Nursing Times has spoken to senior nurses and medical specialists about their views on standards of care for older patients
As part of an investigation into views on standards of care for older patients, Nursing Times asked senior nurses and medical specialists for their views on the issue.
The analysis article in which their comments feature can be viewed separately, but we also thought subscribers would be interested to read the views of contributors to the investigation in full.
We asked them the following five questions:
- What are the main causes of the issues identified by the Care Quality Commission in their report this month and, in your view, what is the scale of the problem, if there is one?
- What do you think are the most likely solutions (for example, changes in education and training, tighter recruitment requirements, HCA regulation, more staff, something that affects society as a whole regarding the way older people are viewed)?
- What is the impact of this sort of report and its associated coverage on the profession (for example, does it generate much needed review of training and practice, or does it have a negative effect on morale, or lead to negative views of nursing by the public)?
- How should this issue be viewed by the profession (for example, is it something that nursing itself must sort out internally, is it something that will always be around as a problem, is it something that the profession can lead society in solving)?
- Please feel free to comment further on any other aspect of the issue that you wish to
This is what they said:
Kate Pickering, Lead Nutrition Nurse Specialist, University hospitals of Leicester, and member of the National Nurses Nutrition Group
The CQC has provided another window into the modern healthcare environment.
From a nutrition perspective the average the dependency of older patients has increased, their fragility meaning when they become hospitalised they require more time to settle, adapt to their surrounding, find food choices that appeal from the bemusing selection and attempt to get the food and drink from their bed table to their mouth which, given their frailty may not as simple for them as it used to be.
Ensuring adequate food and drink is taken is key to the patients welfare and there are many tools such as the MUST tool which can identify under nutrition and allow action planning however these are only useful if there are enough staff, they are trained and have appropriate resources to take these forward.
It is interesting to me that the CQC find that provision of resources came third behind management buy in and staff attitudes as a key issue. Although by no means is this across the board there are clearly trusts that are struggling and have lost their way.
Is poor care in the hospitals identified the knock on effect of hospitals run as businesses? Staff wreathed in paperwork and targets struggle to see the wood from the trees. 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. Key to this are protected meal times.
Solutions for failing wards and hospitals in the current climate are hard to find however managers in those hospitals identified need to re-focusing on providing and funding safe staffing levels with a nutritionally aware diverse skill mix that keeps basic nursing care as their focus. These practitioners should be overseen by experienced qualified nurses with enough time to work along side their staff.
This approach twinned with an overall back-to-basic nursing care in pre and post-registration nurse training which concentrating on assessment and provision of nutrition and hydration and the facets that support this delivery must inevitably increase standards of care.
As a Nutrition Nurse I welcome this report. 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. I hope that the CQC monitoring process will ensure action must be taken.
Often these reports are seen as a yet another stick to beat nurses with and there is no doubt there is significant room for improvement in the hospitals highlighted and in a percentage of those yet unchecked.
As a profession our responsibilities are two fold.
Primarily we must see to our own house, ensuring pre-registration and post-registration nurse training is fit for purpose and nurses are competent in basic nursing care including assessment and provision of nutrition and hydration.
Secondly I feel the DH needs to unwrap the profession from it’s constraints of paperwork and targets inflicted upon it by ever expanding middle management.
The government is supposed to represent the people, in this case not just the vulnerable elderly patients receiving, in some cases, questionable nursing care but also the nurses themselves. The government has to take responsibility and protect the role of the nurse who should be competent and empowered to give the level of care they would wish to receive themselves.
Anne Marie Rafferty, Professor of Nursing Policy, Florence Nightingale School of Nursing & Midwifery, King’s College London
The “causes” are multiple and systemic, often involving the interaction of several elements on the supply and demand side. We are dealing with multiples on both sides of the equation. On the demand side we have a growing segment of the population with complex care needs-often involving cognitive impairment combined with sensory deficits and communication challenges along with multiple co-morbidities. By any reckoning these are intensive care needs.
On the supply side the quality of the practice environment is crucial since it is the environment which produces the behaviours we see translated into poor or excellent quality of care. In my opinion the most important influence on our behaviour is role modeling therefore we need to model the behaviours we want to embed in the culture and reinforce them at every turn. Staffing, culture and leadership all need to be aligned.
Sure you need the right people with the right skills deployed at the right time but that is just the start; culture is crucial and resources need to be organised to accomplish the goals – setting and communicating these goals and expectations within a culture that is aligned with these is the role of leadership, mobilising the resources-material and motivational to achieve these is key and a sense that everyone in the organisation sees it as their role to lead to keep these objectives on track is a major focus of leadership-leadership, I believe, is everybody’s business.
Regarding scale glass half empty or full? We need the glass to be full and to work towards that with a relentless focus.
As stated above this is a system issue that links across the organisation through staffing policy and deployment, investment in training and CPPD and regulation of HCAs so that they get a decent deal and in social care salaries need tackling. The minimum wage for care workers is a national scandal and one of which we should be ashamed. 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? We need to calibrating risk in extremely vulnerable adults better perhaps by treating patients or residents as candidates for intensive nursing care. If we change the lens of perception the rest will follow. Where the political will exists the ways and means will follow. As the case study of the Royal Free demonstrates we can do it if we set our mind to it.
3) Impact: As the Royal Free case demonstrates the CQC was a wake-up call setting the organisation on an improvement pathway. But hearts, minds sand a fair bit of managerial muscle have to be engaged too.
4) Reaction: We need to take responsibility for what we can do and mobilising others to act with us. We need to lead and sometimes light the way and help to design and develop the best environments for our vulnerable patients to be cared for optimally and 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. Political resolve, clarity of purpose, collective action and solidarity with others-doctors, managers, carers has to be part of the way forward.
British Geriatrics Society nurse leads Soline Jerram and Sarah McGeorge
There are several factors involved. Firstly there has been a systemic failure to provide healthcare staff with appropriate skills and training and in sufficient numbers to meet the increasing complexity of frail older people in hospitals and in care homes. There has also been an assumption that there is no need to teach staff about what compassion, empathy, dignity and humanity in routine care means to the patient, resident of a care home and their next of kin. The changing nature of older patients in hospital has given rise to the need for every member of staff to have training in understanding how to manage challenging behaviours in those with delirium and dementia.
The lack of integration between primary, secondary and social care presents a barrier to continuity of care, for example when a patient is first admitted to hospital, perhaps from a care home, and/or when they are discharged. Information and knowledge about the person often does not follow the patient. There is also misinformation passed between care sites in times of pressure. This may result in the person being transferred to an environment not suitable for their needs. For example, transfers between acute and community settings when there are bed pressures.
Although older people account for the majority of hospital users, the NHS has not come to terms with this fact and sadly many ageist attitudes prevail. This has been recently evidenced by the PANICOA (Preventing Abuse and Neglect in Institutional Care of Older Adults) study - Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts, Win Tadd et al., June 2011. This study identified the “almost unanimous view expressed by all staff that the acute hospital is not the ‘right place’ for older people.” The study concluded that “ the prevalence of this view results in the physical environment, staff skills and education and the organisational processes acting as barriers to delivering dignified care to older people.” However, Patterson metrics to meaning identified that staff have positive attitudes to older people but in times of stress staff will use strategies such as distancing themselves as a defence mechanism against the knowledge they are not able to do everything they would want.
There is nothing to be gained from a culture of constant blame. Instead we need to create environments which encourage people to act on constructive criticism. Attitudes are crucial and many staff find it difficult or intimidating to challenge poor behaviours, whether ageist or undermining dignity, particularly when these are observed in more senior staff.
All staff, including CEOs, need training about the needs of older people in care. Older people account for 70% of bed days in NHS hospitals and 60% of admissions. We have seen all too plainly that staff (including nurses and others) often do not have the skills to treat people effectively. Pre reg training needs to use older people as teachers as class room teaching is unlikely to be effective unless meaningful. Staff are part of society and we need to create more opportunities to ensure that children have engagement with and knowledge of older people and the value of their contributions so that society accepts ageing in a positive way instead of seeing it as an avoidable issue.
We need to focus on individuals and their care and rights, especially those who can’t look after themselves such as those who may have dementia. Undignified care occurs most often when the needs of the patient are not put first. For example, there may be a need to make beds available for emergencies and as a result a patient, possibly with delirium and/or dementia, will be transferred from one setting to another in the middle of the night. As soon as care becomes task driven rather than person-centred, there is a failure to deliver ‘do as you would be done by care’.
Nursing needs to be re-branded so that new recruits understand and accept that the majority of their work will be with older people, many of whom have mental health as well as physical health needs. Universities continue to fail to promote this message, both through recruitment and teaching.
These reports are often negative and can have a detrimental impact on morale in the work place. They ignore the fact that many nurses are delivering high quality care day in day out in tough circumstances. There are many nurses though who welcome such reports, however negative, provided that they are followed by action. There needs to be a balance as negative reports without a counterbalance undermines public confidence. We need patients and relatives to work with us in sometimes challenging situations. If they enter this relationship with suspicion and expectation that it will be bad or go wrong, then people become hesitant and lacking confidence on both sides. This can lead to poor decision making, risk-averse behaviours and can result in paternalistic care plans which are not person centred.
Nursing should accept that some things have gone wrong. However, we should be very clear about how they’re going to be put right. But we should stop trying to separate nursing responsibility for failures in care from that of our medical and AHP colleagues. We are all responsible. If a patient cannot reach a drink, all members of staff who walk past the patient are at fault; if a call bell is unanswered all members of staff on the ward should be held to account.
We need to be more articulate about the skill and expertise in doing care well. Both the BGS and RCN and other professional bodies need to work together to improve and lobby for appropriate funding for older people. Calls for more staff are often greeted with an attitude that staff are whinging about having to work hard, and that being able to sit and listen to a patient is lazy. However, we do know that as a colleague said recently an older person (or any person) will say I have had a good experience because the nurse put the venflon in well, but they will remember the nurse who sat and listened to them when they were scared or sat with them when they felt sick rather than just giving them a vomit bowl.
5) Free comment:
The BGS has run two campaigns aimed at improving the delivery of dignified care. The first, ‘Behind Closed Doors’, focused on improving dignity around using the toilet and promoted a toolkit which included a decision aid for using the toilet in private; an information leaflet; a set of standards and a template environmental audit for toilets in any setting. This campaign was launched in 2007 and the BGS still receives requests for materials to assist with staff training.
The second campaign – ‘Don’t Forget the Person’ - consisted of a poster and flyer which highlighted what should be standard practice with regard to ‘Dignity and Respect’, ‘Communication’, ‘Eating and Drinking’, ‘Mobility’ and ‘Use of the Toilet’. The resources were distributed to care homes and nursing staff and are designed to encourage all those caring for older people to treat them as individuals by listening to them and their relatives when appropriate.
There are also a number of Good Practice Guides and Clinical Guidelines available from the British Geriatrics Society and they can all be accessed free of charge from the BGS website: www.bgs.org.uk - see the resources section. There are clinical guidelines covering Advance Care Planning, Assessment of Pain in Older People, the Prevention, Diagnosis and Management of Delirium in Older People in Hospital and the Management of Patients with Dementia. Good Practice Guides of particular interest include Acute Medical Care for Elder People, Palliative and End of Life Care for Older People, Continence, Falls and Comprehensive Assessment of the Frail Older Patient.
John Starr, Professor of Health & Ageing & Director of the Alzheimer Scotland Dementia Research Centre, University of Edinburgh
The CQC identify lack of leadership within the NHS on the issue of care of older adults, inappropriate staff attitudes, and a lack of resources as major contributors to poor care.
The CQC are keen to emphasise person-centered rather than task-based care, and I think this is important to remember before making generalisations. Older adults are individual people rather than a homogeneous group. For example, those with dementia have care needs that differ from those who do not have dementia. Hence the scale of problems with care affecting older adults may differe widely between patients on a ward in addition to differences between wards in the same hospital as noted by the CQC.
The NHS, which is the largest UK employer, cannot be isolated from society as a whole. For example, leadership models in UK party politics have recently emphasised youth over age. Society needs to address the stigma which is often associated with old age. Attitudes to older people, especially those with dementia, can reflect a prevalent behaviour of treating them like children rather than respecting them as older adults (this is often seen in the way younger relatives wish to make decisions about their older relatives).
In Scotland there is a linkage between the new dementia standards and training/education and this is a model to be commended.
Increasing staff does not provide a simple solution: as the CQC point out two similarly staffed wards can deliver very different standards of care. Good practice, such as ensuring meal times are protected, can be introduced without any alteration in staffing.
Many NHS buildings are no longer fit for purpose (see the Kent & Sussex County Hospital redevelopment in Brighton as an example). It is difficult to ensure privacy/dignity in such conditions. A move to more single rooms with en suite facilities is to be welcomed.
It has a major impact on medical staff in Medicine of the Elderly: there was a major debate on the ‘Big Society’ at last week’s national meeting of the British Geriatrics Society, two days after the report was released, where the importance of care and how this is delivered were central issues. It is generally welcomed because people who work in this area realise the inadequacies and need such reports to focus the minds of those in positions of leadership within the NHS who are usually more interested in easily measurable outcomes such as waiting list times.
This is not purely a nursing issue. It needs societal change, but also nurses do not work in isolation in hospitals but are part of teams of health professionals.
5) Free comment:
People with dementia are most vulnerable to poor care/nutrition in hospitals. A first step would be to focus on this group where there is a lot of evidence to describe good practice and excellent training materials for NHS staff ranging from porters through to specialist doctors.
Steve Iliffe, Professor of Primary Care for Older People, UCL
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.
I think it is a toxic mixture of ageism (avoidance because of fear of ageing & death) + task oriented training (and the inability to solve problems) + demoralised local medical and nursing leadership + adverse changes in the skilled:unskilled staffing ratio.
It contributes to the attrition of commitment to public services, and it is a warning to the nursing profession.
It’s time to redefine professionalism in nursing