the confused patients are less agitated when they are on duty, they respond to their kindness. The problem is because there are three different shifts a day and very few caring staff, a kind word is rare.”
So tomorrow the Francis report is published. This inquiry happened because patients suffered and died due to lack of care in a health system that no longer saw care as its primary function. As a profession we have to gather the strength and confidence to ensure this never happens again – and ensure that patients and their families can feel confident when they are admitted into our care.
