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Frontline nurses are key to ensuring quality care


Rosemary Kennedy on how to drive up care standards

Last week I spent over an hour talking to a lady who trained as a nurse and had recently been a patient in one of our major teaching hospitals. She had asked to speak to me because she was distraught about her experiences at the hands of a profession she had once been proud to call her own.

She did not wish to make a specific complaint about poor care - she was following the correct route for that directly with the trust - but wanted to speak to someone in authority as she was bewildered by ‘what had happened to basic nursing care’.

Coming so soon after several damning media reports on NHS care, I shared her feelings of disappointment, as well as a sense of shame as her story unfolded. She told me of patients being denied privacy and dignity in the mixed-sex bay of an admission ward; of the lack of compassion about patients’ fear of being in hospital, facing an unknown diagnosis; the embarrassment of having wet the bed because of poor mobility or confusion; the refusal of nurses to mop up spilt urine as it was ‘not their job’; the noise of nurses chatting and clattering around the nurses station at night depriving patients of sleep; of food being left out of reach of the patient so that it went cold and uneaten - again, ‘it’s not my job’ to feed patients. Pardon me? Since when was patient nutrition not part of a nurse’s job?

I asked my visitor where she thought we had ‘gone wrong’, and although we discussed several possibilities we did not come up with any single factor.

If you think this is several individual slip-ups cobbled together in order to make a sensational column for Nursing Times, then think again. This was my visitor’s personal experience during a 48-hour stay in a hospital where I know that many, many examples of excellent practice can be found; where the nurse executive or her team ‘walk the wards’ on a daily basis; where there are sufficient nursing staff to provide adequate care; where there is active patient and user involvement in an attempt to maintain standards and improve patient experience.
I am confident that if I had spoken with any of the nurses who had been on duty during this lady’s short stay, they would have been mortified to learn how it had felt to be a patient on their ward. We have invested heavily in the RCN Clinical Leadership programme and most of the participants would say that they have changed their practice as a result of patient stories. So how is it that these, thankfully infrequent, shameful experiences are still happening?

On my bookshelf I can see countless current policies and guidelines concerned with the sort of problems described above. There are care standards galore, strategies for creating a ‘world-class service’ in the NHS in Wales, and specific strategies aimed at the range of professional specialties in nursing and midwifery. The recently refreshed major document Designed to Realise our Potential is a beliefs and actions statement for nurses, midwives and specialist community public health nurses in Wales, built around five principal aims, including improving the environment of care and ensuring quality services for all.

‘Nursing leaders will continue to produce well-intentioned policies but without the unrelenting efforts of all members of the nursing team poor episodes of care will persist’

What is more, in 2003 a partnership between health and social care and the Community Health Councils resulted in a set of guidelines - the Fundamentals of Care. These describe the standards of care that people can expect from health and social care professionals, covering those areas that patients and clients had expressed as being of key importance. Included in this is the need to ensure good communication and information giving, rest and sleep, personal hygiene, assistance with eating and drinking if required, meeting toileting needs and, above all, showing respect for people.

In 2005 we conducted an audit to see how well these fundamentals were being met. In all of our NHS trusts, serious attention had been paid to getting this right for patients. Some trusts had appointed facilitators or coordinators of care for clinical areas to oversee the implementation of Fundamentals of Care - including the trust where my visitor had been admitted.

As part of the Free to Lead: Free to Care (2008) ministerial initiative, the emphasis is on the role that ward sisters and charge nurses play in ensuring that technical nursing skills are being delivered to the highest level and that professional personal skills are in place. Ward sisters and charge nurses will be specifically supported - and expected - to ensure that the aspirations of Designed to Realise our Potential and Fundamentals of Care are achieved for every patient, every time.

The Department of Health and nursing leaders will doubtless continue to produce a stream of well-intentioned policies and guidelines in the hope that these will have a positive influence on care. But without the unrelenting efforts of executive nurses and their teams, facilitators and coordinators of care, ward sisters and charge nurses, CHCs and patient/user groups and, most importantly, every member of the nursing team, we will continue to uncover similar episodes of poor care. Sadly, these will overshadow the deeply devoted and inspirational care provided by most nurses.

Rosemary Kennedy is Chief Nursing Officer for Wales


Readers' comments (6)

  • My relative, who is a nurse, has just been in hospital. She was appalled by the care given as was all the family(mostly nurses). There was a catalogue of poor care by carers and nurses including being left in pain because she was not someone's patient. The senior nurse in he area appeared to know about some of the problems but had not dealt with them and the rest was but down to poor staffing levels.
    I have run an area which has fifty patients and even with only two carers and two nurses on duty due to sickness we still washed each patient and gave pain killers etc. There was no she is not my patient there was just a team of people working for the best for patients.What is missing is the vocational aspect of care and the pride of doing a good job despite the odds. The realization that people have feelings and needs even if they are patients!! With people continually criticizing nurses and carers instead of asking them what would make their job easier and better it is not surprising that staff in hospitals and other care environments feel fed up and in despair.

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  • I don't know if it's because, being a nurse, I'm so much more aware of how things 'should' be, but I've recently had experience in a mixed bay on an admissions ward too. I was mortified that the doctors appeared to care & had great communication skills, but the registered nurses care was non-existent (being left distraught and crying all afternoon whilst the paperwork was done). Also as a nurse, I can understand the pressure to get the 'visible' parts of the job done to avoid being told off, but that now seems to take priority over really caring. How did we get here?

    One of the places, in this case, it seems to have gone wrong is that, in response to my complaint, all the positives were picked up on, but I was merely told 'curtains can't be drawn for privacy as it obscures patient observation', and 'you were not in a mixed bay' (Must go and revise my anatomy as I saw 2, and they were both being called 'Mr' by the medics!). If that's the example being set/lack of insight from the manager is it surprising junior staff are developing into the nurses they are?

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  • I am afraid I can see evidence of this change in quality of nursing even in the palliative unit to which I am attached. We used to be held up as a beacon of excellent nursing care. I am not sure whether it is the new way of nurse training, or the people who are now attracted to nursing as a profession, but we seem to have lost much of the passion for giving excellent care. There is no replacement for having high-quality role models shaping a group of staff into a highly motivated team who care passionately about their work. Yes, and even a bit of that old-fashioned sense of "calling" and "dedication"!

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  • I agree the quality of nursing has decline the sad thing is it takes only one nurse's attitude and lack of compassion to ruin the reputationof a ward. When my Dad was in hospital most times nurses were rushed off their feet but still found time to care however on one particular day there was one nurse who seem to lack compassion I approach her for a blanket her words to me I am busy doing paper work look for an HCA I was speechless. I reply my Dad is cold show me the linen room I can get the blanket myself I was ignored. At this stage I demanded to see the nurse in charge told her what happened then I revealed to her I was also a nurse and her colleagues behaviour was very unprofessional and reflected negatively on the whole ward. Therefore how can nursing care be improved I wish I had a simple answer.

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  • Some people are allowed into the nursing profession and are entirely unsuitable. They need to be screened/assessed to see if they have the right attributes for becoming a nurse. Nowadays if you can get into college with the right score then you can become a nurse. Perhaps we should introduce a caring and compassion assessment.

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  • Gillian Dargan

    I can only concur with the disappointment in nursing as a whole (we all know there are great nurses out there). Our NURSE, leadership has failed to protect the Art of Nursing, the 'caring about' not caring to. Metrics, are paper driven and measure the tangible, it is the intangible passion of caring that cannot be easily measured. Over the past 30 yrs of my career we have focused (Internationally) on the science of nursing and have made wonderful strides in outcomes, we have failed to give the same attention to the art of caring for the patient. Not every A student is going to make a good nurse. There needs to be a measure of capability to care about people in an altruistic mode. It is that apsect that I am focusing my research upon to define a tool to measure, Being present with the patient, compassionate and empathetic dialogue. We can be too busy, short staffed and poorly managed, it should not affect how we respectfully communicate to our patients. Rounding is key, it sounds as if we wouldn't have time, and yet at one facility we found it actually saved time and improved producivity and pt. satisfaction. Our nurse leaders know the problems and need to own up they are NURSES and patient advocacy is the primary responsibility. Take it to the politicians and fight for the Art of Nursing.

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