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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)

  • Until Trusts realise that nutrition is an integral and vital part of treatment and that it is not a hotel service, sadly we will need red trays and other measures to ensure our patients get the nutrition and hydration they need. The gradual erosion of the nurse's role in the nutrition of patients began as far back as the early 80s when hospital food was handed to caterers and unskilled catering assistants. Patient feeding was taken away from ward sisters and nurses. We were told it was not our job. Thus patients were not monitored and trays were removed from them untouched.
    I deplore the use of the red tray and red jugs but sadly in this climate they are a necessary evil.At present we have a whole generation of nurses who do not see feeding and monitoring patient's nutrition as their job. I am not talking about newly qualified nurses. I am talking about those who trained in the late 80s and 90s. Neither am I blaming them - this is about what was expected of nurses at that time. Patient feeding was not deemed to be their job - so they did not do it.
    I know there are plenty of nurses out there who do get it - I know that my comments may provoke outrage but we have to be honest and recognise where it all went wrong.
    Neil makes some good and valid points - we need to remember to use our eyes and our senses and our intuition - not just tick a box.

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  • These nurse/medic by number protocols are springing up rapidly everywhere, for everything, and for one reason only, MONEY! Senior staff with years of hands on experience are expensive. Get them to write protocols 'if A happens, then you must do B', under the guise of homogenising treatment. Sack senior staff, replace with cheap, inexperienced labour with little or no formal education, or foreign workers with poor language skills who meander across the globe taking the best paid work they can get their hands on ( but don't stay for 'gold-plated' pensions). Cheap overheads equals attractive business proposition, Government free to privatise what it likes ( it would love having no more Drs and Nurses telling the Government what should be done, and how to do it, as we all know politicians are expert in every walk of life. Bar politics). Sell our family silver to the 1% of people it is truly interested in, get a directorship of said company when voted out at the next election, £50,000 a year for two, two hour meetings a month on top of a gold-plated MPs pension on top of the other two hour meetings with the other directorships, in, say, the arms and petrochemical industries. Set themselves up as a limited company, and pay company tax at 28% instead of 50%.( Has your Chief Exec just retired at the age of 50? Wondering what they are up to when not playing golf or exposing their left nipple at the Masonic Lodge? Hiring themselves back to your trust under the guise as a 'consultant', more than likely using the above wheeze) Laugh all the way to your seat on board of the gravy train, waving to the paeons as you pass them by. You have been warned, THE END OF THE NHS IS NIGH, and not just because of the Myan apocalypse in December.

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  • "Need to strip away uniformaty" yes but that should also apply to End of life pathways. How can individual palliative care be done followinf LCP? One plan for all, fat. thin etc with nothing new under the sun. Surely we ALL know how to care for the dying and Drs know how to prescribe appropriate symptom control drugs. If not, let;s have more training both of nurses and of Drs, esp in palliative care, please

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