Month: July 2013

“Missed care” in Hospital, we may need more nurses*

Yesterday this research based report argued “There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’ “. To investigate this a survey was undertakenof 2917 registered nurses in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. This is a decent enough sample frame to begin to make inferences, so what did the researchers conclude? That, according to this cohort care is frequently left undone and that this, unsurprisingly, is related to lack of time. The activities include: comforting or talking with patients, educating patients and developing/updating nursing care plans. Two factors also highlighted was that 1) the number of patients per nurse  and 2) ward patient safety ratings are significantly associated with missed care. This report follows a warning by nurse leaders over nursing numbers and a call for minimum staffing levels.

The wider context is of course the concern around the quality of nursing and medical care given in some Trusts, some of which have focused on ‘compassion in care’. However, following the publication of the Francis Report, the health secretary,  Jeremey Hunt, failed to argue for minumum staffing levels. That being said NICE is working on a tool to be used to establish just such levels. It has been reported that Hunt confirmed that it is not the job of the health secretary to do so.


It is very hard to see that when the NHS is experiencing the Nicholson challenge and may well have to deliver further costs savings  that Trusts, will spend any more on staff.  Considering ward budgets,  pay for staff can be the single biggest expenditure.  The context is that, as I heard clearly stated in a Trust recently, that “this is not a hospital, this is a business” and that budgetry control involves making financial savings year on year. Bruce Keogh, in his recent 2013, report argued that three dimensions of quality were: clinical effectiveness, patient safetey and the patient experience. These three in reality have to be delivered withing a context of cost savings.

This is market discipline in the health service. Private sector organisations (whether they for example, like Farmers, receive state subsidies or not) know this discipline very well. Control your costs or you competitiors will undercut you and force you out of business. However, even in the private sector cost is not the only concern – quality is and customers make decisions not only on cost but the quality of the service or product.

People know however that the NHS is not a private sector organisation and that switching brands is not an easy way to signal dissatisfaction. People also know that poor staffing levels seriously diminishes the quality of the service they recieve. there is no geting away from the fact that care costs money.

This is therefore political and a social battle. The NHS is currently compared to other healthcare systems very good value for money. However, chroinc staff shortages will challenge public support and may make some consider private provision. This is the wrong solution to the wrong problem.



The medics get it – sustainable literacy in education

Sustainability, health and education – Priority Learning Outcomes for health professionals.



Although some scientists and commentators such as Indur Goklany, have disputed claims about the precise impacts of climate change and human health, it is nonetheless accepted that wider environmental factors can and do impact severely upon health. Climate change, as has been pointed out before, is only one aspect of the relationship between the environment and health and focusing on it may not always be helpful. Instead, many medical and other organisations in the UK have clearly accepted that our relationship with the environment is a foundation upon which health is based. This relationship is also part of our socio-political relationships and forms the matrix of connections and systems that life on earth depend on. Oil and its production, distribution and exchange is a fact of that socio-political and environmental relationship – what John Urry calls the carbon based economy-society.


At this point the connection between health and social analysis might begin to seem tenuous, especially to those steeped in a biomedical frame of reference. However, within health education there are two perspectives that bring issues around sustainability, whether they be political, social and/or environmental, back into focus. The Social Determinants of Health and the Inequalities in Health literature raise issues about our relationship both to the environment and to each other and the impact this has on individual, community and population health. Both of these perspectives on health may well be addressed in undergraduate medical and nursing education, but the extent to which they are, is not currently mapped. Although these two perspective do not always explicitly discuss the environment they do focus attention beyond the individual and biology. A great example is Barton and Grant’s (2006) ‘health map’ which clearly models determinants of health. Their paper, and model for health, would or should be a foundational read in undergraduate health education emphasising as it does biodiversity, climate change and the global ecosystem as key determinants of health.


This has now been explicitly accepted by some in the medical profession following the publication of three specific priority learning outcomes for the education of ‘Tomorrow’s Doctors’. This publication follows calls for medical graduates to be sustainability literate and is based on a General Medical Council’s request for learning outcomes for environmental sustainability in medical education. A call for nursing in general, and the Nursing and Midwifery Council (NMC) in particular, for nursing to be more explicit on sustainability and environmental health in its educational standards for undergraduate nursing education has not resulted in a similar request by the NMC for learning outcomes of this nature. The NMC prefer to see this subsumed under general public health.


The priority learning outcomes just published on the Sustainable Healthcare Education network are:


1. Describe how the environment and human health interact at different levels.

2. Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems.

3. Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment.


The site helpfully expands on these outcomes.


An important point is that although sustainability literacy may involve explicit new curricular content for doctors, for example critical reflection on the philosophy of dualism and anthropocentrism, it is also about developing a perspective on health, a lens through which we see anew the relationship between human health and the environment. Medical schools may already address models of healthcare delivery that go beyond the biomedical to embrace and examine biopsychosocial, salutogenic and complementary approaches. The European Centre for Environment and Human Health based in Truro, Cornwall,  is an example of a research centre specifically and explicitly addressing sustainability and environmental issues.


Thus we have the medical profession very clearly stating that sustainability and environmental health should be explicit in the education of our doctors of the future. This of course follows on from other clear statements such as the first University College London and the Lancet Commission on managing the health effects of climate change report.


These learning outcomes have been called ‘priority’ learning outcomes and this perhaps reflects the seriousness with which the issues are taken. A counter is that of course Public Health is a core component of both medical and nursing education, so why the need to make sustainability specific? Why indeed have ‘priority’ learning outcomes if this is being covered already within public health education. The answer may be that ‘Public Health’ itself is a multi perspectival subject in which it is possible that biomedical and epidemiological approaches could dominate while downplaying the environmental and social determinants of health. It is certainly possible to address public health without critically examining and understanding sustainability. The General Medical Council seem to have accepted this,  and hence their call for these learning outcomes. The Nursing and Midwifery Council have considered that their own standards that inform education practice are broad enough so that sustainability can be incorporated into undergraduate programmes within Public Health teaching. This might be a mistake, because if educators do not have a sustainability perspective, or lens, then they may well miss a vital aspect of health education.


The publication of the medical priority learning outcomes on the other hand gives a very clear message to those developing educational experiences for doctors. The message is that to fully understand human health one has to address environmental, social and political determinants of health. This understanding then feeds into strategies and actions  to address inequities in health and the environmental health crises that may severely impact on individuals, communities and populations. Other health professions might learn from this approach taken by the GMC.

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