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Janice Sigsworth on raising standards of care

No one wins when they play the blame game


As the Care Quality Commission wades into yet another trust where standards of care are poor, you have to wonder what’s going on. There have been reports of curtains splashed with blood, poor cleanliness in general and much more. Have the nurses working here really done nothing to sort things out? Have they sat back and simply turned a blind eye?

Nurses know care is about doing things right. Understanding the needs of patients and their families means we need to ask them what they want done and how, and what’s important to them. Nurses must build on their care planning skills, creating partnerships with patients that are based on reciprocity and mutual recognition of expertise. Care must be individualised. This is a change in emphasis and we need to talk with nurses about the implications of this for practice.

Different patients want different things from the same experience; unless we act on this we will continue to hear more sorry tales. Care and caring is complex and it is the nuances and differences between patients that make the difference.

Do nurses find interaction with patients and their families difficult and time consuming? Do they have the right skills? Have we designed this ability in or out of nurse recruitment, education and staff development? Is it a bridge too far to involve patients and their families and make them central to the discussion?

‘Improving nurses’ practice is only part of the solution. Does the workplace help or hinder nurses? Is it designed to meet patients’ needs or are patients expected to fit in?’

Older people appear to get a raw deal when it comes to caring, but this is not confined to them. When my young son was admitted to hospital I was glad to be a nurse - not because I was proud of my profession but because I knew what to expect and, when it didn’t happen and no explanation was given, I was able to advocate and navigate the system.

There are some fundamental truths and challenges that nurses must face regarding lack of care. How this should be presented on an individual and organisational level is a difficult question. Are nurses ready and willing to change? Will the regulators, educators and employers work together to set out a clear, common standard?

Accepting our shortcomings is the first step - the second is moving away from routine practices that we have followed for years and embracing innovation.

Raising the bar of our ambition has caused a tidal wave of comments. If each and every nurse doesn’t get it right, the Nursing and Midwifery Council has said it will follow close behind the CQC, holding individual nurses to account for their actions or lack of them.

Improving nurses’ practice is only part of the solution. Questions have to be asked about the workplace - does it help or hinder nurses? Is the system designed to meet patients’ needs or is the patient expected to meet the system’s needs? What are the components of the workplace that come together to make the whole greater than the sum of the individual parts?

If you ask nurses what would help them, they usually say more staff, and they are probably right. It’s rare to hear patients and families complain about their experience in intensive care, where one to one nursing reigns supreme. Indeed, many patients and families fear being moved off these units to clinical areas where nurses are spread more thinly. Organisations with better staffing levels have better patient outcomes and those that have cut back struggle. Sickness rates and the use of bank and agency staff all add to the ward sister’s woes.

The other thing nurses say would help is reducing bed occupancy and acuity. What is the optimal level of bed occupancy? Probably not 100 per cent. Yet many wards run at this level, day in, day out. Demand and capacity is often stretched to the limit, and staff are left feeling pressured and unsupported. The environment is equally important. Staff cannot segregate patients by sex if the accommodation does not support this.

Care and compassion must be delivered in a more overt and focused way. We need to create a system that helps rather than hinders nurses. When care and compassion are lacking, let’s get everyone in the organisation asking what they can do rather than laying the blame at the nurse’s door. Let’s stop the system blaming the nurses and nurses blaming the system.

Last year, my focus at Imperial College was on improving patients’ experiences and I worked with many nurses. We launched a nursing and midwifery strategy, and acted to improve patients’ experiences. When I reflect back, I wonder if my time would have been better spent improving the experiences and working lives of the nurses - after all, satisfied staff generally have satisfied patients.

Focusing on staff might help us to right the wrongs of the system. The beginnings of this are embodied in the national staff survey that may hold the answers to good care, and the inclusion of workforce and productivity metrics in the nursing score card - happy staff deliver on the whole good care that patients are satisfied with.

So, let’s make 2010 the year of the nurse and work as hard as we can on improving the working lives and experiences of our nurses so that they, in turn, can deliver the kind of care we all aspire to.

Janice Sigsworth is director of nursing at Imperial College Healthcare Trust


Readers' comments (3)

  • Management must take the major responsibility for the entirely unacceptable standards we are seeing exposed, but which we, the general public (and ex-nurses!) already knew about from weary and bitter experience. However, there is no excuse for the shabby and careless nursing we also see - however demoralised and disempowered staff feel, how much more undignified and de-humanised it someone deemed to be a patient? Or part of the patients circle of support? Individuals make a difference despite - or even because of - the chaos and shoddy management that creates the environment in which patients are expected to thrive - pause for laughter. By all means let's include and consult staff - but let's also make the expectations crystal clear: care and compassion, or don't bother.

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  • P Rogers

    My first reaction to Janice's latest offering was here we go again, a bit more meaningless socio-management babble from the corporate ivory tower. Unfortunately it's worse than that, the detachment with which Janice ponders the effect of the various environmental factors suggests she really doesn't seem to recognise the part the Director of Nursing plays (often by inaction) in creating the environment which causes so many problems for frontline nurses. One positive, at least for the nurses at Imperial College, is that their leader has come to realise that it might be worth thinking about the experience of the staff she purports to lead - well better late than never eh!

    Lets set aside the rubbish about 'partnerships based on reciprocity', there is always an imbalance of power in any nurse patient relationship which means that it's more important for nurses to respect patients and their wishes than trying to cast them as partners, something many patients find intensely patronising. Janice says "nurses must build on their care planning skills" what is she talking about? Nurses have been care planning for 30 years if there are problems today with the quality of individualised patient care perhaps it's more about the capacity of nurses to respond to the ever increasing demands being placed on them, rather than their skills and abilities. Instead of standing passively aside whilst finance directors freeze nursing jobs and cut education and training budgets nurse directors might consider standing up to be counted, those they supposedly lead would appreciate a little solidarity!

    Where there are problems perhaps Janice and her chums should look at the quality of clinical supervision and support offered to those actually delivering nursing? Instead of Matrons spending Fridays going back to the wards (and if you didn't laugh at the irony in that you'd cry), perhaps they could spend all their time doing what they were originally intended to and not just chasing beds and infection control audits, the former being a great example of a non-nursing job dumped on nurses whilst their leaders, seduced by the cult of management, stood passively by.

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  • Janice says, "Nurses must build on their care planning skills, creating partnerships with patients that are based on reciprocity and mutual recognition of expertise. Care must be individualised".
    Every nurse knows (on the wards) that most care planning is a paper exercise, and has been for years (obviously with the exception of district nurses, where, again, one patient at a time would be very nice to deal with)
    In fact, most of the paperwork involved with admitting a patient to a ward, whether it is the falls risk assessment /waterlow/VIPP/manual handling etc is done on admission, and is unlikely to be read again, unless something goes wrong, and a scape-goat is sought. Occasionally, they are updated, but very rarely referred to when actually caring for the patient.
    Most paperwork seems to be in place to cover ars*s legally, and nothing more. The trouble is, if more time was spent WITH the patient, we might not NEED to cover our ars*s! If nurses are SOOO professional, why are a lot of our notes and assessments thrown away instead of being attached to the clinical notes??
    Some trusts have brought in care-pathways, which can help greatly in assessing and planning care, ensuring that the patient undergoes a safe and thorough passage through the system. Most trusts do not have these pathways, and an admission is usually a scramble of getting all the right forms filled in, or Matron will notice and have you in the office! The forms are filled in at the desk, and the odd reference to the patient (such as religious needs), if you don't know the answer.
    I would LOVE to have the time to complete every admission form at the patient's bedside (based on reciprocity and mutual recognition of expertise), unfortunately, patients usually arrive either at the start or end of the shift, and I usually have 25 other patients to care for and hand over!

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