Tag: care quality

The personal is political; care in an age of spectacle.

Are we really surprised that the BBC’s  Panorama has again uncovered  poor quality care and abuse in a home for older people?

We know the roots of this, and I have previously argued that this is a political game. This is also personal because, and this point has been made many times  before, I will be old one day and may well require care. Therefore I do not want to be treated like sh*t as a resident on the Panorama  film stated. It happens because the care sector is undervalued, invisible, ‘women’s work’ and it is thought by some  that it can be done by those with little training, poor supervision, risible pay, poor patient ratios, no professional development and inadequate management.

Individuals will of course be blamed and sacked citing ‘accountability’ as if it is the holy grail of quality care and patient safety.

What to do? The first is to recognise that this personal trouble is a political issue and nurses are front line staff in the trenches. In the UK for far too long nurses have been reluctant to use union power to address these fundamental issues. Yet, just when we need it, union membership across all employment sectors have dropped as workforces became more docile in the face of deregulated labour markets. Faced with the ‘flexibility’ requirements demanded by employers, resulting in the growth of zero hours contracts, part time working, minimum wages as targets rather than base lines, workers have become more pliable generally. Nursing, being a gendered occupation with its emphasis on self sacrifice and care, has historically shied away from exercising any worker power while simultaneously picking up the crumbs from the medics table (doing their ‘skilled’ tasks for nowhere near the pay) and now bowing to the control of their work as dictated by management.

In California, in the US, nurses are joining Unions and have a staffing ratio law of 5:1 for med/surg, 2:1 for ICU, and Psych 6:1 meaning five patients with 1 nurse. CA AB394 came about by the CA Nurses Association to implement their RN Staffing Ratio Law. William Whetstone (Professor of Nursing California State University)  states “Staff nurses were sick and tired of being abused, putting up with crappy workloads, incompetent nurse administrators and managers, and on and on. I can remember when I did staff nursing dealing with a patient load of 10 to 12 patients with no thought to their acuity. As a result, CA became the first state through the effort of the CA Nurses Association to establish RN-to-patient ratios. The law was successfully implemented January 1, 2004”.

Is this an increasing phenomenon? Are we finally seeing a backlash against the dominant political hegemony that does not want to pay for care? We can study this until forever, but that fact remains – care costs. It costs a lot, requires skill and adequate ratios.

In California it seems nurses have had enough, got organised and agitated for change. They have looked beyond the representations of nurses as caring angels and seen themselves as the exploited.  They have plucked the imaginary flowers from their chains and acted.

Consumer capitalism would not want this happen because care is seen, in this context, as a cost to be born not by society but by individuals and families. Consumer capitalism instead wants to fill our heads with distractions and representations using the ‘spectacle’.

News and other media constantly feed us representations of the world that actually do not exist; they are constructed for news and or as entertainment. Panorama falls into that trap because it represents poor care in a particular way and is unable to drill down to the root causes. The TV itself is a medium of the representation of actuality and can lull us in to classifying the poor care we see as almost entertainment; the lines between truth and  fantasy become blurred.

 

“In societies where modern conditions of production prevail, life is presented as an immense accumulation of spectacles. Everything that was directly lived has receded into a representation” (Debord 1967).

Consumer capitalism has ripped the citizen role from the heart of nursing and replaced it with consumerism in which we are presented daily with ‘the spectacle’ – representations of reality that are without form or substance but which service to make sacred the profane. The spectacle specifically aimed at women include the array of women’s magazines which preach that you can never too thin or that your breasts require surgical enhancement; thus are we distracted about what is truly real by a false representation, within care employment contexts that are precarious, undervalued and invisible. Feminists know this, critical theorists know this, those with a sociological imagination know this, many women actually feel the cognitive dissonace that this engenders. In California,  nurses have acted as citizens, able to see pass the distractions for long enough to see exploitation as it really is. In the UK those nurses who can see the reality, need to the support to take charge of care in this country.

Ordinary citizens need to organise their frustrations and anger over health and social care and cohere into a viable opposition. Unfortunately UKIP are currently presenting another false representation with the spectacle of Nigel Farage presented as an ‘ordinary bloke’ that nearly 30% of the electorate are falling for.

We saw a spectacle of poor care again last night, lets not allow it to become entertainment for its shock value, lets instead urge action by all of us to provide the care older people deserve.

 

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.

 

I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 

 

Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.

 

An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.

 

The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.

 

According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).

 

If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.

 

“Let each person tell the truth from their own experience.”  Florence Nightingale.

 

Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.

 

The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.

 

“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.

 

There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.

 

Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.

 

“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.

 

Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.

 

A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 

 

“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.

 

Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 

 

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!

 

It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.

 

Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

Young Nurse Tending to Young Woman with Neck Brace and Arm Cast

 

“Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths”

This is not the only study to suggest this. Not only is the nurse to patient ratio an important factor in reducing patient mortality after surgery, their education they have is also a factor. Degree nurses have a positive impact on reducing mortality after surgery. This should finally nail the ‘you don’t need a degree to nurse’ nonsense. This is an argument that nurses have used when decrying poor standards of care.

 

Government, Society, Hospital Management and even nurses themselves need to realise their true worth as educated professionals. Care costs money, and if you scrimp on that and put pressure on staff, then you get worse mortality rates.

 

I often read comments by nurses that the problem with nursing today is education – ‘too posh to wash’ or ‘graduates lack compassion’ or ‘not enough clinical skills’ or a variant. This is nonsense and plays into the hands of those who want a cheaper workforce by increasing the care assistant to nurse ratio. If someone is too posh to wash or lacks clinical skills it is not because they are graduates. It is for other reasons, such as burn out, stress, lack of empathy or compassion per se. I’ve known many non graduate nurses who display lack of compassion, poor clinical skills and avoid washing patients. There was no ‘golden age’ of nursing when all you needed was ‘the right attitude’ and training by doctors.

Today, the evidence is stacking up – employ more RNs and get them educated!

Do you want to be nursed by someone who can take a blood pressure but can’t interpret it? No? Thought not. I once was told by a member of staff, after taking my blood pressure and being asked what it was, just a few hours after surgery,  “don’t ask me, I’m only a care assistant”.

On the same day that the Lancet study was published the Royal College of Nursing also published the result of a staff survey, now bearing mind the validity of self reported surveys, the findings do not sit well alongside the above study.

“Only 30 per cent of staff think there are enough staff to enable them to do their jobs properly and 82 per cent of nurses continue to work extra hours. 68 per cent of staff have attended work while not being well enough to perform their duties in the last three months alone.”

Another reading of that is the 70% of staff do think they have enough staff, but it is hard to spin the 82% reporting working extra hours. The issue regarding Mid Staffs reported in the media 26th February,  also highlighted the financial difficulties many Trusts are facing and following the Nicholson challenge, continue to do so. Although there are claims about the recruitment of more nurses into the NHS, the context is still one of pressure on the front line.

This directly affects nurse educators as we struggle to support mentors in practice to up the quality of students’ support and assessment. Our Placement Development Team colleagues who have the overview, can tell us both the hard data and soft metrics of the truth of clinical practice support – the areas where students can shine and feel supported and where they don’t.

We therefore still have a political battle to get results from studies such as this taken seriously by decision makers and key stakeholders. Evidence based policy on many health, social care, climate change, drugs and other issues is sadly lacking, instead we get policy driven evidence driven through by one of the most partisan, ideologically focused governments even since Thatcher. This Lancet paper will be of interest to us, but I wait without too much hope that Hunt et al will sit up and take any notice.

 Jane Salvage recently wrote “Nurse and scholar Jane Robinson and sociologist Phil Strong suggested (that nurses were invisible) in their study of the management of nursing following the introduction of general management. They suddenly realized, they said, that ‘despite the impressive statistics… nursing is relatively unimportant to government and to managers in comparison with medicine.’ They went on, ‘The tensions to which this situation gave rise – the nursing group locked into the gravitational force of its internal preoccupations, and the others, on the outside, unable or unwilling to look in and comprehend the nature of nursing’s dilemmas – seemed to us to be the social equivalent of an astronomical Black Hole’ (Robinson 1992)” .

1992. I don’t think much has changed.

 

Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?

 

I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.

 

In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.

 

Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:

 

  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.

 

The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.

 

That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.

 

Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:

 

“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.

 

This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.

 

Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.

 

John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.

 

John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.

 

Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.

 

John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:

 

“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.

 

Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.

 

Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:

 

  1. The Machine
  2. The Choir
  3. The Living organisation.

 

In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.

 

Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?

 

Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?

 

 

Issues to address to address in this regard:

 

  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.

 

  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?

 

  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.

 

  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.

 

  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.

 

  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?

Too posh to wash? Failures of the governing, managerial and political classes

Too posh to wash? Reflections on the future of Nursing.

 

When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual…Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals”. (C Wright Mills – The Sociological Imagination p9).

 

 

In the many contributions to the debate about poor quality care, there is often a distinct lack of a sociological imagination. While individuals can be rightly criticised for giving poor care, the antecedents are to be found beyond the personal trouble of individual nurses and their patients, and can be classed as a public issue: that of the political, social and economic failures of the governing, managerial and administering classes over the past few decades.

 

‘Too posh to wash’ is the title of a recent publication on the condition of nursing in 2013 and reflects newspaper headlines and the Health Minister, Jeremy Hunt’s, call to student nurses in March 2013. In it there is a range of contributions from various practitioners and experts on the delivery of care in the UK. They were asked to address various questions:

 

1. Why do we have lapses in nursing care and what needs to be done to prevent poor care back into caring?

 

2. In striving for professionalism have we over qualified yet undertrained today’s nurse? Are they too posh to wash? What mechanisms and support systems need to be in place to ‘bring excellence’ back into the profession?

 

3. Has the role of the nurse leader been devalued? Has respect for their knowledge and expertise and a desire to emulate them decreased?

 

4. Why have boards within both NHS and non-NHS organisations appeared to have failed to deliver the expected improvements in quality of care? Are board members unaware of the standards on their wards or in their care settings?

 

Various issues and solutions were raised but the answer to the title appears to be: “no”, students are not too posh to wash.  The myth of a golden age was shown to be just that – a myth. Menzies Lyth’s 1960 paper was quoted and is still worth a read today. I would also refer to Kath Melia’s work around the challenges students faced nearly three decades ago.

 

Among the normative statements made, i.e. what nurses ‘ought’ and ‘should’ do, there was some attempt at analysis of underlying reasons for poor care. This included societal attitudes to ageing and caring, and technology and is affects on communication. There was no call however to return to apprenticeship training outside the University. This accords with the findings of the Willis Commission (2012).

 

What was striking was the almost passing references to systemic failures within the NHS around the structures for providing care. These failures are the responsibility of the governing political and managerial classes who are charged with running the NHS. While we are acknowledging ageing populations, increasing frailties and complex care needs, there is a a requirement to examine the context of care. To examine what structures have been put in place to deliver care to increasing numbers of frail elderly people in acute hospitals and care homes. Student nurses in particular are placed in clinical practices which are not conducive to compassionate care, and are often the least equipped to understand, analyse and bring about change.

 

Universities can support the development of critical thinking and underpinning knowledge but are almost powerless to affect this care context in which students find themselves. No amount of curricular changes emphasising compassion and caring will work if students continue to experience Melia’s 1984 and Lyth’s 1960 descriptions of the care environment.

 

Menzies Lyth (1960) argued that nurses experienced high levels of anxiety due to their work and that there was an absence in the hospital of any mechanism through which to ‘positively help the individual confront the anxiety provoking experiences’. The result was a set of defensiveness techniques including the splitting up of the nurse-patient relationship. A more recent research report (Hillman et al 2013) also report ‘defensive practice’ resulting in an ‘us and them’ subject position regarding their patients as nurses felt the pressures of litigation, complaints and the pressing need to meet the managerial requirements of the organisation.

 

Melia (1984) outlined two competing ‘segments’ – the ‘educational’, focusing on learning, and the ‘service’ which focused on ‘getting the work done’. In learning to ‘fit in’ students experienced a transient approach to nursing implicitly supporting a lack of commitment to nursing as an occupation. This is mirrored in a 2010 study of Norwegian students in which it is argued:

 

“While clinical practice often has focus on practical problem-solving and procedures, the college tends to focus on abstract theory. Both of these promote the privatisation and neglect of the students’ experience of care. The paper concludes with a call for teaching and learning strategies targeting the use of nursing students’ personal experience of care”. (p73 Solvoli and Heggen 2010).

 

So, no ‘golden age’ then or now.

 

In the 2013 ‘Too posh’ document, three commentators pointed out the critical place that clinical practice experiences have which implicitly build upon Menzies Lyth and Kath Melia.  Professor David Sines argued that there needs to be:

 

 

1. dynamic placement opportunities for students that expose and challenge them to confront the complexity of health and social care, within, between and across clinical care pathways, supported by a curriculum that is ‘wrapped around the patient’s/user’s real experience and journey’;

 

2. robust, enhanced and effective mentorship and preceptorship partnerships with our Trusts;

 

These 2 ambitions will not be achieved in care environments where there is poor skill mix; care given by care assistants who may be poorly supervised and trained; poor staff-patient ratios and minimal professional support and development. Sines goes on to argue:

“Above all our next generation workforce requires access to expert mentorship and role models to nurture and inculcate excellence in practice and resilience in attitude to deliver optimal standards of care at all times, turning each patient encounter into a learning opportunity that leads to sustainable excellence” (p15).

 

Again this is a key issue: ‘Access to expert mentors’. Far too many students report the lack of both access and the quality of support in this area. Therefore this may sadly, in the current context, be too idealistic. This might be born out by Bradbury Jones et al (2011) who reported that not all students have a positive experience:

 

“Unfortunately there were many examples of disregard and disrespect of students as learners. Lack of encouragement and responsibility were significant issues and this had a negative impact on students’ knowledge and confidence. These findings are consistent with nursing literature in terms of lack of support and encouragement and specifically, lack of interest in learners (Lindop, 1999). The findings also mirror those of Levett-Jones and Lathlean (2008), who reported that while a number of students in their study had positive placements, too many had experiences where their learning was not optimised and their competence and confidence were negatively affected. Like the students in this study, Levett-Jones et al. (2009) found that some mentors seemed to disregard students’ feelings and made little attempt to hide their impatience and frustration” (p371).

 

 

Maura Buchanan also focuses attention on the clinical environment:

“ I would argue that the main responsibility for failing standards lies not with nurse education, rather, with the clinical practice environment for which employers must take blame” (p17).

 

Jenny Aston also points to deficiencies in the clinical environment:

 

“With university based training (sic), considerable responsibility is left with the placement mentor to ensure that students have the necessary hands-on nursing skills. Many students have minimal one-to-one learning from their clinical mentors,who are busy with their own responsibilities, and have little or no protected time to teach the essential skills…University lecturers rarely have the time to visit, let alone work, in the clinical areas”. (p21)

 

The responsibility for safe compassionate care rests with Trust boards. NHS management has taken its collective eye off the ball and is often ill equipped to know if poor care is being given. Universities cannot do the work for Trust boards. Any call for a return to apprenticeship training within NHS trusts must address this fundamental issue. In far too many cases there are insufficient governance practices in place to ensure care standards are upheld. Aston argued:

 

“There is a need for governance measures to be in place to ensure that care is of a high standard as there will always be a conflict between cost and quality. Board level

decisions need to be based on a good understanding of how care can best be delivered and measured so on the ground clinicians need to be informing high level decision makers. Great care needs to be taken to measure the right things and not just numbers; otherwise real improvements will not be demonstrated. An experienced pair of nursing eyes and ears can identify good and bad care in a way that complex audits or form filling may fail to achieve”.

 

Roy Lilley has often stated: ‘Fund the front line. Make it fun to work there, that way you will make Francis history”. Nurses and nursing students have been criticised as lacking in compassion. No doubt this is true for some nurses. However, it is the lack of governance and poor clinical environments that both grows uncaring attitudes and fails to weed them out. Trust Boards through excellent management must implement strategies that ensure the front line is properly supported and developed.

 

When only 1 nurse provides poor care, that is their personal trouble….when we have had a catalogue of reports into poor care,  that is a public issue and we should not find the solution in the situation of any one nurse. We must look into the economic and political nature of NHS Trusts and of society to move beyond criticisms of individual nurses and their personal failings.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Beer, G. ed. (2013) Too posh to Wash. 2020.org  Too Posh to Wash?

 

Bradbury Jones, C., Sambrook, S., and Irvine, F. (2011) Empowerment and being valued: A phenomenological study of nursing student’s experiences of clinical practice. Nurse Education Today. 31 p368-372

 

Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. doi: 10.1111/1467-9566.12017  pp1-17

 

Levett-Jones, T., Lathlean, J. (2008) Belongingness: a prerequisite for nursing students’ clinical learning Nurse Education in Practice, 8 pp. 103–111

 

Levett-Jones, t., Lathlean, J., Higgins, I., and McMillan, M. (2009)

Staff-student relationships and their impact on nursing students’ belongingness and learning Journal of Advanced Nursing, 65 (2) pp. 316–324

 

Lindop, E, (1999) A comparative study of stress between pre- and post-Project 2000 students Journal of Advanced Nursing, 29 (4), pp. 967–973

 

Menzies Lyth, I. (1960) The functioning of social systems as a defence against anxiety. Human Relations. 13 (2) 95-121

 

Melia, K. (1987) Working and Learning: The Occupational Socialisation of student nurses. Tavistock press. London.

 

Solvoli, B., and Heggen, K. (2010) Teaching and Learning Care – exploring nursing students’ clinical practice. Nurse education Today. 30 (1) p73-77

 

Willis Commission (2012) Quality with compassion: the future of nursing education. http://www.williscommission.org.uk/

 

Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.

 

Care Quality in the NHS. We can do better than this.

Care Quality in the NHS. We can do better than this.

 

Just published: a research study into culture and behaviour in the NHS. Dixon-Woods et al (2013) undertook a mixed method study from multiple sources using surveys, ethnographic data, board minutes, publicly available data sets and interviews. The reasons for doing this of course are well known post Francis and Keogh. So what did they find?

 

“an almost universal desire to provide the best quality of care…bright spots of excellence…but considerable inconsistency”.

 

The reasons put forward will resonate to many interested in quality and management issues in the NHS. Nonetheless it is useful to have some empirical data to support what we think we already know. Working against the desire to provide high quality care are the usual suspects:

 

1. Unclear goals

2. Overlapping priorities that distracted attention.

3. Too many external regulators

4. Poor information systems

5. Variable management and staff support

 

They concluded “…put the patient at the centre…get smart intelligence, focus on improving organisational systems, nurture care cultures by ensuring staff feel valued, respected, engaged and supported”. This last sounds like Roy Lilley’s oft quoted ‘fund the front line, make it fun to work there…’

 

Where does one start with this little list? First…get those pockets of excellence out in the light, let everyone see exactly how some are getting it right. Network, share, talk!

 

There are many intelligent people in the NHS, some of the staff are the cream of the educational system and others, what they lack in super cognitive functions, they more than make up for in commitment and care. What is lacking is the organisational foundations to harness this.

 

Nurses tell me that they have little or no time for professional development, clinical supervision or networking because they fill their time with giving care. They are already ‘putting the patient first’ but they lack ‘smart intelligence’, i.e. data that tells them that care is good or poor. Instead they are bombarded by other data that provides managerial information but little in the way of the patient’s actual experience. My blind uncle’s cup of tea being placed on the other side of his bed out of reach and with no verbal communication to tell him it was there, is a bit of data that does not get fed back to anyone. The RN’s need to be able to know if poorly trained staff require performance management. They need an ‘organisational system’ that allows the supervision and training of support staff that they oversee so that cold cups of tea are not left bedside.

 

 

Managers need to give more than lip service to making staff feel valued, respected, engaged and supported. And that is the crux, because Trusts chasing other organisational goals are liable to take their eye of this particular ball, measure success in terms that do not relate to the care experience and are liable oversee a culture in which staff become disengaged, disillusioned, distracted and demoralised.

 

The issue is of course wider than Trust and NHS management. It is about the value society is willing to place upon care, and thus how society structures itself to provide that care. Are we then asking too much of Trust managers?

 

It is of course the case that the vast majority of care is done outside the NHS most often by family, most often by women. This of course applies to both health and social care. This is the socio-political context in which the NHS has to work, picking up the pieces when care cannot be given by this informal unpaid army. The NHS can intervene magnificently when that care need is medical or surgical, but it just was not designed for the sheer number of frail elderly people requiring some form of care. Neither is society now structured to cope.

 

Social and geographical mobility that fragment communities and families; different societal and individual expectations; the changing demographic of an ageing population; longevity and medical advances that keep us alive but also result in many more experiencing chronic illness that requires supervision and care; the unglamorous nature of care; the still gendered nature of care; the structure of financial penalties for leaving the job market or career ladder to look after ‘mum’; the structure of rewards that channels money into socially useless bullshit jobs; the structure of rewards that sees prizes, fame, medals, celebrity heaped upon narrowly talented non entities too often still just out of nappies; the ability of the feral elite to ferret the lion’s share of the nations’ wealth into offshore tax havens; a government that sees public service and the public sector as dirty words; a government that is leaving it to the market to sort out, an education system working for the minority while the majority compete against each other in a rigged system; a job market increasingly characterised by an increase in low skilled, part time, low waged employment; a private sector that will not rightly touch getting involved in care, a risk averse managerialist, bureaucratic and financial accounting approach to care…

 

In short, care costs, but the costs are externalised onto those who too often are unable to pay. We have increasingly individualised the risks and costs arguing that health and social care cannot be afforded by the state, especially now in times of ‘austerity’. The State is not the same thing as society but society needs some organising structure to put its values into action. We have left the values of individualism and market freedom blind us to the changing nature of society and the care pressures that come with it. We are now ill equipped in many areas to provide the context for high quality care.

 

A question then can be raised about whether the bright spots of excellence exist despite the overall socio-political context? Could the NHS better foster those bright spots if its supporting context was different?

 

NHS is not just about Trust management, it is also about society having a different vision.

 

 

 

 

 

 

Care quality in the NHS

.”‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9). (C Wright Mills – The Sociological Imagination).

….today we hear about the safeguarding tragedy that was Daniel Pelka. Again, communication issues between agencies and the failure to act have been highlighted. His parents are in jail. If only one social worker failed then we should look to the character of that social worker. When we have a historical record of failures which all highlight communication issues and failures to act, we will not find solutions only in the failings of individuals, the socio-cultural systems itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society.

….we have heard about the care failings that was Mid Staffs. Again, neglect and abuse of frail elderly patients were highlighted. If only one healthcare professional or manager failed, then we should look to the character of that professional. When we have a historical record of failures which all highlight neglect and abuse, we will not find solutions only in the failings of individuals, the socio-cultural system itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society and not just the striking off professionals from registers.

Sir Brian Jarman stated in a recent Lancet article:

“To improve the quality of care in UK hospitals, I would reintroduce the Independent Review Panels and Community Health Councils and develop monthly complaints alerts similar to the mortality alerts. Regulation would be more independent if the CQC reported in public to Parliament, and there would be better communication if it were integrated with Monitor. Additionally, it is important to ensure  there are minimum staff-to-patient levels of doctors and nurses, with 65% trained nurses and  regulation of health-care assistants (my emphasis). I would aim for

total physicians per head of population at the EU average. Ideally I would also like to see training  introduced for the boards of trusts and for them to
have equal representation of patients, clinicians,  finance, and managers. There has been a decade  of concerns about the quality of care in our
hospitals: patients have been ignored, the  regulatory systems have failed, and there has been a culture of denial”.Instead we get the mess that is the Health and Social Act which is supposedly a ‘reform‘, and the NMC engaging in ‘re-validation’.

When will we learn that inspection and revalidation are external post hoc care quality issues, there is of course a place for these processes but there is a need to ensure the quality of care is structurally built into care delivery systems – and that means ensuring that you have enough staff, enough of the right sort of staff, educate and support them and engage in continuing professional development, appraisal and performance management if necessary.

“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 NHS needs Registered Nurses. Patients need Registered Nurses

 

First let’s deal with the title ‘Nurse’. In the UK it is illegal to call yourself a nurse if you are not on the register, Nurse is a legally protected title…this is a fact which gets lost in media talks about poor ‘nursing’.

Too much ‘nursing’ is in fact done by care assistants.

Too many student nurses are being supervised by care assistants.

Care assistants often are good people trying their best but they are not always supported, trained or supervised enough. They need to support nurses in their roles rather than replace them, which is in fact what is happening.

In ‘Skill mix and the effectiveness of nursing care’ Carr-Hill (1992) argued that ‘grade mix had an effect on the quality of care in so far as the quality of care was better the higher the grade (and skill) of the nurses who provided it’. In other words skilled nurses reduce poor quality care.

In the United States a Philadelphia hospital (2012) adopted an all RN care model, they eliminated the use of care assistants and patient outcomes improved and costs reduced.

This comes on the back of another 2006 in the US  study indicating that increasing the ratio of nursing by RNs reduces stay, adverse outcomes and patient deaths.

Finally as published on the nursingtimes.net a UK study suggests:

“There is a link between higher death rates and the number of healthcare assistants employed in NHS hospitals”.

A study by the University of Southampton found trusts with a higher number of unregulated HCAs also had a higher mortality rate.

A higher HCA-to-bed ratio increased the mortality rate up to a maximum of 5.4% more than would be expected, the new study found.

The study also identified a clear link between the number of registered nurses and mortality. It found there were fewer deaths the more nurses were employed. For every 10% increase in the number of registered nurses the odds of patients dying dropped by almost 7%.

Based on hospital admissions in 2010-11, the study found a 10% increase in the number of nurses would result in 2,600 fewer deaths.

Lead study author Professor Peter Griffiths told Nursing Times the findings on HCAs needed further investigation, but said: “It certainly calls into question a workforce strategy that moves registered nurses further away from the bedside and replaces them with assistants.

“This echoes some of the findings of the [Mid Staffordshire Public Inquiry] report, which expressed concern over the lack of regulation for this workforce.”

Professor Griffiths added: “The fewer registered nurses a hospital has, the more patients die. So the significance of nurse staffing levels seems to be well established both in the research and in the tradition of the profession.”

He added that, while the government appeared “dead set” against introducing mandatory staffing levels, “there is surely a level at which we can be clear it cannot be safe under any circumstances.”

He suggested a ratio of eight patients per nurse, saying in his study 60% of shifts were at this level or better.

“The findings taken as a whole point to the need for more qualified nurses at the bed side,” Professor Griffiths said. “It is hard to conclude from this evidence that the solution lies in downgrading the training of the nursing workforce as a whole and reducing the number of registered nurses.”

On Graduate nursing:  

http://jama.jamanetwork.com/article.aspx?articleid=197345 ?

Reference Aiken et al (2003) Educational Levels of Hospital Nurses and Surgical Patient Mortality. JAMA 290(12):1617-1623

June Girvin argues:  The evidence clearly shows that graduate nurses offer better care than non-graduates and the more highly skilled and educated nurses there are in clinical areas, the better care outcomes are. The tendency to attack the academic elements of nurse education as being at the root of the current perceived crisis in care has no place in modern healthcare environments.

‘Nuff said.

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