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The truth
About NHS Hospitals: Nurses
NHS:
National Health Service Millions
of pounds are being pumped into our hospitals – so why are they in such
chaos? Harriet Sergeant investigates. “I
would not trust my dog, let alone my mother, to many nurses” A patient in an NHS hospital exists in a power vacuum. Who
is in charge of my health? Who is responsible and accountable for what?
These are the questions that many patients are asking with increasing
panic. It is a revelation to anyone spending time in a hospital to
discover how little of hospital activity is actually managed. The closer
you get to the patient, the less management there is. No single person
appears to have the authority to oversee all the elements of a patient's
care, pull them together and take responsibility for that person's
wellbeing. Whether you enjoy attentive nurses, a proper diet and clean
wards is simply pot luck. Nor can this arbitrary standard of care be
blamed wholly on staff shortages; rather, it is a catastrophic failure of
management, combined with substandard training, that has brought
about a crisis in the wards. A nurse consultant who prepares hospitals for audits gave me
an example of a scene that she comes across every day in the NHS. She had
walked into a ward where a second-year nurse was taking care of six
patients, unsupervised by a senior nurse. An old man wearing an oxygen mask was sitting in bed,
staring disconsolately at a wash bowl. Next to the wash bowl lay his
breakfast, uneaten, and beside that, an overflowing sputum pot. A full
bottle of urine dangled beneath the bed. The nurse had left him with the wash bowl "to do what
he could". No one had taught the nurse that she should clear
everything away first, remove the urine bottle and then present the bowl
of water. No one had taught her the purpose of nursing: to do for the sick
what they cannot do for themselves. The training of nurses has promoted them further and further
away from the interests of their patients. In the late 1980s, nursing
turned itself into an academic profession. Nurses desiring increased
status and greater parity with doctors sought to transform their training
into a graduate profession. The result is "a frigging mess",
according to a member of the King's Fund, a charitable foundation
concerned with health. One senior staff nurse at a hospital in the West Country,
who teaches at the local university, pointed out - logically enough - that
the academic status of the qualification means "there has to be a lot
of theory". But there is too much theory, too much emphasis on social
policy and communication skills - and not enough practical work. At a London A&E department, a staff nurse who had
recently qualified complained to me that her training had not prepared her
at all. In 18 months of study, she had spent only one and a half hours
learning how to take blood pressure and a patient's temperature. On the
other hand, a whole afternoon had been devoted to poverty in "They don't prepare you for the things that
matter," said the nurse. Instead, she had learnt how to approach a
patient and what mannerisms to adopt. She shrugged. "If you don't know that already, then why are you
becoming a nurse?" she asked rhetorically. Or, as an Irish sister of
17 years' experience put it: "No, I have never felt the lack of
studying sociology. Kindness and common sense go a long way.'' The staff nurse had been astonished to discover how little
anatomy or physiology her course contained. Anxious that her grasp of
these essential subjects was "not as good as it could be,” she
approached her tutors. But they took a relaxed view. Soon, she discovered that her ignorance did not matter. Her
first exam, tackled after 18 months, was multiple-choice; her final exam,
at the end of two and a half years, allowed her to answer three out of six
questions, and so avoid revealing her ignorance. For assignments, her tutors had set her work on social
issues and ethics - including patient rights. That patients might have a
right to a person qualified in how to look after them did not seem to have
occurred to her teachers. She said: "Theoretically, you could go through the
whole three years without anyone asking you about bed sores." She
managed to qualify with only a vague knowledge of the bodies soon to be in
her charge. After graduation, she recalled vividly putting on her
uniform for the first time and pinning on her badge. She had looked at
herself in the mirror with a sense of disbelief. "You are expected to cope with situations that you know
you just can't. There is no one to ask - or they are too busy or they
don't know because they are agency nurses." Another nurse recalled the shock of her own first days on
the ward, with phone calls coming in from everywhere and acutely unwell
patients. In one 10-minute period, she had to arrange transportation for a
patient, give morphine to a man screaming for pain relief and see to
another in a side room, who was dangerously short of breath. "I was on my own. I did not know which way to run,
which was the most important. I remember thinking, 'Shit, I just want to
get out of here'.'' She added: "I learnt more in the first three
months on the job than in three years at college.'' The Irish sister had scant respect for new nurses:
"They picture themselves at a computer or with a doctor on his
rounds. They are horrified to discover that 90 per cent of their time is
doing things for the patient. "I see nurses walk past a patient, ignoring his
distress. I will not have on my ward a patient apologizing because he
needs to ask for care. We are dealing here with sick and vulnerable
people, many of whom are dying. I aim to see them die in dignity and
comfort, and for their relatives to have good memories of their last few
weeks.'' The Irish sister's training had been very different -
learning practical skills side-by-side with what she was studying in the
classroom. She had practiced washing a patient and making beds. Every
three months, she had taken a three-hour exam in the morning, followed by
a two-hour exam in the afternoon. "If you failed, you had one chance to repeat it - then
out. You also had to go through every task observed by a nurse until you
were ticked off on it." A former matron recalled being watched and criticized -
"and woe betide if you got anything wrong" - while learning to
wash a patient, feed him, put on a dressing and make him comfortable.
"No one learns how to make a patient comfortable any more," she
said sadly. Rather like the concept of hot milky drinks - which she used
to offer to patients every night at Once on the ward, "a nurse took you under her wing to
show you the ropes", recalled the Irish sister. Nowadays, the
overseeing and training of newly qualified nurses can be overlooked. One
staff nurse said that the atmosphere on her ward is so unfriendly that
when "you screw up your courage to ask someone to show you a
procedure, they give you a withering look.'' A sister explained to me that, when a nurse asks for help,
"you have to set aside half an hour to show her how to do it. If you
don't give her the time, she will make a mistake. But we don't have the
time.'' Thirty years ago, the newly qualified nurse knew exactly
what was expected of her. In one morning, she might be asked to polish all
the bed pans, or give each of the 17 patients on the ward an
"up" bath. Then, when she became a senior nurse, she dressed all
wounds on the ward. In the mid-1970s, task-centred care changed to client-centred
care. Each nurse was allocated a group of patients for whom she did
everything. "All that did was create a mountain of paperwork,"
said the sister. Nurses had to assess their patients, then plan their care -
and all this had to be written down. It was fine if there was enough
staff. But if a nurse had to cover for a colleague, she suddenly had 10
patients about whom she knew nothing. The former matron said she had heard a woman asking a nurse
for a bedpan for her mother. "She's not my patient," said the
nurse. The irony is that nurses thought that making their
qualifications more academic would gain them the respect of consultants.
This does not seem to have happened. Nearly every consultant I interviewed
complained that the standards of nursing were, as one put it,
"dangerously low". He added: "It's very frustrating to see
our patients treated to such poor standards of care.'' A consultant anaesthetist at a "The catering staff slam the food down. No one bothers.
Spooning food into a patient is just too demeaning for professional
nurses, it seems. I always thought nurses were meant to care for patients.
I might be wrong. I may have missed the plot somewhere.'' Another described the difficulty of trying to find a
particular patient on a ward. Every patient is supposed to have his name
above the bed. But, in some hospitals, they refuse to display the name
"in case it infringes your autonomy". So the consultant found
himself wandering around, trying to find his patient. "There never
seems to be anyone in charge who knows anything," he said. He would try to find the patient's nurse. Then the patient's
notes. "I don't often strike lucky with all three." Finally, he
had to translate the nurses' diagnoses. "They refuse to use hierarchical, male-dominated
medical terms, so they will not say the patient is unconscious. No, the
patient has to have 'an altered state of awareness'.'' The voluntary service co-ordinator of one hospital told me a
shocking story. As he was passing a room, he heard an elderly lady call
urgently: "Please take me to the toilet. I have been pushing and
pushing the button, but no one will come." He pointed out that only a
nurse could take her and went to find one. Three were clustered about the nurses' station, listening to
Radio 1 and dipping into a box of chocolates. The co-ordinator told them
about the patient, adding: "Can't you hear her calling?" "Oh, she's always calling,'' they said, without moving.
When he went back, he found the old lady face-down on the floor. He
returned to the nurses. "You had better come now," he said.
"I think she's dead." The voluntary service co-ordinator added: "That has
happened more than once.'' Many of the patients I met had stories of neglect. One woman
suffering from a placenta praevia found herself abandoned in a side room.
No one came. No one checked her blood pressure or temperature. Her
catheter was left in for three days. The toilets were all blocked up. Finally, her cousin - a qualified gynaecologist - came to
visit and was so appalled that she had a showdown with the nursing staff.
"I would have had better treatment in the Many also told of unexpected kindness and good nursing. One
woman said: "The older ones are better. The younger ones are quick to
tell you: 'That's not my job' or 'That's not my patient'.'' An older nurse had taken her down to the theatre for her
operation and kissed her. "It was so comforting and sweet - it made a
big difference to me." But whether patients received a kiss or a reproof for "whingeing"
- as one man did after a traumatic road accident - seemed entirely a
matter of chance. The attitude of the nurses is of enormous importance to a
patient who is helpless and totally dependent. It is bad enough being ill
and in pain. To be abandoned or treated unkindly is almost insupportable. Traditionally, sister attended the ward round with the
consultant. She saw her job as taking the patient's side and putting the
patient's point of view. She had, after all, taken care of the patient
over the past 24 hours. The loss of sister's authority means the loss not
just of patient care, but also of a patient's advocate. Nursing is mainly done by young women, and there is a
constant turnover and shortage of nurses - particularly at the lower
grades. Until recently, the only way to gain promotion or an increase in
salary was to move into management. This takes nurses and auxiliary nurses
away from the patient and the practical care at which they should excel. Sir Stanley Kalms, an entrepreneur who became chairman of an
NHS trust for three years, remarked: "People say nurses are angels.
Well, nurses are employees who do nursing." And, like every other
employee, they need managing. The "modern matron" - a new post that puts a
senior nurse in charge of three or four wards - lacks the tools to manage
her nurses. One former matron, now a nurse consultant in audit work,
pointed out how difficult it was, for example, to discipline a nurse for
incompetence. First, the busy matron or sister (who looks after one ward)
has to notice what is going on - and most are too occupied to do so. Then,
even if she does, discipline in the no-blame culture of the NHS is a
"long-winded process". The emphasis is on being "nice" and making sure no
one is blamed. She continued: "You can't bawl them out or they'll sue
you for harassment." Instead, "in a nice soft voice, you have to
ask if that was the way she was taught. Does she consider it appropriate
care?" Modern management is meant to "nurture" its
employees. So, the errant nurse is offered training, supervision and, of
course, she is given another chance. This can go on for a year. "In
the meantime," said the former matron, "patients are going
through her hands and suffering.'' Most matrons or ward managers take the easier option and
promote the incompetent "to get them out of your hair", she
said. Even if the nurse is disciplined, the modern matron faces a
further difficulty. Who will replace the nurse? A bad one is better than
none. Trusts around the country are struggling to find the staff they need
for present workloads, let alone take forward government plans. Hence, the
shortage of nurses insulates the profession from the normal disciplines of
working life. Nurses enter the profession to care for people. Yet their
training, combined with the lack of supervision on the wards, robs them of
the means to show their compassion. Those who do manage to give good care
succeed despite the system, not because of it. A male modern matron with 15 years' experience in the NHS
summed up a view I heard from nearly every medical person I interviewed,
including many nurses themselves: "I would not trust my dog, let
alone my mother, to many of them.'' The failure of management around the patient is evident in
other areas. Many patients, for example, complained
about the food: it was inappropriate for their age or illness
(elderly people are flummoxed by pizza), it was plain bad, or it simply
didn't arrive. "My family bring me sandwiches," one old lady told
me. Another commented: "I just took one look at [the meal] and I said
no.'' One woman had not eaten for 48 hours. "They did offer
me a tea cake which had been in the fridge for months. I had to throw it
away." Her nurses seemed indifferent or helpless. The NHS Magazine states that 40 per cent of adults are
suffering from malnutrition on hospital wards. Many elderly patients are
already malnourished on arrival, but studies show that their condition
deteriorates in hospital. Malnutrition results in "substantial" morbidity
and mortality, complicates illness and delays recovery as well as reducing
wound-healing and increasing the risk of infection. The King's Fund
estimates that this costs the NHS £226 million a year. The fact that so
many elderly people are actually going hungry on our wards, unnoticed, is
an appalling indictment of the NHS and the management of the wards. Essence of Care, a book distributed by the Department of
Health, describes best and worst practice for patient care - from bed
sores to feeding, from patient notes to incontinence. The book also
categorises levels of care, beginning with "deliberately negative and
offensive behaviour and attitude". These basics are what nurses 30 years ago learnt as a matter
of course. These basics were nursing. Now, the Department of Health has to
regulate something as fundamental to the sick person as privacy and
dignity. As a member of the King's Fund said: "What state must
nursing be in that the NHS should have to put this around? " The foreword by Sarah Mullally, Chief Nursing Officer, makes
grim reading. Essence of Care, she writes, focuses on those "core and
essential aspects of care" that matter to patients "quite
rightly", yet that rarely attract the attention they should during
the "quality improvement process''. You cannot help but wonder at a "quality improvement
process" that fails to notice bed sores or malnutrition. Ms Mullally
suggests throwing a weekly tea party at which carers and patients can
"express concerns". Here, then, is our modern culture of caring.
Bed sores and malnutrition alongside tea parties, and a happy experience
for all concerned. There can be no doubt that the lack of management around the
patient is due to matron's loss of power and the shift from the practical
to the academic in nurse training. Yet this has not been recognised, let alone tackled. If the
Government was serious about improving patient care, it would give
hospitals the power to pay nurses a proper wage and modern matrons the
power to hire, fire and reward staff. Copyright
© 2002 Global Action on Aging |
