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How do we improve older people’s care?

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Following a rise in complaints about the care of older people it is up to all nurses to help improve the way they are looked after, writes Adrian O’Dowd.

You would think that giving older people respect and dignity in their care would be instinctive for any nurse but recent reports have proven the NHS has a long way to go before that is the norm. Whether this is due to work pressures, lack of support or inadequate training, nurses have been criticised, along with doctors and managers, for failing to provide dignity for the older people they look after.
The extent of the problem was put in sharp focus in a recent Healthcare Commission report, Caring for Dignity. This was highly critical and used the words ‘inhuman’ and ‘undignified’ when describing some of the care provided to older patients. In addition, a report by the Commons joint select committee on human rights, published in August, said the human rights of older people in hospitals and care homes were sometimes ‘shamefully’ abused.
These findings are all the more embarrassing given that the National Service Framework for Older People is six years old and a Department of Health Dignity in Care campaign was launched a year ago, aiming to eliminate tolerance of indignity in health and social care services.
But whether nurses may or may not be considered part of the problem, they will certainly be part of the solution and hope is on the horizon in the form of new guidance from the NMC. Before the findings of the commission’s report were made public, the regulator already had plans to look at this area, prompted by a relatively high number of cases of nurses being struck off that originated in an older people’s care setting.
Although the guidance is not due to be published until 2009, discussions are already under way. The end result will look at several areas, including best practice, dignity and cultural differences, to help nurses ensure they know their responsibilities when looking after older people as well as giving them advice, support and information in this area.
NMC figures show 35 nurses were struck off the nursing register for neglect of older people in 2004–2005. Figures vary annually, but out of some 130 nurses who are struck off per year, 35 remains a ‘significant percentage’ of all nurses who are removed, says Sarah Thewlis, NMC chief executive.
‘We have always recognised that this is a small but significant issue for us in terms of fitness to practise,’ says Ms Thewlis.
‘We want to look at how we can support nurses in dealing with what I think are quite challenging patients and how we can say what is appropriate care. We need to make sure that nurses understand what their responsibilities are.’
The NMC is now carrying out a scoping exercise across the UK and has formed the Older People Project Board, which met for the first time last week.
Elaine Hayward, NMC professional adviser for adult nursing, has been leading the project, working closely with Susan Aitkenhead, professional adviser for policy and strategy.
Ms Aitkenhead says: ‘We are trying to be as creative as possible on this and we want to go out to older people in different settings and ask them what they feel about their care as well.
‘We don’t want to be totally negative but look at what the good practice is as well. We are looking at what has been done for the NSF and how best practice can be disseminated to have that regulatory push behind it.’
The reasons why concerns raised in reports like that of the commission exist are many, says Ms Thewlis: ‘What used to happen is that people were looked after at home. People living longer, there being far more complex pathologies in the conditions people have and the issue of residential care settings – it’s a range of things.’
The report was, sadly, largely accurate, according to Linda Nazarko, independent nurse consultant in older people, who believes the problems need to be tackled in several ways: ‘Most people being cared for in the NHS are older people and what we need is nurses with expertise in this area of care,’ she says.
‘First, what we need to do is address the nursing curriculum. When you are educating your nurses of tomorrow you need them to understand the needs of older people.
‘You need specific modules in gerontology and care of older people throughout a registered nurse’s training – that raises the profile right away. We need to get nurses allocated in care of older people throughout their training and not just at the beginning.’
The status of care of older people also needs to be raised, she says, adding that there is a problem with grading. ‘In Agenda for Change, in some hospitals you might be a band 7 ward manager but in the older people’s wards you will only be a band 6. It gives the impression that you don’t need to be so clever or skilled because you are only dealing with older people’.
Ms Nazarko also believes more nurse consultants and nurse specialists in this area would help. ‘You need good nurse leadership and that means having people like nurse consultants in places of power,’ she says.
Jill Jarvis, head of the professional nursing department at the RCN, says: ‘There have been a few recent reports that have come out which have not shown nursing in a good light and it’s a real concern to us. We are not condoning poor practice but also we don’t want nurses to find themselves in a position where they are scapegoats for systemic problems.’
Ms Jarvis’s background is in older people’s care and she recommends it, saying: ‘I think it’s a particularly challenging area because it’s more complex and people’s needs are so much more complex.
‘It’s not an area that we should be looking at as somewhere that is easier to work. It’s somewhere that people’s needs are complex and therefore you need the most skilled nurses working.’
The NMC’s guidance, she believes, should look at clinical leadership, issues around dignified care, resources, education and the image of older people’s nursing as well as the skills and expertise needed to do it well.
If anyone can tackle the current problems in care of older people, it is nurses.

‘Older people just want to be listened to’

In the past few years the University Hospitals of Leicester NHS Trust has set up an Older People’s Champions network and it now has 520 members of staff trust-wide (all volunteers).
Each champion completes a two-hour training programme, which includes a dignity workshop, and all wear a badge to identify their status. They influence care at all levels, from housekeepers focusing on older people’s nutritional needs to consultants improving care pathways in areas such as falls. This has raised awareness about older people’s concerns on issues such as ageism, nutrition, communication and dementia.
The profile and successes of champions have also led to the trust creating a new Directorate of Services for Older People, which reaches across the organisation’s existing directorates and beyond to community partners to influence and improve older people’s services.
Julie Burdett (pictured), a matron in emergency care at the trust and an education and champions network manager, says: ‘It’s an awareness of what older people want – they want to be listened to, for someone to take on board their issues and then make sure that things happen around them.
‘A lot of the complaints we receive are around dignity and respect and not about clinical issues.’

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