Practice team blog
Six months ago I received my second favourite text to date. A picture of an eight week ultrasound and the words “You’re going to be an aunty!”
My sister-in-law’s pregnancy was ridiculously smooth. No morning sickness, no drama, in fact the most exciting things got was when she posted on Facebook about eating pork pies – was she finally experiencing a pregnancy craving? No, she’d just found a really good pork-pie shop.
Things went so smoothly in fact that when, four weeks before her due date, the baby hadn’t turned we all assumed she was just taking her time and all would be fine. But she didn’t turn and remained breech.
As the realisation that she would most likely be having a caesarean hit home it occurred to me that despite my three years of nurse training, I had no idea what was going on.
“They’re going to try and turn the baby” They can turn the baby from the outside? “The fluid levels are the low-end of normal” Babies have fluid levels? “She’s going to be conscious throughout the c-section” She’s going to see the operation?
Whenever I voiced my lack of understanding or grilled any mothers I know about their interpretation of what was going on, I was met with the same quizzical look and the comment “But you’re a nurse – surely you know about all this!” But the truth is that I didn’t know. My training is in mental health and even my general placements didn’t go anywhere near perinatal care. I may be able to recite section-rights in my sleep but advice on anything remotely physical? No chance.
Although the feeling of helplessness is so much more acute when it’s your own family, it occurred to me that I often felt like this working on mental health wards whenever someone came in who had a physical problem.
The word ‘nurse’ covers so many different areas that at times I’m almost hesitant to use it to describe myself. The roles of mental health nurses and general nurses are so different I sometimes wonder if they should even carry the same title. Particularly as public perception of what a nurse is tends to be limited to general nurses, despite nurses being present in all areas of healthcare.
Is this something only mental health nurses experience or do nurses from all specialties have those moments when they feel their knowledge doesn’t quite live up to their Staff Nurse title?
Incidentally, I now have a new favourite text: “Isobel Eve Entwistle born at 11.59 today, all is well with everyone”.
Many nurses feel like they are working in a war zone even though they are actually working in a NHS district general hospital in a town or in the outskirts of a city. They don’t have enough staff, enough equipment and feel stretched to their limits. They feel concerned they are failing their patients and not supporting families.
Although many will welcome the Francis report and what it recommends, many will feel that it will not change the reality of their day to day struggle.
They will wholeheartedly agree with the call for more professional and compassionate care, the need to improve workplace culture, the call for the ward sister to return. Clear labeling of staff, regulation and standardised training for HCAs and aptitude tests for potential student nurses. All to be welcomed.
But what does the report do to address the fact that too few nurses are looking after too many patients with complex comorbidities? The only chink of light that I can see is that Robert Francis calls for “evidence-based tools for establishing the staffing needs of each service”.
Until services and units are properly staffed, it will be difficult to offer the quality care that Francis outlines without the majority of staff finishing their shift in a state of exhaustion and frustration. The recommendation in the Francis report to establish staffing needs of each service is not one that has hit the headlines, but it is one of the most important.
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?
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”.
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.
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.
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.”
“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.
“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.”
“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.”
“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.
Pressure ulcer reduction is one of the latest targets directed at nurses, as reported by Nursing Times last week. New rules linking them to trust funding mean you will face increased pressure to hit targets on reducing pressure ulcers this year.
The problem of pressure ulcers has always been with us. When I was a student nurse 30 years ago we saw pressure ulcers, sometime terrible ones, particularly in long-stay geriatric wards. But other than turning, an ineffective ripple mattress or a matted sheepskin there wasn’t much we could do. We didn’t know how many patients had pressure ulcers or how to describe or classify them and had no effective dressings to heal them.
In 2013 we have a wealth of knowledge and equipment at our fingertips, yet pressure ulcers are the biggest single cause of avoidable harm to NHS patients.
While targets may help to focus attention on the extent of the problem I am not sure punitive financial penalties will necessarily produce results that patients deserve. In fact they may actually encourage under-reporting. Tissue viability teams across the country are already making efforts to improve pressure ulcer rates without the stick of financial penalties, and these innovations need to be shared and celebrated.
On 7 February we are holding a NTclinical webchat with Vanessa McDonagh and Amy Oldfield, tissue viability clinical nurse specialists from University Hospitals Coventry and Warwickshire Trust. They set up a campaign to raise awareness of pressure ulcers and motivate wards to become free of hospital-acquired pressure ulcers.
Their “100 Days Free” campaign motivated nurses to take control and ensure their areas were free of pressure ulcers for that length of time and beyond. The campaign has reduced hospital-acquired pressure ulcers by 69.5% and saved £600,000. In a recent article in Nursing Times Vanessa said, “We did it because we are passionate about harm-free care.”
Vanessa and Amy are happy to share their experience with you so please join us on 7 February at 4pm. Go to the home page at www.nursingtimes.net and you will be directed to the chat. If you would like to submit a question in advance please email it to email@example.com
You can also update you knowledge on pressure ulcer prevention by completing our Nursing Times Learning unit on Pressure Ulcer Prevention.
It will teach you:
- Factors that increase a patient’s risk of developing pressure ulcers
- How to undertake a pressure ulcer risk and skin assessment
- A variety of techniques that can be used to minimise a patient’s risk of pressure ulcer development
- How different pressure-relieving/reducing equipment can help to prevent the development of pressure ulcers
- How ongoing pressure ulcer prevention should be addressed when transferring or discharging at risk patient’s
- To identify causes and the classifications of pressure ulcers
It’s freshers’ week and all over the country student nurses will be starting out on a training that will contain experiences and challenges that will be with them for the rest of their life. Nurse training changes your life – not just in career terms but also personally.
Are you a student nurse? Fancy some FREE tips and advice for new student nurse freshers?
I feel excited that they are at the beginning of a journey where they will learn the skills of how to look after patients with fundamental care at its heart. I think many of us will remember the difficulties and the challenges of learning procedures, the anxiety about if you are doing it right. The first time you gave an injection, flushed an IV line, changed a dressing or helped someone walk to the toilet. And remember the enjoyment of being able to care and support patients at a time when they need care.
But I think the way that nurse training changes you in a personal way is the experience of meeting patients. However many years ago that is was that you trained, I imagine you will still remember some of the patients you met during your training, especially in the early days.
The conversations that you had with them about their condition and about their life. The opportunity that nursing gave you to meet people from all ages and from all backgrounds. And the trust they placed in you to help them get better or at least to be made comfortable.
So I feel quite excited on the new student’s behalf – wishing I could turn the clock back and go through again some, if not all, of the variety, challenges and real life experience that nurse training offers.
And don’t forget that student nurses can be supported by the resources for freshers’ week at studentnursingtimes.net which will help with tips on essay writing and the first placement and much more.
And a student subscription is only 70p a week.
While there can be few groups within the NHS looking forward to the Francis report into Mid Staffordshire Trust, the nursing profession appears to have most to fear. Large swathes of the general media already seem to assume that the largest proportion of blame rests with nurses.
They will almost certainly report numerous distressing stories of neglect and appalling practice among nurses at the hospital. They will also doubtless demand major changes to nurse education, question once more the move to degree-only entry, and accuse nurses of becoming at best box-ticking robots and at worst cruel sadists who cannot be bothered to cross a ward to help a patient in distress.
There is, of course, no excuse for what happened in Stafford, and it is crucial that lessons are learned so it can never be repeated. And yes, some nurses are individually culpable. But that is far from the whole story – other individuals and professions played their part in these tragic events, so why is nursing being singled out for such vilification? Why is there an assumption that nursing is broken and that all the failings can be laid at its door?
The Daily Telegraph has been particularly keen to accuse the profession, yet its sister paper the Sunday Telegraph reported that complaints had been received about 41 doctors and ‘at least’ 29 nurses at the trust. Given the ratio of doctors to nurses, it would be reasonable to assume that by far the greater proportion of complaints would be about nurses, yet I don’t hear doctors being attacked so vociferously.
Nursing cannot be allowed to carry the can for all the wrongs at Mid Staffordshire. Yes, it must hold up its hands and accept its share of the blame, but other professions must do the same. Nurses cannot fail so spectacularly in a vacuum – it takes an entire hospital and numerous failures in regulatory systems to allow up to 1,200 people to die unnecessarily.
If the NHS is to learn from Mid Staffordshire, the Francis report must be considered in an even-handed manner with a willingness to make changes wherever they are needed rather than focusing on one profession.
And the government must be willing to take a constructive approach to addressing any resource issues that this raises. Anything less is unfair to the nursing profession and, more importantly, an insult to the people who died needlessly and the families they left behind.
Everyone has an opinion on what makes a good nurse. Words such as kind, caring, empathetic, patient, efficient, compassionate, organised, giving and thoughtful trip off the tongue – and then there are the thorny question of cleverness and vocation.
Funny thing is, whatever words are used to describe a good nurse we all know one when we meet them.
In my experience good nurses are good people.
This was brought home to me when a friend died on Boxing Day after a long illness. She was a nurse and loved her job. I never worked with her but in her life she portrayed the all the characteristics of a good nurse. She had an endless capacity to give of herself and her time, she was always there when people in her community needed help, visiting the sick and recently bereaved. She motivated people to get involved and helped to raise huge amounts of money for charities and good causes.
Most of all, my friend cared about people. She noticed when those around her looked sad, discouraged or unwell. She touched everyone with her kindness.
So I am left wondering, are nurses born or can they be taught to be caring and compassionate? What makes a good nurse?
No one should be in any doubt that nurses need a high level of education and training, but they also need to come to the job with qualities that help them translate this education meaningfully into practice.
You can teach the elements of nursing but I am not convinced you can teach the compassion, empathy, kindness and care required to deliver good care. And there lies the challenge. We all know people who would make great nurses but don’t have the qualification to get in, and others who could easily pass the theoretical part of a course but lack qualities that a nurse should have.
In 2013, nursing is facing probably its most difficult time in decades. Publication of the Francis report on care at Mid Staffordshire will focus again on nurses’ failings and I suspect we will be engulfed in another debate about degrees and who is “too posh to wash”.
Although the report is likely to make for painful reading, the profession can ensure that it has a positive effect by using it to rebuild nursing. Perhaps the first step is to ensure our recruits to nursing have the right qualities and values and the NHS is prepared to support them to use these in practice.
It seems that my resolutions have a five to one hit rate – that is of five resolutions only one will come good. But nevertheless I am thinking now about my list of do more/do less and hoping that some of them will stick.
Some New Year resolutions are easier to decide than others. It’s not hard to make the obvious ones of eat less, exercise more, go to the cinema once a week, read more books, drink more water, drink less tea and of course just drink less. But making them around work can be more tricky.
Policy overload – both national and local – can leave you feeling that there is no space for you to make change as an individual. Perhaps New Year resolutions at work should not be about meeting targets or reaching objectives but should be about wellbeing in the workplace. After all you are your responsibility. And the New Year gives us a chance to judge how we are feeling about the past year and the one coming up.
So New Year resolutions offer a chance to to think about how best you can nurture and protect yourself in the workplace. I am thinking about resolutions that will improve my work life balance. Leaving on time, taking a proper lunch break and eating healthy food at work – no more biscuits! How about you? Will it be about getting enough sleep before an early, how you use time before a late shift that means that you don’t feel as if you spent all day at work, cycling to work, getting the earlier/later train, taking proper breaks or what?.
I hope that your resolutions have a better hit rate than mine. Perhaps one of mine should be – stick to my New Year resolutions. Good luck with yours and have a good 2013. If you have any that you would like to share with us please do.
One of my oldest and dearest friends reappeared in my life late last year, over 20 years after disappearing. She had spent the intervening years battling severe mental health problems that made her assume her friends and family wanted nothing to do with her. These have not gone away, but she has felt able to get back in contact with people.
Having her back in regular contact has been one of the highlights of my year, and since she tracked me down via this website I have Nursing Times to thank for that.
However, she also brought home to me that the work we do can make a difference, even if it is simply by ensuring the wider profession hears about some of the excellent practice and innovations nurses are responsible for.
We recently published an article on the use of reading groups in mental healthcare, and the same week my friend told me she had gone to such a group for the first time. It had taken her weeks to pluck up the courage as the new situation provoked anxiety for her. However, she had met new people who had a love of literature in common, rather than only mental health problems, and they discussed novels and poems that meant something to them, instead of these problems.
She was so enthusiastic about the group that I sent her the issue of Nursing Times containing the article. Three days later she told me she had read it out to her group and it had touched them all so much that many had cried. She thanked me for publishing it and said the group hoped it would enable more people to benefit from similar initiatives.
Of course I played only a minor role in ensuring the article was published. The authors did all the hard work in setting up and running the group, and writing the article – which highlights the importance of sharing good practice through publication.
However, it did bring home to me that even though we may not directly transform lives ourselves, we at Nursing Times do give you information and tools that can help you to make a difference. That seems like a pretty good reason to get out of bed in the morning.
I was idling my time away on twitter a few weeks ago and came across a blog by Dean Royles, the director of the NHS Employers.
It made me smile.
He bemoaned the fact that “Hardly anyone supports and encourages NHS managers, or shows any recognition or appreciation of the context they work in or the difficult, sometimes intractable challenges they face”.
His blog struck a cord with me.
We often describe managers as faceless bureaucrats, men in grey suits doing terrible things to make our jobs more difficult.
But any nurse who has had to juggle a Christmas off duty will know what it is to make difficult decisions. Hours spent deliberating, manoeuvring and negotiating and despite every effort no one is happy.
I don’t believe any of us came into healthcare to deliberately annoy and antagonise our staff.
I was speaking to a manager the other day who has spent 10 years building a team and service and the last 18 months dismantling it. Clearly staff and patients were angry but funding had been withdrawn and difficult decisions had to be made.
I asked why she didn’t leave and she described how committed she was to the last 10 years and the staff who had made it work. Despite the flak she was getting from those around her she felt she had to hang on in there for the good of the team.
So in the season of goodwill think about your managers and the difficult jobs they have. And to quote from Dean’s blog, “We have some – in fact, a lot of –brilliant managers doing a tough, demanding and mostly rewarding job that they love and care about”.
So if you have one of them, go on, buy them a Christmas present!
As the news focuses again on the dangers of going into hospital and the pressure I wonder if we are missing something fundamental.
I know from my own experience how quickly things can go wrong when the bed pressures take precedence over safety. Some years ago I worked a night shift on a ward with seven empty beds.
Within 15 minutes of starting work we had four patients arrive, three at the same time. The admissions ward refused to hold off on the next three patients who arrived in short succession. At 2am we were still completing assessments, trying desperately to get through the work.
Then the cardiac arrest buzzer went off. One of the new patients had arrested and by the time we confirmed she was not for resuscitation, CPR was well under way and the team had been called. No-one remembered the transfer nurse handing the DNR over and the admitting nurse had not had a chance to look in the patient’s notes.
The patient didn’t survive, she died alone and she didn’t get the end of life her family had been promised.
We wrote an incident report but like many nurses we finished a shift feeling we had worked really hard but let our patients down.
I seems to me that just as the Beveridge Report could not have anticipated the effect of modern pharmaceuticals and medical advances on longevity, neither have we really got to grips with the demand that an ageing population is putting on our health care system.
There is endless talk about the need to provide more care in the community but while there is a shift in that direction, these developments are not keeping pace with demand.
Without adequate community services is it surprising that pressure on beds and pressure on staff is increasing and mistakes happen?
Currently we have hospitals with too few beds and community services that are not sufficiently developed to provide acute care at home. Between the two is a huge gap that no one wants to take responsibility for.
The people who suffer most are the old and vulnerable who end up in a system that is not designed to meet their needs being cared for by people who care but simply don’t have time. That is not good for anyone.
Alzheimer’s disease and other forms of dementia are devastating both for those unlucky enough to develop them, but also their families.
The early stages of dementia must be terrifying, as cognitive abilities disappear, and while we cannot know how it feels to experience advanced dementia when the ability to communicate or to understand what is being said is affected terribly, we can only assume that for most people it can only be worse than that.
For family members, watching their loved ones gradually losing not only their independence, but also the personality traits that made them who they are, is horrific.
Many families continue to care for their loved ones when their dementia has rendered them unrecognisable as the partner or parent they once were, seeing it as their last opportunity to show love or gratitude.
While dementia can reach a stage where 24-hour care in a specialist setting is essential, this is often reached as a result of personality changes resulting in challenging behaviour that compromises the safety of all concerned. If this behaviour could be addressed, it may give families more time together.
News that an American team has developed an approach to managing these symptoms offers some hope to these families.
The six-step approach can help clinicians to identify and manage most behavioural symptoms of dementia without medications.
Instead the focus is on identifying triggers for these behaviours and establishing structured routines, both of which are likely to reduce the distress caused by confusion.
Designed for use in any setting, including primary care, this tool has the potential to give families extra time together, and to reduce some of the fear that dementia causes.
I hope those commissioning care for this patient group will make resources available to test its efficacy, and assuming it has positive effects, will ensure it is rolled out widely and quickly.
It was when I was editing one of this week’s articles on stroke that I was struck by the reference to interdisciplinary working and how it was benefiting patients.
When discussing early mobilisation and positioning in stroke the authors identify how the patients need 24 hours care, particularly in certain aspects of care to make the best recovery.
They point out that if nurses learn safe and correct ways to move and handle individual patients, it means the patients are not waiting for the physiotherapist to move them.
The skills would come from training but also from working with the
with the unit-based physiotherapist. This is where interdisciplinary skills come in so that the different professions are working together rather than side by side.
Nurses are with patients 24/7 so the benefit to the patient is huge meaning that their mobilisation can continue at weekends and out of hours. The patients’s outcomes will be better and also their engagement with the project of recovery will not be frustrated, for example by them waiting for the physiotherapist.
In recent years there has been a lot of discussion about the changing role of the nurse, and the blurring of boundaries between medicine and nursing. Yet patients also benefit significantly from interprofessional learning and sharing skills with other members of the healthcare team.
In many universities interprofessional learning is common practice with OT, medical, nursing and physiotherapy students learning together and sharing knowledge and skills. But this should not be confined to under graduate programmes. We need to move to develop true interprofessional practice to ensure holistic care for all patients
Upskilling nurses with crossover skills from the other disciplines will be good for the patients and for the profession. It’s not a case of doing someone else job as, for example in moving and handling patients, it is part of nurses’ job. It’s a case of refining and developing those skills in partnership with other professions to benefit patients.
Multidsciplinary was the new buzz word about 20 or more years ago. Perhaps it’s time to move things onto interdisciplinary.
For 35 years my mother lived with bipolar disorder. It is difficult to imagine what it must have been like for her not to sleep for days on end and at other times just sit and cry and cry and cry. It was hard enough watching it.
Over 35 years my family got used to a pattern of care; crisis, hospital admission, medication, non-adherence, crisis. Mum had numerous hospital admissions, ECT and plenty of medication but very little interaction with health professionals.
Support in the community was hit and miss. CPNs were our lifeline, but as Mum did not always co-operate and on several occasions she was often signed off CPN caseloads because she did not appear to benefit from the visits. This meant that when a crisis happened we had no direct access into mental health services, resulting in delays in treatment and sectioning under the Mental Health Act, which could have been avoided with early intervention.
So why am I telling you this? Well a report published last week by the The Schizophrenia Commission describes care for people with schizophrenia and psychosis as falling “catastrophically short” . It highlights the value of preventative work in the community, which can do so much to improve patients’ quality of life.
The long-term consequences on Mum’s physical health only became apparent in later life. We found GPs, hospital consultants and general nurses had very little understanding of the complex relationship between her mental and physical health problems. It is easy to overlook physical problems when you are dealing with someone who has an understandably deep-seated suspicion of doctors and is reluctant to communicate with them.
I am not an expert, but it seems to me that the sensible ideas in the report could apply to many other mental health conditions. For 35 years my Mum was cared for in underfunded services, in generally poor conditions, where staff were often forced to ration care to those most in need. What this means is people like my Mum got her anti psychotics and mood stabilisers but very little else. I think she deserved better – as do people in her situation today.
I know there is excellent practice going on and we regularly publish examples of innovations that make a difference in mental health. It is vital that this practice is shared so if you are doing great work please tell me about it!
One of the worst examples in recent history was the hysteria whipped up about the MMR jab, on the basis of highly questionable evidence from a tiny sample of children. This evidence has now been utterly discredited, but not before vaccination rates dropped to dangerous levels.
The latest target is the Liverpool Care Pathway, or the pathway to death as the Daily Mail prefers. A torrent of stories about hospitals being bribed to put patients on the LCP, patients being routinely denied food and fluids, or health professionals being too keen put patients on the pathway and refusing to take them off if they show signs of recovery have bounced health secretary Jeremy Hunt into declaring that the revised NHS Constitution will require patients and or families to be involved in end-of-life care decisions.
Anyone who took the time to read less sensationalist sources – or to look at the LCP documentation itself – would see that the pathway is simply a tool to help health professionals to make the last hours of their patients’ lives as peaceful as possible. It is only to be used in patients who are dying, and any who show signs of recovery can be taken off the pathway. Food and fluids are only withdrawn in specific circumstances where this will reduce patient distress, and patients and families are already required to be involved in the decision-making process.
Of course, like any tool, the LCP is only as good as the people who use it, so it is vital that it is implemented by health professionals who understand its principles and purpose, and who stick to the guidance.
Properly used the LCP is a way of providing the best possible care to dying patients and their families. Attacks on the pathway on the basis of instances of improper us, or presenting opinions as facts will simply lead patients, professionals and families to avoid using a tool that has spared countless people distress in their final hours.
A recent US study has revealed that overnight noise levels in intensive care units often exceed levels recommended by the World Health Organization. The assumptions seems to be that if patients are asleep, sedated and even unconscious they won’t be affected by the beeping and noises of machines.
However the researchers concluded that sleep disruption was prevalent and could impact on levels of delirium and negatively impact on immune dysfunction, as well as potentially adversely affect outcomes.
It can seem old fashioned in this world of high-tech health care to remember how important rest and sleep are to recovery. Sometimes malfunctioning equipment keeps beeping and being reset without anyone thinking of how it is affecting the patients. And when working at night, it is too easy to forget that others need to rest when the night has become your day.
We all know what it is like to be woken up by a car or house alarm at night and how this affects your performance the next day, giving us some insight into how patients feel about the constant beeping and alarms on hospital wards.