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'Sorry, not my patient'

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18 February, 2013

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”.

Readers' comments (17)

  • michael stone

    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.

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    Yes, I agree - I have arguments with people, about the appropriateness of writing guidance that seeks to be very clear about 'the principles' (my gut preference) as opposed to defining 'lists of rules' (what the NHS usually seems to end up with).

    But it is tricky - you need to know how well-trained and expert the staff are, because the 'list of rules' works better for poorly-trained/non-expert staff, while the 'principles' approach works best with highly-qualified, expert, staff. And good training costs money, doesn't it ?

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  • Easier said than done when you have four or five times the number of patients that is generally considered safe.

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  • Whatever happened to holistic care. This fragmented task orientated approach looks more cost effective on paper but in reality leads to patients being seen as work to be done and ticked off. Goodness knows how this intentional rounding will end up - if there is one thing that NHS is skilled at its finding a way to meet targets without addressing the reason a target was needed in the first place - just look at a& e departments who glance at patients log them as seen then leave them for the long wait they would have had before the target came in. You really can't look after patients and targets - we need a way to measure what we do not a way to do what we measure.

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  • Brilliant post. I was almost hopeful when I first read the White Paper a couple of years ago, because it replaced targets with outcomes. So no 4h waits, and the clinical indicators were developed with practitioners and they actually made sense. I remember rushing down with them, saying look, isn't this sensible? Finally I thought, we can replace artificial numbers with real patients. But they went back on it, and the national clinical director resigned because of the pressure he was put under to retain targets and went back to clinical practice. So another broken promise. And another clinician disappointed by his experience of management.

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  • I agree with above. too many people with clip boards making plans for my patients. every body refering to specialist nurses instead of thinking and dealing with the patient as a whole. Hours of "important" meetings. and most important not enough nurses on the ward. We used to treat the patient as a whole. we did not need dozens of tick boxes to know to "touch base" with the patient every hour!!! i could go on and on but it is pointless. I am fed up with millions being wasted to research what a first year student nurse could answer and that is if there are too few nurses ....Guess what?? standards of care drop, staff get burnt out and patients DIE THAT PROBABLY WOULD NOT HAVE DONE!!!!!!!!!!!!!

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  • Introducing General Management to the NHS was probably the biggest mistake that was ever made during its whole long history.

    It is an industrial management model which came from America with McDonalds, etc. and is well adapted to the successes of running supermarket chains which involve production, marketing and sales of goods, but it is not and never will be a healthcare model despite all the subsequent patching up and reforms. The NHS needs to develop its own healthcare management model based on its founding principles.

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  • Angel nomore

    Without the extra staffing levels,and reducing paper work,all this is hot air ,in deflating balloon.
    Im giving up! leaving the nhs as trained nurse,and at considerable cost to my self,become a community HCA. The job satisfaction will be emeasurable better .

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  • Angel nomore | 21-Feb-2013 1:11 pm

    with your skills and experience as an RN I am sure you will be welcomed with open arms in the community, and provided you are given the time, patients will really benefit from your care. there seems to be a great shortage of community carers and especially for the elderly.

    It is sad, but understandable, you have felt it necessary to make this sacrifice but good luck and maybe hospital services will improve and you may one day, if you wish, be able to return and take with you all your experience of community care.

    Dear Angel once more.

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  • As a student nurse, I remember the introduction of the 'named nurse' in the 1980's, that along with the nursing process which was introduced to a ward of innovation and pioloting of 'excellent ideas' in a leading teaching hospital caused me to be so thankful I could return to other wards less exemplary where the 'named nurse' was held were the ward sister(s)/charge nurses who had omniscient knowledge over 24/7/52 - oh for a CPD in that! Looking back, they were actually leaders of practice

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  • Dear Angel nomore. I am community staff nurse. We also have our never ending rounds of tick box nursing by numbers problems but if you fancy a change of environment why not be community nurse rather than HCA. Our HCA does a fantastic job - she actually does pretty much what we do. She has recently been told she will be expected to remove suttures etc one wonders why we trained sometimes and she wonders why her pay grade so much lower etc. Still good luck in all you do.

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  • I have witnessed unsafe staffing level ,where 2 qulified nurses had to care for 28 patients at night shift ,when there is only on call doctors avilable.There were patients with epoprostinal infusion,thrombolysis,(who needed to be monitored half hourly) 2 post op patientS,2 hdu tranfer,atleast 12 patient on IV meds,PCAS,Epidural ,TPN,many dependant patients and what not. AT times the third qualified was sent to another area and they were given an extra support worker.Iwonder how on earth can a HCA replace a qualified nurse.

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  • Its true community nursing is subjected to the same tick box approach. The next big nursing scandal could well relate to the level of 'tasks' that managers push for HCA's to do in community as they are on paper cheaper but in community you work unsupervised and patients rarely just need an insulin injection, they have other problems, the trained nurse can answer questions during the visit the HCA will -hopefully- bring them back and then the trained nurse will spend the same amount of time dealing with them. Unregistered and trained in a task only is hardly a recipe for safe administration of insulin.

    We also suffer in community from having to fit into community boxes like the safety thermometer - recording falls that happen before we even meet the patient as harms - its like living in satirical comedy in the NHS these days.

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  • I wasn't aware that hca's were allowed to administer insulin. Ours certainly are not. Our HCAs are not allowed to administer any medication whatsoever, they can only prompt medication to a patient. If any nurse is allowing a HCA to do this they bear the responsibility. I'm pretty sure it's against NMC Code and certainly not allowed according to our local policy & procedure.

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  • I wasn't aware that hca's were allowed to administer insulin. Ours certainly are not. Our HCAs are not allowed to administer any medication whatsoever, they can only prompt medication to a patient. If any nurse is allowing a HCA to do this they bear the responsibility. I'm pretty sure it's against NMC Code and certainly not allowed according to our local policy & procedure.

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  • Without sounding like a grumpy old man I concur with the comments and Eileen here. I’m not a nurse but a Registered ODP and undertook my two week ward allocation in the early eighties. It was only a snapshot but on a 34 bed ward the Sisters insisted we make notes of every patient every day and get to know them all as we made beds, changed bladder irrigations, undertook the drug round etc., etc. My wife was training as a nurse at the time and assured me it was the same in the rest of the hospital. I’m extremely grateful to these Ward sisters for what they taught me about holistic care. Hence my frustration now when I’m 100 miles away and ring that same hospital to enquire of my 92 year old father on the Cardiac ward to hear the response, I’m not sure, I’m not in that team. The ward sister of old would have gone wappy if she heard one of her team reply in such a way.

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  • John Dade | 28-Mar-2013 9:38 am

    Reminds me yesterday of a response I received from a young sales assistant when I asked for information (with an excuse me, please and thank you) about a product and why the more powerful one was cheaper than the weaker one (same make, same model).
    Oh, I haven't a clue she said, and went back to stacking her shelves and chatting to her colleague! Irritating when you have come from some distance and it is near closing time. Needless to say, the store also lost a sale although I don't think that bothers the young sales assistants.
    I always use these encounters to observe what constitutes good and bad service and try to apply what I have seen of the very best to my own work. It is a good way of learning what is poor quality and how one reacts to it. as a customer it is easy to walk away from, frustrating though it may be, but such attitudes are greatly magnified in healthcare where patients are far more sensitive and vulnerable and do not expect such unhelpful responses from those to whom they entrust their care.

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  • I have been nursing for 38 years and have watched the profession deteriorate steadily into a culture of lawyer generated verisimilitudes. When I started in 1975 it was about personal and professional discipline and moreover the simple but effective delegation of nurse-in-charge authority. Thus the second-in-command "enrolled nurse" was crucial. Intelligent, trained, resourceful but crucially subject to the authority directives of the responsible NIC who in turn was subject to that of the ward sister. Tasks were simpler and within a simpler nursing milieu. The NIC would typically delegate the morning drug round and whatever other tasks to the EN who then would take 30 minutes admistering and not four hours as now within a medical/NMC supported fuss culture in respect of many spurious drugs developed with eyes on quasi-academia and profit as much as actual patient benefit that is very often marginal to say the least. The NIC would focus upon actual "real" patient-centred care, supervising directly junior staff and thus observing first hand the issues that needed clarifying and addressing as they occured. Paperwork would focus on real available care plans i.e. who does what when where and how ..1,2,3,4,5, not the college induced folder-filed-away verbiage that passes for "assessment planning" currently. The basics of care were observed as they occured by nurses and very often ward sisters directly who like hawks would swoop in immedietelly as any poor practice raised its head, not later as now when it was being worked out in the aftermath by expensively trained and superannuated specialists what had gone wrong. "HA regulation?" Cannot the "profession" work out a new way to waste money on top of of a self-aggrandising lawyer-driven NMC police force now apparently pointlessly duplicating the role of employer but with absurdly excessive powers that they appear to relish abusing?

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