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Strategy for change
What causes poor care and what can be done to stop it? As part of our Care campaign with the Patients Association, we invited experts and commentators to tell us. Jennifer Sprinks and Adele Waters report
Public confidence in nursing is deteriorating but the profession has an opportunity to restore it. This was the consensus of experts and commentators who gathered in London to discuss the actions needed to prevent poor care.
Nurses, academics and representatives of the regulators and royal colleges met patient representatives and media commentators at the special meeting, organised by Nursing Standard and the Patients Association.
Agreement quickly emerged from the discussion, chaired by association vice-president Phil Hammond, that the causes of poor care, and its solutions, are complex. Nevertheless, at the end of the two-hour discussion, the group had drafted a ten-point list of priorities.
The first action identified was the need for healthcare organisations to have quality patient care as their central focus.
One of the difficulties with trying to improve care is that the patient experience is not adequately documented or measured, the group agreed.
Organisations must develop and use tools to measure care quality and patient harm, and results should be reported to boards and used to inform future care management, some suggested.
The NHS needs to get better at sharing resources for monitoring quality, including having a standard patient metric tool, said Mid Staffordshire NHS Foundation Trust former chief executive Antony Sumara, who was brought in following revelations of appalling care. This would eradicate the postcode lottery and ensure all patients receive excellent care.
The group discussed measures to ensure patient experience was monitored and fed back to boards to effect change. Using 'patient stories' or setting up 'patient experience boards' are useful ways for organisations to gain insights into how care is received.
Another route is for a senior nurse or manager to accompany a patient through the whole care journey.This method is powerful, according to Martine Price, head of patient experience at Musgrove Park Hospital in Taunton, Somerset.
'It enables you to pick up issues as you go along,' she said. Care Quality Commission public affairs manager Matthew Trainer said board executives should be visiting staff and patients on the wards so they can keep in touch with the issues on the ground. 'They need to give staff support to give proper care.'
Around 3 per cent of patients complain officially about their NHS care, representing thousands of people. But often, it was suggested, patient complaints are not properly evaluated or acted on.
To prevent complaints from the outset, many suggested proactive measures to ensure patients experience a quality service in the first place, such as 'intentional patient rounding', where a nurse goes round the wards every couple of hours and asks patients if they have everything they need.
Because the contexts of care differ, delegates said care management systems should be integrated across acute and community settings to ensure smooth pathways for patients.
The second problem outlined by the group is the wide variation in care standards, even within organisations. To tackle the problem, they said poor staffing levels must be recognised as an indicator of poor care, and that organisations must provide adequate resources to ensure correct staff-to-patient ratios.
Palliative care bank staff nurse Gay Lee said the hospice model of nursing care is successful because it provides a richer skill mix. 'I think the NHS has got a lot to learn from hospice care. We have higher staff-to-patient ratios so we can give good care, whereas in older people's care wards staff-to-patient ratios are much poorer.'
The discussion then moved to the role of ward managers and community nursing team leaders. Reinforcing the case made by Nursing Standard's Power to Care campaign, there was a strong message that nurse managers needed greater support through supernumery status, higher pay, and administrative support. In addition, it would make sense for ward sisters to wear a recognisable uniform so it was clear who was in charge.
Royal College of Physicians president Sir Richard Thompson said a ward sister should be considered an important person, and be paid as much as a consultant 'so he or she does not have to go off into management'.
He added that doctors should join nurses in the holistic care of patients, and that each ward should have a named consultant.
Reducing bureaucracy was considered a priority. The group agreed that integrating medical and nursing notes where possible would help release time, but so too would simplification of patient discharge paperwork. Team managers needed greater assistance and support from human resources departments to manage under-performing staff.
Ms Lee said: 'We need to teach those skills to ward sisters and managers because there are some people in nursing who should not be nurses.'
There was a strong feeling that essential nursing care needs to be valued more highly, both by staff and boards. Where it is not valued by nurses, this is perhaps because of increasing pressure on them to take on more complex tasks, leading to the essentials, such as assistance to use the toilet, being neglected.
Core tasks
Basic or essential care should be understood as 'fundamental' care - a baseline requirement and a privilege to provide.
'We have to raise the profile and the value of the fundamental aspects of care,' explained Sir Stephen Moss, chair of Mid Staffordshire NHS Foundation Trust.
Related to this is the issue of people confusing nurses with healthcare assistants (HCAs). Regulation of HCAs would create a clearer understanding of the different roles and would enable HCAs to focus on fundamental care.
The group said executives needed a more sophisticated understanding of the importance of nursing and the profession needs to build the case that good nursing makes economic sense.
Another problem identified was that professional behaviour can change over time, resulting in burn out. Executive teams must understand this has consequences for patient care.
RCN head of nursing Steve Jamieson said 95 per cent of people who come into nursing do it to care for people. 'But there is something that can change people from being caring nurses to uncaring,' he said. Therefore, there should be a recognition in pre-registration training that nursing is emotionally challenging. This would ensure the NHS developed measures to build nurses' resilience and prevent burn out.
Another measure would be to rekindle individuals' love of nursing through job rotation, said Jill Maben, director of the National Nursing Research Unit at King's College London. 'If you have been on the same ward for years you can become desensitised,' she said.
Another subject for discussion was exposing poor practice. Agyness Daylan, who was named Nursing Standard student of the year at the 2011 awards for revealing poor practice, said nursing students are ideally placed to speak out, and this practice needed to be more common among nurses.
But Margaret Haywood, who was struck off the register for misconduct after exposing poor care in her organisation, said her concerns were not taken seriously.
'I went to the ward manager, and I kept going higher and higher, but no one was listening to me,' said Ms Haywood.
Cardiff University school of social sciences reader Win Tadd added that nurses are afraid to speak out. 'Not only are nurses reluctant to raise concerns, they are going off-duty late and in tears because they cannot give the care they want to give,' she said.
It was agreed that a priority for action should be to ensure a supportive process for speaking out. Measures could include the reporting of concerns as part of the appraisal process, or the use of Twitter to enable nurses to speak anonymously.
To make it more common for people to report concerns, Dr Hammond said the NHS should move away from the word 'whistleblowing', which has negative connotations, to a more positive 'speaking up'.
The view that the transition to a graduate profession is often to blame for substandard care held little sway around the table, although delegates agreed that aspects of training needed to improve, such as teaching in the clinical setting.
Council of Deans of Health representative for Wales Melanie Jasper said the barriers between universities and the NHS needed to be broken down to ensure the theory taught related to clinical practice.
Baroness Audrey Emerton, a nurse peer, said: 'The correlation of theory to practice is something we neglect at our peril. If we do not have this, we will fail.'
It was pointed out that public expectations of nurses may be out of step. Improving poor nursing care requires honest appraisal of society's values and a discussion about the investment society is prepared to make to ensure high-quality care.
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Journalist Christina Patterson, said: 'We have to acknowledge that this shift in the focus of care reflects the shift in our culture. We cannot expect to have a profession of fantastically compassionate people in a society that does not care.'
However, there are some basic requirements for anyone in a caring role. Ms Patterson recalled her 'devastating' ordeal when she was treated in hospital for breast cancer.
'The area that let me down spectacularly was nursing care,' she said. 'I did not have a single ally in hospital to speak up for me, and I felt lonelier than I have ever felt in my entire life.'
Setting out explicit behaviour standards for how all nursing staff should treat patients would be a good thing, it was agreed, so that patients could form realistic expectations. As part of that process, all staff would need to receive training in compassion, communication skills and customer care.
June Andrews, director of the University of Stirling's Dementia Services Development Centre said: 'We need to teach people communication skills to create that culture of caring. This ensures that even when nurses are tired they can still give out the message that they care.'
Finally, the group identified an absence of good nurse leadership at organisational and national levels.
'We have lost our figureheads,' said Brenda Somerfield, a staff nurse at Royal Devon and Exeter Hospital and winner of the 2011 Claire Rayner Patient's Choice Award. 'Ward sisters used to be seen as a figurehead and were highly respected by everyone.'
It was said that organisations could provide visible leadership on the wards, perhaps with chief nurses carrying out clinical work periodically. Strong national leaders would improve the reputation of nursing and restore public confidence.
As well as the need to get more nurses represented in the House of Lords, the group felt there was a need for professional practice to be led by a national body. Steven Hams, deputy chief nurse and head of quality at East Kent Hospitals University NHS Foundation Trust, said although the RCN does some 'fantastic' work, there is no professional college dedicated solely to 'driving forward standards of nursing practice'.
The ten action points emerging from the meeting will inform the two-year Care campaign launched by the Patients Association and Nursing Standard.
Nursing Standard :: November 16 :: vol 26 :: no 11 :: 2011
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Watch the film
Top nurses, policy experts, patient champions, doctors, and managers, attended the emergency meeting held in London.
The RCN Publishing Company is a wholly owned subsidiary of the Royal College of Nursing, the world's largest organisation for nurses. RCN Publishing produces one weekly, eight monthly and two quarterly nursing publications. Nursing Standard, the flagship journal, is the UK's biggest selling weekly for nursing. It is produced by RCN Publishing Company along with a suite of specialist nursing journals - Cancer Nursing Practice, Mental Health Practice, Learning Disability Practice, Nursing Children and Young People, Nursing Management, Emergency Nurse, Nursing Older People, Nurse Researcher and Primary Health Care. RCN Publishing Company also produce the RCN Bulletin, a major source of up-to-the-minute information for RCN members in all specialities, grades and working environments. With the latest nurse vacancies from trusts nationwide, it has become the most cost-effective nurse recruitment magazine available.