Practice team blog
In the NHS some patients are more equal than others.
That was a message I got from delegates at the Association for Continence Advice conference last week.
Because some commissioners think bowel and bladder care is important and others don’t.
We have discussed the outcome of rationing care on this website before. Remember the case of Elaine McDonald? Ms McDonald 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 was told to use incontinence pads – even though she has mobility problems rather than incontinence.
The indignity of passing urine into a pad when you know you could go to the toilet is unacceptable. Yet our continence services are under immense pressure and in some areas commissioners, looking to save money, may see continence as an easy target.
Why treat a problem when you can throw a pad at it – and, while you’re at, it ration the number of pads?
Those who have the money can top up their supplies, while everyone else has to make do. In a #NTtwitchat last week people talked about the human cost of rationing: drying pads so they can be used again or providing a pad that lasts 12 hours so less care is required for toileting.
It is nurses who inevitably have to deal with the consequences of offering different levels of service to their patients depending on who is commissioning care.
How do you explain to Mrs Smith at number 46 why she gets one service while Mr Green at number 72 – with a different GP – gets another?
How do we reconcile the compromise this inevitably entails? Is it just the new economic landscape of healthcare that we have to get used to?
The uncomfortable realities of competition care are beginning to bite. What is your experience?
The Telegraph’s website the other day carried the headline “Minister: NHS will collapse if elderly bed-blocking continues”.
The story itself was a reasonable discussion about the need for better integration of health and social care to ease pressure on hospitals and ease the crisis in A&E, but the headline implied older people were to blame for all problems in the NHS. It conjured up images of stubborn older people refusing to give up hospital beds they no longer need, selfishly forcing younger people to wait for urgently needed care.
My 85-year-old mum recently spent two weeks in hospital, and the nursing care she received was faultless – every one of the 6Cs shone through in all the nurses on her ward. Nevertheless, the experience was distressing and confusing and all she wanted was to go home. And that’s exactly how most hospital patients feel, whatever their age.
The casually insulting tone of The Telegraph’s headline reminded me what a shame it is that the government has not accepted Robert Francis QC’s recommendation to create a new older person’s nurse specialty. These nurses could have expert knowledge of the ageing process and age-related conditions, and an understanding of the particular needs that ageing brings.
Older people’s nurses could help non-specialist colleagues across multiple wards or teams, and take a lead in caring for patients with particularly complex needs. And like cancer nurse specialists, they could smooth their patients’ path through health and social care, chasing test results, co-ordinating discharge plans, and ensuring all relevant professionals, family members and carers are involved and informed as appropriate.
I hope that when it makes its more considered response to the Francis report later this year the government will announce that it will, after all, create an older people’s nurse qualification with registered status. These nurses could do much to improve the experiences of older patients, and may also help to reduce the pressure on hospitals by reducing inappropriate A&E attendance and speeding up discharge by coordinating all care providers. Maybe they could also teach lazy headline writers that older people aren’t to blame for NHS problems – in fact they have spent a lifetime paying for it.
This is Dementia Awareness week which is a good way to call attention to this common condition. But in reality every week needs to be dementia aware for nurses. And it’s not just for nurses working in care of the older persons and in nursing homes. All nurses will come into contact with patients with dementia – on surgical wards, in A&E, outpatients, GP surgeries and out in the community.
Simple strategies can really help to make communication easier. Take a look at an article we published recently which gives some useful tips. It sounds simple but it will make a difference. For example, avoid asking open-ended questions such as “What would you like to drink?” but ask instead “Would you like a drink of water?”
And think about the environment where you work. With the increasing number of people who have dementia, and will have it in the future, it is time to think about how you can make the space where you see patients more dementia-friendly.
Take a look at our excellent article written by June Andrews at the Dementia Services Development Centre at the University of Stirling. Even small adjustments can make a difference. For example, having doors in contrasting colours to the walls makes it easier for the person to navigate their way around.
We are having a twitchat at 1pm on Wednesday 22nd May. If you have strategies that you would like to share please join us for the chat. It is an important subject – this and every week.
Rapid tranquillisation on mental health wards is much-debated.
On the one hand, rapid tranquillisation is sometimes needed to maintain the safety of the ward, on the other hand it carries with it extreme risks to the patient, can be addictive and arguably should be the last resort when all other methods of de-escalation have failed.
Patients are often subscribed tranquillising and antipsychotic drugs PRN so they can approach staff if they feel they need additional medication. In my experience, this can work well with patients being afforded the opportunity to take responsibility of controlling their symptoms before escalating.
However, as a staff nurse what do you do if a patient asks for medication they do not appear to need?
As you can’t tell what’s happening in someone’s mind, should you take their word for it that they know what they need?
What if they have been sitting watching TV, appearing calm for the past hour, and strolled to the nursing station to request highly-addictive benzodiazepines?
Giving medication without clinical need is not in the patient’s best interest and may in fact be feeding an addiction.
But, what if saying “no” leads to aggressive behaviour, putting patients, staff, visitors and the hospital environment at risk?
I have witnessed patients requesting lorazepam without clinical need only to be, rightly, refused this by nursing staff. In order to ensure they got the medication they wanted, I’ve seen patients then damage hospital property, threaten staff and other patients and escalate to the point that staff have no choice but to medicate in order to maintain the safety of the ward.
This positive reinforcement of disruptive behaviour only leads to the same happening again.
Benzodiazepines are all too often given without consideration to the long-term consequences. The MDT must look at ways to balance the short-term benefits of using these drugs with the long-term affect they may have on the patient and the nature of their care.
What do you think? Do we give out too many benzodiazepines without considering the consequences of long-term addiction? Are we too quick to use rapid tranquillisation to de-escalate?
There is an old man who occasionally catches the same bus as me to the station. When he arrives at the bus stop there is an odour which in the confined space of the bus gets worse.
It took me a while to work out that the smell was from compression bandages on his legs which are usually heavily stained with exudate. Month after month the smell hasn’t improved and I would assume neither have his ulcers.
How does he feel when people instinctively move away from him, look the other way or fan themselves with a copy of the Metro?
I can’t make a judgement on his care or whether he is compliant but I do wonder whether his wound management is based on the best available evidence.
Management of leg ulcers, unlike other nursing activities, has a fairly robust evidence base. A well-managed venous ulcer can heal and we have a host of products for management of odour and exudate.
Sadly, the evidence has also highlighted the profound psychological effect ulceration has on people’s lives leading to social isolation, depression and anxiety.
So when I look at my fellow bus companions bandages I am left wondering about the research-practice gap.
Who is removing this gentleman bandages and assessing his symptoms?
Is anyone talking to him about how he is managing is hygiene and washing is clothes?
Has anyone talked to him about his shoes that don’t fit comfortably over the bandages?
Has anyone asked him how he feels?
The application of compression bandaging is a specialist skill and the Leg Ulcer Forum is clear that it should be undertaken by nurses with specialist training.
However not all patients have access to specialist services and the net results is on-going, expensive and ineffective care that has a negative impact on patients.
We all have a responsibility to use evidence based practice but practitioners need to have access to it. While practitioners should ensure they are up to date, researchers must ensure that their work is disseminated as widely as possible.
The problem is academic institutions usually measure the value of its researcher by their publications in academic journals with impact factors. This measure is not based on the impact on patient care but on the number of citations to the journal - those with higher impact factors are deemed to be more important than those with lower ones.
Perhaps it is time for researchers’ success to also be measured by their impact on patient care.
A friend recently tried to have a Doppler scan and tissue viability assessment in the community rather than in the hospital.
Sounded sensible – just around the corner.
But the saying is there is no such thing as a free lunch. And in this case it seemed there was no such thing as accessible care.
A trip to the hospital is only another 30 minutes on the bus and as it turns out this would have been time well spent.
Appointment number one failed as the staff member who could work the Doppler machine was not in until later. Appointment number two failed as the nurse using the Doppler machine could not get it to work properly – no back-up support available to assist. Appointment three failed because the wrong type of gel was available to get a reading.
Three weeks have now passed as the clinic only runs once a week. And the venous ulcer in question continues to exist but fortunately not to expand.
Running outpatient clinics and other services out in the community is good for the patient as it makes services more accessible and can be cost-effective.
The plan is that services for long-term conditions such as venous ulcers will be looked after by outreach and community services. But for this to work they must be properly resourced in terms of staff and equipment.
Community care is not supposed to be care on the cheap.
My friend did not feel the failure of each appointment was down to the willingness of the staff as each time the staff did their best to rectify the problems that occurred at each consultation. But that there was not the human and equipment resources to offer the service that deserved the commitment of the staff.
Throughout university we’d been taught that patients with this diagnosis can exhibit “challenging” behaviour, that they can divide teams and we should reflect on how we feel to avoid burnout.
Although we spent a great deal of time analysing how best to nurse patients with a personality disorder (PD), this was approached in a clinical manner. We barely covered the reasons why someone might choose to behave in these ways and want to spend their time in hospital.
So, what is it about this diagnosis that worries nurses before they’ve even met the patient?
Although those with PD can often put a strain on nurse time, I don’t believe reluctance to engage is the result of laziness.
Nurses join the profession wanting to help people. But trying to care for someone who appears to be thwarting attempts to be helped can leave health professionals feeling hopeless. It can be difficult to empathise with someone whose behaviour doesn’t always appear to fit with what they are saying. And even harder to put yourself in someone’s shoes when they are doing everything they can to avoid discharge, a situation that can often come up when nursing this patient group.
Let’s face it, mental health wards are a far cry from the Hilton so why do they want to stay?
It can be easy to forget thatBPD is an illness in itself and the challenging behaviour that can come with it is a symptom, not a personal attack. Understanding this behaviour makes it easier to get a grip on what is actually happening.
In my experience, this is where compassion can often fall down.
And, in these situations, maintaining unconditional positive regard can be difficult.
I agree with the Willis Commission that nurse education is of a high standard, but I feel that training is focused solely on helping and supporting people who want to get better. Little time is spent exploring the reasons why someone might rely heavily on services, often without any apparent reason.
Learning why someone may want to stay in hospital and go to extremes to resist discharge may help nurses, particularly those newly qualified, to remain compassionate when faced with challenging behaviour.
For this reason, it is essential that education on personality disorders centres on the reasons behind the presentation, rather than simply how to manage challenging behaviour.
After all, not everyone can learn compassion, but everyone can learn understanding.
Last week the ABPI released figures suggesting that doctors, nurses and other health professionals in the UK received £40m last year from pharmaceutical companies. The money pays for medical education events, training and development, and fees for services such as speaking engagements and participation in advisory boards.
I know many nurses, particularly those with specialist roles, benefit from the educational events and sponsorship offer by drug and appliance companies. But should professionals, who make objective decisions about purchasing products and drugs, rely on this financial support. Is it naïve to think there is no undue influence?
We all like to assume we would not be open to influence of the drugs industry but we have to question why spends such large amounts of money on us – after all their job is to ultimately to generate sales.
I have attended sponsored educational events and seen the benefits that could be gained from amassing potential customers in one place at the same time. If you have a new product to sell this is the ideal way to market it. Yet it is clear these events also provide valuable information and a chance from nurses to network and share experiences.
Many nurses are struggling to find funding for education and training and there is a growing dependence on industry financial support. Nurses who receive such support need to be clear about their relationship with industry, and this must be open and transparent. This is vital to ensure that we continue to serve the needs of the patient not the company who funds training.
But an additional concern is how we meet the training needs of nurses whose jobs do not fall into the target groups for drug industry investment. Post Francis there is clear evidence that all nurses need time out to reflect on care; to have supervision and regular updating. Who is looking out for all their training and networking needs?
Over the years I have seen the nursing profession deal with some enormous challenges, including seismic changes in nurse education, the eradication of an entire level of the profession and countless media storms – both justified and not.
For the most part, when the chips are down, nurses roll up their sleeves and get to work. Their morale may suffer, stress levels may rise and they may have a moan among themselves, but they generally handle whatever is thrown at them without kicking up too much of a fuss – at least not publicly.
However, the mood of the profession seems different as it absorbs the implications of Patients First and Foremost, the government response to the Francis report. I’ve seen far more openly expressed anger – from nurses at every level of the profession. And little wonder.
No other profession has faced the implication that it has been accepting the wrong people, with aspiring nurses facing a year’s work on the lowest salary rung as HCAs before three years of study. And exactly who did the government consult about this proposal? The entire nursing community appeared to be in the dark until the response was published.
Nursing competes to attract the brightest and the best – it wants people who have other options rather than those with nowhere else to go. While income is unlikely to be the primary motivator for most, the prospect of an additional year of financial hardship is likely to deter many excellent candidates from a nursing career. For people contemplating a career change or a return to work after having a family, that extra year could be simply unaffordable. And don’t get me started on how this flood of one-year-only HCAs will affect the wider nursing and HCA workforce – it’s too horrific.
I believe the profession has been insulted and shouldn’t simply accept its lot with weary resignation. Can you imagine doctors taking this on the chin? I can’t. So go on - get angry. Let the government know what you think of this insulting proposal.
The Francis report was clear that nursing was not working and made a series of recommendations broadly welcomed by the profession. Although it was damming about some nurses and the care they did not give it gave hope for the future. But this response to the detail and consideration in the Francis report feels a bit too much of a sideways swerve, a dodge even.
The Mid staff inquiry was permeated with stories of patients and relatives who felt invisible to the nurses who were supposed to be caring for them. Unfortunately it feels that the government response may have stripped out some of the elements that would have made the difference to day to day work on the wards. It does not mean that they will not happen but being left out today does not strengthen their cause.
For example the proposal of the key nurse that meant that an individual nurse would feel responsible for a patient’s care, the emphasis on how important it is for nurses to be present and active in ward rounds. Getting the ward sister out of the office and supervising staff and speaking to patients and relatives is mentioned but not supported in resource terms.
All these sensible and practical measures have instead been overshadowed by a scheme, not even proposed by Mr Francis, to have student nurses do a full year of pre-training training. A scheme so full of problems – how it is supervised, supported and resourced. What is the point/cost of continually training HCAs who will then disappear off?
The impact of the pre-training year will not be felt by the patients for many years, if at all. There are however some measures in the Francis report that will make a difference now. Let’s be sure that we don’t lose some of the good stuff and don’t let it be overshadowed by the crowd pleasing candy.
Years ago I worked with a nurse manager who was happy to tell her staff that their standards were too high. She rarely ventured onto the wards where standards of care were a problem. Wearing a suit and managing with extremely long arms from an office several floors away from her wards meant she rarely saw a patient let alone what was happening behind the curtains.
Can you manage nurses if you don’t actually nurse?
The recommendations of the Francis report suggest nurse managers need to be more clinically involved. But we have created a system that undermines the value of clinical care. Career progression with higher status and salaries takes our most able nurses away from the bedside. This creates barriers between clinical nurses and nurses who don’t nurse. Nurses commenting on this website appear to have little regard for their managers because in their eyes they lack clinical credibility.
Perhaps, on this issue, we can learn something from medicine. Doctors place great value on clinical skill and expertise. Doctors in management positions practise medicine and also go to meetings. Medical directors look after patients. So when they talk about medical issues they are informed by first-hand experience, who can argue with that?
Sadly, walking wards and spending time with staff once a month or even once a week does not equate with being a clinical expert.
It would be great if nurse managers carried a clinical caseload but how would it work in practice? I am interested to hear your views.
We often receive calls from people with random queries or requests that we simply can’t help with.
I’ve had students asking me to send everything we’ve ever published on the subject of an assignment, authors asking for copies of articles they wrote over 20 years ago but can’t remember exactly when, and patients asking me for a second opinion on advice from their GP.
However, something told me this call was different – the caller was obviously struggling to control severe distress and I knew I had to at least listen, whether or not I could offer any practical help.
She was a nurse who had raised concerns about patient care and been rewarded with a horrific experience of bullying that had left her traumatised and unable to work.
The only practical help I could offer was to refer her to Patients First, the organisation set up to support NHS whistleblowers.
However, the call brought home to me the reality of just how badly some health professionals are treated when they try to take issue with colleagues’ poor practice, in a way that simply reading about similar stories couldn’t.
We decided to wait until the Francis report was published as we knew this would bring the issue into the spotlight. It was a long wait, but we hope it was worth it.
We have since had people question elements of the campaign, and in particular, whether we are aiming only to improve protection for people who take their concerns outside their employing organisation.
So, to be clear, we want to make it safe for health professionals to speak up about patient care and safety issues within their organisations, and to have their concerns taken seriously so that they don’t need to take them outside.
We realise that after serious harm or injury is too late, so we want to achieve a situation where people will feel able to speak up when their concerns are at a level that can be easily addressed and nipped in the bud.
After all, the dreadful examples we’ve all read about at Mid Staffs, Winterbourne View and elsewhere didn’t appear out of nowhere.
At some point, people got away with minor incidents that made them feel they had a licence to get away with worse.
So our petition calls for implementation of Mr Francis’ legal duty of candour for healthcare providers and professionals, obliging them to speak out when patients are harmed.
His other recommendation that it become a criminal offence to prevent someone speaking out was added to ensure health professionals have legal protection against the sort of bullying my caller and many others have experienced.
And we’re also adding to his recommendations that disciplinary action should not be taken when people speak out, unless a criminal offence has taken place or it would be unsafe for someone to remain in practice.
We believe this will enable organisations and individuals to learn from incidents, and for those responsible for poor practice to realise they can’t get away with it (and hopefully to receive training or support to improve before it becomes a disciplinary issue).
The other two elements of the campaign focus respectively on concerns raised internally and externally. Persuading trusts to make explicit that staff will be supported when raising genuine patient concerns should help to ensure their concerns can be addressed internally.
However, if they do need to take their concerns outside, we believe a full review of the Public Interest Disclosure Act is needed to ensure they are protected and that any as yet unidentified loopholes are closed to ensure others don’t have the experience of Jenny Feccit and her colleagues, who did not receive the protection from bullying they had hoped for.
We’re in it for the long haul on the campaign – asking governments to enact new laws or amend existing ones rarely results in a quick response.
But if you all sign our petition – and persuade colleagues, friends and family to do so too, we’ll get there.
And that’s vital – for both patients and professionals.
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