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Practice comment

"Systems such as red trays erode essential nursing skills"


Nurses need to be allowed to provide holistic care that is individual to the needs of their patients

Last year proved turbulent for nursing, and hospital nursing was in the line of fire for many failings in care. The 2011 Care Quality Commission report on patient nutrition and dignity in hospital unveiled significant deficiencies in essential care. With 17% (n=100) of hospitals not meeting standards, and a further 32% needing to improve, nursing was unfavourably under the spotlight. Accounts of personal care being delivered while privacy curtains were not being drawn properly and call bells left out of reach left many in the profession astonished that such simple but fundamental omissions could occur.
While we accept that nurses must play a part in strategic planning in the health service, professional credibility is lost when the essentials of care cannot be delivered at the very foundations of practice.
The introduction of a vast number of initiatives - such as nutritionally screening all patients on admission, even if the initial nursing assessment identifies they are at minimal risk of nutritional deficiency - has increased paperwork for nurses. Alongside this, red tray systems and red water jugs for those at risk of dehydration/malnutrition have just put a sticking plaster over the problems of poor nursing direction, leadership and the lack of managerial support for good-quality nursing care. These initiatives have been promoted by organisations such as Age Concern and the CQC, which now inspects for them, so they need to be recorded too.
But such initiatives, although well intended, can erode the clinical decision-making skills and development of critical-thinking skills of nurses. Although I accept there have to be systems to support the delivery of good care in hospitals, I believe we are moving further to system-driven processes. This is where nurses are unable to use their initiative to provide individualised holistic care for patients.
Instead, they follow regimented protocols and standard care plans, which in turn increase workloads unnecessarily and remove them from direct patient contact. For example, where patients have not been started on a red tray or red water jug system but are at risk, a nurse may not act on that risk because of the lack of clinical experience and inability to make a decision.
The prime minister’s plan to improve care in hospital by introducing hourly rounds has infuriated many health professionals. Yet again, the government is introducing a measure that is target driven and will have to be recorded. This creates yet more bureaucracy in a system that is already heavily loaded with pathways that reduce the personal caring patients want.
We need to strip the layers from those systems that are uniformly target driven, and allow nurses to provide holistic care that is individual to the needs of their patients. Senior nurses should be allowed to manage, teach and lead their teams, sharing their experience and supporting the development of practice for junior staff. This is surely what patients would ultimately welcome.

Neil Wilson is senior lecturer and admissions tutor, preregistration adult nursing, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University

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Readers' comments (13)

  • You took the words right out of my mouth. We are really struggling with low staffing and very poor management and this nursing by numbers is no solution.

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  • I soent my training learning about the new holistic, patient centred care where sensible judgment and clinical experience allowed for individualised care to be the benchmark of good practice.

    Many of my tutors spoke of task orientated care where everything was done irrespective of need and all patients received the sae care where their uniqueness was not recognised, so someone heals faster and better receives the same care as someone who is at risk of infections and delay in their healing due to co-existing morbidities.

    All these initiatives, whilst papering over the problems, seem to hark back to the task orientated times, and flies in the face of evidence based best practice.

    A friend of mine states that "it is best practice not common practice", whichthe hierachy of the NHS/government seem to be losing sight of.

    Please accept my clinical judgement or ask me if you do not understand why I have not or have completed something in the care of my patient. I worked hard for my qulaification and feel undervalued because my seniors in the NHS management and government do not respect me or allow me to do my job properly.

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  • Chris Elston | 19-Feb-2012 8:56 pm

    one of the best comments i have seen in NT in over a year of reading them daily. Especially the last two paragraphs. The message needs to be spread!!!!!!!!!!!!!!!!!

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  • Training could be shortened. You can cut out assessment, planing and evaluation, just concentrate on implementation.

    Chris Elston | 19-Feb-2012 8:56 pm Sadly Chris, if it is best practice, and that is what is delivered, then it becomes 'common practice'. I must also add that your tutors were wrong about the concept of the 'task orientated' system. I know becuse I have experienced it. Specific tasks were only undertaken for the patients that required it. We did an obs round, which tends to be no different from today and ask patients if they wanted help with the toilet, but only the ones that needed assistance, not everyone. There was an assessment first to identify which patients needed assistance for a specific task. What we seem to be adopting, through no choice of our own, task orientation without an assessment. There lies the difference.

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  • You've hit the nail on the head. We need common sense and compassion not more tick boxes, however well meaning.
    But to allow nurses to do this we need trust and that means we need to have the right calibre recruited. Sadly some nurses, without their tick boxes to be held accountable to , will not see, hear or recognise what the patient might need.

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  • I am so glad someone has said this. When my Trust introduced a similar scheme using red napkins I argued vehemently against it, saying that as a nurse in charge of those patients you should know which ones need help and ensure they get it,either from you or someone you have asked to help. A red napkin does not mean the patient gets the help they need- staff can still walk by and not do anything about it. I argued similarly against Early warning Scores- while I accept they are a good guide to how your patient is, they do not take away the need to assess your patient as a whole and use that special nurse'spidey sense' to see that something is wrong. I hate this tick box guided, non holistic path that nursing seems to be going down in order to answer its critics. Know your patients, know their needs and deal with them appropriately.

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  • I am pleased that Neil Wilson challenges the way that new systems can endanger holistic care, critical analysis and the clinical skills of the nurse. However, as coauthor of the original 2003 publication on the Red Tray with Lindsey Bradley, I would like to plead that we don’t accidentally demonise a nursing success story that was a response to improving individual patient’s needs. Lindsey developed the Red Tray system in Cardiff precisely to avoid patients being compromised nutritionally because their food was either left tantalisingly out of reach, or taken away without first asking the basic question of whether the individual needed help with eating. Following nutritional assessment, the red tray acted as a visual danger sign to encourage staff to think of the patient; it does not replace thinking. To my knowledge, there is no evidence that it has led to the erosion of clinical decision making skills or the loss of nursing critical thinking skills. Quite the reverse; the audits that took place following its introduction showed it was a ‘win-win’ development that was both nurse and patient friendly. Patients and their relatives were pleased that their needs had been recognised, and nurses had a visual cue to help them when in the business of the nursing day it is easy to miss someone’s needs. Far from being simply ‘well intended’, this was a carefully developed and evaluated system that was an outstanding nursing initiated response to patient need. The audits showed that there was a drop in the number of patients whose nutritional needs were unmet and the system ensured that the care was individualised to those who needed it. There were no complaints raised about increases in record making or tick-boxing activities. So, can we please stop labeling improvements automatically as wrong without first looking at the implications from the patient’s perspective, and let’s use the evidence that shows where we should be focusing our attention. Things are hard enough without those with sound and evaluated ideas being reluctant to share them for fear that they will be seen as another attempt to erode essential nursing skills when in fact they are enhancing them!

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  • As a Learning Disabilities Liaison Nurse working in two acute hospitals I agree wholeheartedly with Colin Rees's comments.
    I do not think that having a system in place to identify someone's additional needs prevents acute staff from thinking or delivering person-centred holistic care. Sadly, in my experience, the system does not always work as there are usually limited staff available to ensure all people with additional nutritional care needs receive their meals in a timely, safe and effective manner.
    Where clinical judgement can be utilised in such instances is to determine what reasonable adjustments need to be made to ensure everyone receives adeqaute hydration and nutrition during their hospital journeys. Again sadly, research suggests that particularly for people with learning disabilities and other vulnerable people, their nutritional needs are often not met in hospital, and in some cases may contribute to health deterioration or even death.
    I firmly believe we should embrace systems put in place to help not only the patient but the nursing staff, and rather than only seeing the negatives (ie: increased paperwork) we should look at the health and general wellbeing benefits to the patients.
    The hospitals I work in use the red tray system and whilst it is not without it's problems it quite clearly identifies the nutritionally vulnerable which may not always be immediately apparent. Rather than saying it doesn't work, we are trying to identify what else we need to do to make it work.
    You have to remember that this system was only developed because of concerns with meeting vulnerable people's nutritional needs in hospital ... back at the time when nurses were relying on their skillls, expertise and clinical judgement alone. Why can't the two work hand in hand?!!

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  • Some protocals are good, child protection, care of the over 60s sustaing injuries. If the nurses follow them caer is improved and is more holistic, however medical officers can override the protocals and care then is at a lower level. Looking at holistic care- cultural aspects need to be taken into consideration, the care of the elderly by families in overseas countries, is not the samew as England where there aften no relatives to provide support

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  • Thank you all for the comments, both positive and those challenging my view (which might I say is merely that, based on clinical experience in this field). Having been a Nutrition Nurse Lead for a hospital and community Trust, I was responsible for implementing such systems. Some of which worked, others provided the audit results but these could have been achieved without the tray. I do firmly believe that we 'should know' our patients and unfortunately, many nurses do not, because of failings in good supportive leadership to help junior staff work in new and innovative ways, deal with workload and manage the stress that accompanies the job. I have no doubt that many organisations can present audit data on paper, and believe that these systems improve the identification of at risk patients. However I firmly believe that we could have achieved this 'recognition' by actually changing culture, recognising mealtimes as not only an important part of the day for patients but also the nurse to continue to build a relationship with the patient and continue the monitoring of the patient well-being as a whole.

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