Shocking is a word used often to describe reports of poor care standards for older patients, such as those from the Care Quality Commission earlier this month.
Behind the headlines lie many questions for nursing. What is the true scale of the problem, what are the causes and can it be solved are just some of the more obvious questions facing the profession.
The scale of the problem is difficult to measure. While there have been three major reports published on care failings over the past 12 months, two focused on a small number of serious cases and this month’s CQC report covered inspections of only two wards each at 100 hospitals.
Click here to see what people said about older patient care in full
Dr Steve Iliffe, a GP and professor of primary care for older people at University College London, says: “The scale is large, and the problems are endemic – present on a low level in many places, and very visible in some. There is nothing new about what the CQC has identified.”
“Some kind of systemic problem” exists, according to Professor Jessica Corner, vice chair of the Council of Deans of Health and dean of faculty of health sciences at the University of Southampton. She says the problems associated with older patient care may not be new, but they are “very complex” and go way beyond the “simple top lines” of reports.
For example, she notes the “dreadful” design of some wards that hinders provision of dignified care, the increase in the “shear acuity” of older patients over the last decade or so, and the “pace at which patients are in and out” of wards in an attempt to reduce hospital stays.
A key issue is “the way work is organised” in hospitals today, Professor Corner says. The increasing tilt of staffing ratios towards healthcare assistants has resulted in a return to more “task based” care, rather than nursing the “whole patient”, she says – despite nursing seeking to move away from a task based approach 30 years ago.
This change in skill mix is one of the reasons commonly mentioned in relation to older patient care failings, along with basic lack of staffing and inadequate training.
The suggestion often made is that modern nurses lack the compassion of their predecessors – possibly because they are more technically skilled and increasingly educated to degree level.
Professor Corner describes this sort of “knee jerk” reaction to the issue as “very depressing”.
“Education is being given a hard time and treated in a simplistic way. Nurses need to be trained to a high level,” she says, arguing that compassion and technical ability are not mutually exclusive.
However, British Geriatrics Society nurse lead Soline Jerram argues against assuming there is no need to teach staff about “compassion, empathy, dignity and humanity in routine care”.
Staff shortages are naturally seen as a major issue by the profession, especially with cuts taking place during the current financial climate.
The time pressures on nursing staff are perhaps best characterised by the response to the CQC report left on nursingtimes.net by one nurse who said they worked on one of the wards highlighted by the regulator as failing to meet essential standards.
The comment painted a picture of a ward with 35 patients but sometimes only four staff: “We try hard! A lot of the patients are very dependant and sometimes need two [nurses] to assist them but you are breaking your back doing them on your own as there is no one to help! It’s very degrading to keep being in the news when most of us staff work really hard.”
The CQC was, however, quick to highlight that it had observed two similarly staffed wards could provide widely differing standards of care.
John Starr, professor of health and ageing and director of the Alzheimer Scotland Dementia Research Centre at Edinburgh University, says increasing staff need not be the only solution. “Good practice, such as ensuring meal times are protected, can be introduced without alteration in staffing,” he says.
Kate Pickering, lead nutrition nurses specialist at University Hospitals of Leicester, agrees that protected meal times are key to improving standards for older patients.
“Trust managers and senior nurses must be charged with managing their staffs workloads, sending a clear message that provision of nutrition and hydration should be prioritised with other critical nursing care above the ever expanding list of jobs,” she says.
But she says she found it “interesting” that the CQC had placed provision of resources third behind management buy in and staff attitudes as key issues: “There are clearly trusts that are struggling and have lost their way [on staffing resources].”
As well as the impact of staffing and training, Professor Anne Marie Rafferty, dean of the Florence Nightingale School of Nursing and Midwifery, King’s College London, says the “culture is crucial” within a hospital and affects all its staff.
“In my opinion the most important influence on our behaviour is role modelling, therefore we need to model the behaviours we want to embed in the culture and reinforce them at every turn.”
Whatever the scale of the problem, all agree that nothing will change without action at all levels, from the government down to the front line.
Ms Pickering says: “Those staff in the hospitals highlighted, who are battling to prove good nutrition and hydration on a daily basis, now have the opportunity to demand training and input and for their concerns to be heard.”
Professor Rafferty adds that nurses need to “challenge the dynamics that sometimes drive organisations in the wrong direction”. “That means getting out of our comfort zone and taking a clear stand on standards,” she says.
But she also suggests dignity and nutrition should be singled out at national level. “We should do what we did for hospital acquired infection for dignity and nutrition, where a forensic focus on a system approach has yielded year on year improvements. Are the human costs for dignity and nutrition not as great?”
Professor Corner says a “strong national debate around staffing levels and skill mix, and leadership preparedness” is needed, especially in light of the current financial climate.
She warns: “If we think we might have a problem now, how will it be in a year or two.”