Time To Act: Crisis in Nursing, Patient Care and Safety

I broke my left knee 8 weeks ago today. When I emerged from a 4 day hospitalisation process in the John Radcliffe Hospital, Oxford, I began to write about the experience.
I finished my story, conclusion and recommendations sent it off to the Chief Executive last Friday.

Today on Radio 4, I heard a Royal College of Nursing (RCN) representative and Christina Patterson, of the Independent, sharing their views about what is being/should be done about re-introducing care into nursing practice.
The RCN guy told us about their new campaign to educate the public in how our nurses are in fact still wonderful people it’s just that they work in a highly dysfunctional organisation and this means they haven’t got time to do the caring bit anymore. Or words to that effect. Christina said, and I agree with her, that it’s not about persuading the public to just value nurses more it’s about changing how they and hospitals operate altogether.

This means getting the government to act on our (tax payers) behalf to take responsibility for preventing putting vulnerable people (the injured and unwell) in a high risk environment (our hospitals staffed by incompetent, even dangerous (for whatever reason!) staff, managers and practitioners alike). Sorry but this is real.

Please read my story and if you have any evidence that can contribute to the growing body please email me. It is only evidence that governments and treasuries can act on.

This is not a witch hunt. It’s a social responsibility.

Here is my story:

This the story of my experience in the John Radcliffe Hospital Trauma Unit, dealing with my broken knee-cap.

Why am I writing about this? Well, having witnessed and been subject to events and behaviour that I now believe constitute a significant problem, I want to record my experiences and observations to provoke, inform and support change for the better.

I had slipped on a very wet floor and fallen hard onto my knee. I straightened my leg and quickly bent it again as the pain ripped through me. The ambulance came within 10 minutes at around 9am. Paramedics listened attentively to all my answers to their very good questions and acted quickly and appropriately. They splinted the leg and tried to get me up. The pain burst through to the surface again. It must be held bent. They adjusted the splint and I said I’d move along the landing and down the stairs on my backside to the waiting stretcher. To their credit and with my huge gratitude they helped me do this without challenge. The pain subsided again. Once in the ambulance we sped to the JR hospital in Oxford.  I realise now that this was the last time I felt safe.  The people who were caring for me were working with me, bringing their expertise to my reality and it worked.

On arrival at the hospital they pushed my stretcher into a smart well-equipped cubicle. The place seemed quiet and efficient. I smiled at a nurse looking for reassurance- a smile returned. No return. Another nurse came and asked me all the same questions the ambulance crew had asked. On querying why this was necessary, it all having been already recorded, she explained it’s good practice (evidence based? I wondered) to get the patient to repeat themselves to ensure accuracy. For some reason it made me feel they didn’t trust each other.

Having waited for what seemed like an age and having been told there had been a major road accident, which would take presidence over my needs, I asked for an update on the time schedule. I was told that there was someone round the corner ‘fighting for their life’ as if this was evidence enough for why I should not need to know when my case might be attended to. It was not explained helpfully as in: so sorry we can’t tell how long the current crisis will take to fix but will keep you updated.  The reference to the ‘bloke next door’s’ condition felt like a veiled threat. If you ask us to address your needs again we’ll make you feel selfish and bad.

Sometime later a trolley with plaster and bucket, pushed by the nurse and  colleague, arrived abruptly through the curtain of the cubicle. We’ll put your leg in a back slab so you can go up to the ward and wait.’ A few messy, white minutes later, it having been decided by the nurses that lying on my stomach to do this would be too painful, they applied a ‘top slab’ instead. I questioned the wisdom of this decision on the basis this would put all the stress on the fractured knee! I felt uneasy again. At this point the nurse briskly removed the top slab and left. I shared my anxiety about the situation with the other who assured me the former had been doing this job for many years and was very competent. I wasn’t assured. She returned and said that I could have a back slab if I wanted one, but that it would hurt a lot Another threat? Maybe not – but the tone of her voice made it feel like one. I think she was finding it hard to engage with me or my predicament.

I suggested we all held the leg in place rather than my lie on my stomach. I held the top and she held the bottom. She made it clear this was not what she wanted to do. We sort of worked together until the knee was adequately supported again. Heaven knows how this would have turned out if I had been in too much pain to question the top slab idea! As it was I was left with large solid lumps of finger shaped plaster for my heel to rest on which I asked to be cut away to avoid unnecessary discomfort. One nurse was kind enough to joke: ‘Goodness have we got anything that cuts properly around here as she gnawed her way through the lumps with blunt scissors! And as the trolley had arrived, like something out of Harry Potter – it evaporated equally abruptly. I was left alone again.

On arrival in the ward I was introduced to another nurse who accompanied me to my bed. The ward seemed wonderfully clean and peaceful and had plenty of glass and light. For some reason there was a heavy, dark green mattress on top of the ordinary one. I was rolled onto this and immediately disappeared into a dark hole in the middle. Pain shot through me. I asked what this was for.

‘Oh it’s a water bed.’

‘So sorry, ‘ I said, ‘but I need a firm mattress if that’s ok.’

‘ Yes sure’. They quickly removed the green thing and I wondered what would have happened if I’d stayed on it. More Pain. Later, the following day, a lady with a broken ankle and other complex issues including having a pace-maker was put on this mattress. Her surgery was delayed (!) and she spent the night trying to turn her body around in this thing, groaning in pain every time. She did not query the need for this mattress, just suffered it – patient, what patient?

I asked a nurse what the regime was in the ward so I could work with it, she said ‘there isn’t one really’. At that stage I did not take on the full implications of this statement. She also told me that what she liked about this ward was they way she could get to know patients, sticking with them over their stay. I felt reassured. Later however, she explained she’d only been working here for 3 months, having just finished her degree. Her expectations were at odds with the reality.

A cleaner entered the ward and cleaned the bed next to me very thoroughly, which was great. We started chatting. She was from Poland and told me she enjoyed the job generally except her good manager had been transferred and now she had an English manager who had a different style. This manager made her leave her walkie-talkie on all the time so she could respond but this had the effect of making her feel pressurised and threatened, for example,     ‘Calling Agate. Have you finished. I need you on another ward.’ Agate would have to say ‘No’ if she had not finished and this was interpreted as her being slow! She said this made her feel threatened and as if she could never satisfy demands, enjoy any sense of achievement or of being valued for what she does. She said she was looking for another job. I could see she was as quick and efficient as possible. She told me that after she had finished cleaning a ward she was assessed and scored.

‘How did they do this’? I asked. ‘Did they take swobs/samples?’

‘No just with the eyes’ said Agate.

Each cleaner was scored for effectiveness on this basis alone. I wondered  ‘where’s the science?’ Bacteria? What bacteria?!

Significantly, throughout the period of my stay in this ward and bed (4 days and nights), I do not remember one occasion when my table, locker or floor was cleaned. My sheets were changed only once, on the day I was expected to go to theatre, which I guess was standard practice. The measurement for success in this and other areas seemed to be more on ‘job done’ (job being: clean the beds, when they are empty, routinely to prevent infection) than on ‘real’ patient care, comfort and hygiene? Only once was I offered washing facilities. I asked for these at all other times. I like to be independent and make my own choices but bed bound and in considerable pain, I really would have appreciated being offered more support.

A note on food. This was reliably and courteously served and empties collected promptly. Breakfasts were cereals only or small  ‘continental  ‘rolls with jam and butter. Everyone cried ‘toast please’. One morning the manager came into the ward and made a general announcement ‘Ladies, toast is not on the menu so it has to be specially made and I cannot do it everyday. We have only a two-slice toaster and 2 loaves of bread a day and the nurses need these. So, you cannot therefore have toast everyday!” We suggested they get a bigger toaster, more bread or put toast on the menu. Why was this obvious, cheap, easy opportunity to improve patient happiness being ignored?

Another nurse came to me who was great, caring and actively listened. At the point when I understood her to be ‘my’ nurse I was in extreme pain and had waited too long for help a number of times. She said she thought that what had happened was that when the nurses came to check on me I’d appeared to be asleep and, though probably ‘gritting my teeth through the pain’ they’d assessed me as ok. This was why I had not been attended too. I found myself accepting this theory (although I would have preferred someone to have asked me if I was ok to make a better assessment of my needs) on the basis that it might change the staff’s approach to my care for the better. She told me I should keep my finger on my call buzzer non-stop until I got a response. If I didn’t do this I could not expect nurses to know I needed them.  She told me,

‘It’s what nurses are here for and it’s your ‘right!’

I could see where she was coming from, but remember thinking that I didn’t want to have to alert nurses to my ‘rights’. I just wanted to feel they were happy to help me and others around me.

Unfortunately, sometime later after ‘hand-over’ (I had no idea who was now ‘my’ nurse and was questioning whether in fact such a dedicated system existed after all), I buzzed as instructed. A shrill voice came through the curtains.

‘Tut! Stop buzzing all the time, if you don’t mind. You only have to buzz once and someone will come. I can’t do everything you know’.

I felt her frustration. She was obviously struggling.  Sometime later, when the patient next to me had returned from surgery and was due to be transferred back to the Churchill for dialysis urgently, the ambulance crew (and patient!) had to wait for this same nurse to help them for some time. She explained,

‘I’m so sorry I’m all over the place because I’ve just got back from a few days off and my head’s in another place still.’

The ambulance crew were not amused again, although it had been their sense of humour and caring for the patient that had carried the day. It struck me then: Should ambulance service training be looked at as a good model for nurse re-training?

I still had no plan. The pain had become increasingly unbearable through the night. My knee had swollen vastly and my whole leg was going into spasm at the slightest movement. I was shaking and felt tears rolling down my cheeks. After numerous attempts to get some attention a nurse suggested I was suffering from anxiety and this could be treated with diazepam.  I tried to explain that my ‘anxiety’ was actually about getting some pain relief. He told me the diazepam would also stop the spasms. I thought (as much as I could at this stage!) ‘ok this all sounds reasonable’ and agreed to take diazepam, the effects of which wore off quickly. So… I had to go through the whole buzzing procedure again. The nurse finally told me he could see I really was ‘in a lot of pain’ – so gave me morphine by mouth. I felt as though I had struggled so hard to ‘convince’ someone I needed help.

No one could tell me when I could go to surgery. I’d had nil by mouth from 2am.  At 3pm I was worried and distressed. Was anyone aware of my needs. I asked again that ‘my’ nurse, of whom I’d already counted 4 could come and update me. One unfortunate moment stands out, when my husband and daughter were waiting with me. I asked a passing nurse if she could help me find out what was happening. She came and sat on the bed, which caused me to yelp in pain. She jumped off and left. Then she popped her head through the curtains saying.

‘Good news, you’re definitely on the list today, except they’re doing a pelvis which could take 8 hours. Who knows! If you’re done today it’ll be a miracle. You’ll have to take that jewellery off to. Can’t have that!.’

I recognised this might have been her way of ‘helping’ but, for my own sake, I challenged her.

‘What does that mean? I said, (high, upset and angry by now).

‘Don’t shoot the messenger’, she said loudly.  ‘I don’t know!’

‘So why did you say what you said?.’ I demanded.

‘Don’t shout at me I won’t be shouted at!’

“I just want to know if I can drink some water. I haven’t drunk anything for 14 hours on the basis I’m going into theatre.’ I pleaded.

‘Alright’ she said, ‘ I’ll only get you a drink if you’re nice to me!!’

It struck me then that patient care had become a power struggle. My struggle was to find out if it was SAFE for me to drink. Hers was to protect her sense of personal power. If she brought me a drink – was this a reward for my being nice to her or was it for my well -being? Above all was it ok for me to drink?!

I was shocked at the lack of professionalism here and wanted to find out what, in this organisation, had put this nurse in this position. Was the system she was operating in undermining her belief in her core values – those that led to good patient care – to such an extent she’d lost sight of the need to be self-reflective, kind and professional? Did she have faith in the system she was working in? Nurse? What nurse?

The following day I apologised to her for having upset her and she said she had been upset but was ok now. I told her I had been upset too. She didn’t really hear me I don’t think.

After this episode this same nurse seemed to use me as an ally in her field of battle for personal power. On one occasion she whizzed into my partially curtained space and told me she’d questioned one of her colleagues on whether she’d cleaned the mattress before making the bed next to me. She told me with alacrity,

‘I was right, she hadn’t and now she’s having to do it again!’. The nurse who re-made the bed was very gracious about this. In fact I got the impression that the two of them were operating in their own zone of task-orientated mutual support and self-regulation. Had this replaced the operational value of patient care? I wondered whether in fact either of these individuals, had the requirement been there to form good relationships with patients as part of their remit, actually had the natural (or trained) capacity to deliver.

This brings to mind a very different nurse.  As she explained when I asked, she’d been nursing for 30 years and was suffering in the ‘new way’ of things. She told me no-one really knows what’s what anymore and there’s never enough time or resources. When I was desperately trying to relieve the pain in my leg by positioning my heal carefully, I asked if they had such a thing as small ring for sitting the heel in.

‘Oh no dear, we don’t have anything like that anymore, this is the new NHS, nothing creative like that anymore.’

She tried to laugh but I could see she had lost respect for a system that had downgraded things that mattered to her – being able to help and care for patients. She was great throughout my stay, bringing me bedpans and helping me wash when she had time, popping in whenever she could and trying to keep me appraised of what was going on – very frustrating for her because all she could often say was ‘I’ve told such and such and they say they’ll come when they can.’ Mmmm.

After a protracted period of buzzing, asking for pain relief, waiting, buzzing again, getting pain relief, waiting for pain relief to work, trying to get to the bottom of whether I could drink or not and dealing with all these wonderful if pretty disempowered nurses and non-existent systems, a doctor came. He began by telling me what he thought I wanted to know and defending the system. I explained that I was in no way critical of his prioritisation criteria for listing cases. I simply was concerned for my well- being. I needed to know whether I could drink or not because I’d had this accident at 8.30am the previous day, had gone through a day and night and another day of bad pain with no understanding of how it was being managed until I’d asked and was told I had to ask for pain killers.

The doctor directed me to ‘carry on nil by mouth because they were definitely going to get me done that afternoon’. I tried again

“ I have been nil by mouth since 2am, what if I follow your instructions and carry on and at 7 pm, as per last night you say it’s not happening after all?’

He then said ‘I think I understand where you are coming from now. In fact I will go and ask theatre what the position is and get back to you.’

Result!!  Thankfully, this doctor then asked the nurse to put in a drip. Sometime later I asked if there was any news from theatre. None came.

I asked one of the nurses how many trauma theatres there were to cover all eventualities. He told me 2. I wondered how many traffic accidents might displace how many existing patients waiting for surgery and how often that is happening. Is the data being recorded? If it is who’s applying it to what? Is spending a fortune on holding patients in wards on expensive and debilitating pain relief really a viable cost effective alternative to having another theatre open. What about recovery/healing time? How is that affected by extended pre-op treatments that impact on resources? Has anyone looked at the possibility of a ‘general theatre’ to cover specialist theatres when they bust?…………

At the stage of finally being put on a drip, I realised how distanced the doctors actually are from ground floor patient/nurse reality. ‘ Nurse please manage this patients pain ‘ was something I’d frequently heard from doctors and consultants over my stay, implying their somewhat blind faith in the system and its nursing teams. Case in point: After 2 days, I’d been told that I had to ask for pain relief. How does that match to the doctors expectation of nurses managing a patient’s pain?! Surely it takes two, the nurse and the patient.

I’d also realised that, judging by the number of times a nurse had asked me when I’d last taken pain relief on the basis they can ‘test a patient’s alertness’ by doing so – it seemed likely that it wasn’t being recorded. On asking this directly of 2 nurses independently, they both told me that was in fact the case – not recorded in the file, but maybe on the database. Aargh.

Are doctors/consultants aware of their own lack of awareness? Another case in point. My husband and daughter had been told that I could go home the day after my surgery as the op had gone well. My husband told me this when I came round. This was fab. I felt no pain because I’d agreed to having a nerve block. The physiotherapist was astonished I’d got this message.

“They just haven’t got a clue!’ she said.

She told me I had yet to experience the pain of the feeling coming back to my leg 12/24/36 hours later. I also needed a new cast, to learn how to manoeuvre my leg, use a frame then crutches to go to the loo and then stairs, also I would need to be ‘signed off’ by the Occupational Health person before I could leave. My God I thought, A PLAN how wonderful. The consultant was clearly not involved in such a plan.

It was truly great working with the physios, except on the last day of my stay when I met a new physio, who was not the one I had made a relationship with. She was clearly very able but questioned why I had the splint that in fact had been given to me as a replacement for the plaster cast that had not worked! She said,

“Why haven’t you got what the consultant drew on the front of your file?’

I replied… ‘I don’t know but I’m happy with what I’ve got. Why are you asking me this and on the day I am going home?’

‘Because I just wondered, when it’s so completely different’.

I showed her the old one that had the day before been removed on the basis it too had not been fit for purpose (left on the chair by my bed for two days since removal!). It also had not apparently conformed to the drawing on the front of the file’ (which I had not seen at any stage!).

‘Mmm ‘ she considered. ‘Oh well I don’t know’

‘Ok so this one’s alright is it?’ I asked. She nodded. I was not reassured but trusted my own judgement here. I liked my new ‘cricket’ splint affair. The consultant’s plan however, had not been adhered to. No wonder really.

A quick note about physio aftercare. None of the physios I have seen since my stay in the JR, have had any notes to refer to about my case, saying that they don’t generally get to see these, stating that they ‘prefer’ to get info. from the horses mouth’. Do they have a choice?

The patient is not the expert here. How can physiotherapists do their job properly with the experts view denied to them? By good judgement, my husband had taken pics. of my xrays showing the springs and pins in my knee!  Once the physio had seen these I felt more confident in her plan for me.

When finally I was taken down to theatre, 38 hours after the ambulance had raced me to the hospital (!), I was told the pre meds would be done down there. Fine. However by this time I was so physically and psychologically drained through pain, frustration and mistrust I was desperate. I was told the anaesthetist was late and given her apologies. Aargh! I was chatted to and asked loads of questions AGAIN. They told me the anti-thrombotic drug I’d agreed to take had made my blood too thin for some procedure but that they could administer a nerve block instead, which they explained the benefits of. I questioned the standard use of this drug. What about the individual patient’s condition? They did their best to settle and calm me. By the time the anaesthetist arrived, laughing and jolly (lovely in most other circs) I was utterly beside myself and was told to calm down – correctly! I said quite simply.

‘Look I’ve had enough, can’t take anymore just do it NOW!.

To her credit the anaesthetist threw herself into action and I was away.

In my recovery period, my husband and daughter were waiting for me. They were told first 8 then 9 then 10pm to expect my return to the ward. When they asked nurses what was going on they were told I was in too much pain still to come back to the ward. My husband told me he’d challenged this on the basis he’d been told I’d had a nerve block so could not be in pain! He asked directly. Has anyone actually communicated with the theatre team.? The nurse admitted not, rectified this and rang down. He was told I was feeling sick.

What was actually happening was that, having surfaced from darkest anaesthesia, I was struggling to convey that I was feeling in great need to see out of windows and feel some fresh air (quite reasonable under the circs.) The nurse kept telling me she could not take me outside (as if !).  I made the mistake of saying I felt sick (again quite reasonable after anaesthetic!).We’ll give you a drug for that. No. No more drugs just fresh air!! Please… Finally they gave in and took me back to the ward where I spent a blissful pain free sleep-filled night aware only of my wonderful nurse who appeared reassuringly regularly at the doorway of my curtained room looking at me and entering data on his tablet. The machines worked (no incessant alarms for faulty drips, and blood pressure kit quietly doing it’s job) I felt as if I was on a cloud. I felt safe. Thank you nurse, so very much.

The following day the anaesthetist came to the ward. She looked at me sheepishly as she came towards me. I smiled and apologised for having barked at her the night before. She beamed brightly and flung her arms around me. ‘I was so angry when I read your notes and the amount of delay you’d had. I am so sorry’. She said. I thanked her and thought of all the other people on the ward who must be suffering the same agonies for the want of better organisation, communication and use of resources.

The first proper discussion I had about discharge with any nurse was on the day (1 and ½ hours before I left). At midday I decided to tell a nurse that my husband could come at 6pm. When she said I may have to go into the day room if they needed my bed, I asked him to come at 1.30pm instead. Having previously been told someone would help me get my things together, no-one seemed to be available. I had clearly been de-prioritised (not that, except for the night of surgery had I ever felt prioritised!). It struck me that maybe this was all part of an agenda to prevent patients outstaying their welcome. No real risk of that for most people I would have thought. Better though to treat them so well their readiness to move on is brought forward.

I got myself up. I was in pain. I really didn’t want to but had to buzz again for pain relief, so took my crutches and walked to the nurses’ station. I was ignored by the one nurse there, which made me feel even more wobbly! I asked if I could have some pain relief to help with my leaving the hospital. The nurse came out from behind her pillar. She had finished her paperwork and was off to her next task. She incidentally turned and said something to the effect,

‘Oh you’re the one with the other lady (who’d come in opposite me the night before with a fractured femur I think). I’ll get your nurse.’

This did not happen. Returning to my bed, I was followed by a man who was clearly steaming, having had an exchange with a nurse about his wife,

‘I won’t keep nagging you ‘cos it makes things worse but you said she could have morphine…. so when is it coming?’

‘It’s not just me then.’ I thought!

My husband arrived. He went to pick up the drugs I needed to take home. Whoever he spoke to had no awareness of any drugs but said they would find my nurse. My husband was dismayed at the approach. Where was the log/database? Where was the system. Were where ‘drugs awaiting patient pick up’ kept? Why didn’t anyone know anything?

A familiar nurse came to us. So sorry she said, they’ve taken you off the list for pain relief so I’ll go and get you some now. Better late than never? She brought the drugs bag we’d been waiting for with her. Another nurse appeared and we said our goodbyes. I asked them both to pass on my thanks to the team.

I had only begun to use my crutches properly the day before, so the walk to the car was a challenge. I nearly made it but then realised I was flagging and in a lot of pain. By great good luck someone was taking a patient to their car in a wheel chair and we asked to borrow it. Phew! Perhaps I should have used one from the outset.

Now just a quick note on the lady who came in the night before with a fractured femur I think. This lady told me she was 81 and was obviously in great pain all through the night. We were alone in this ward together. I asked her if she had the buzzer for calling the nurse. She answered that it was out of her reach. I noticed she had been left with her head balanced on the corner of her pillow with a sick dish under her chin. She held herself in that position for what seemed like hours, all the while flinching, shaking and shivering and moaning in pain. I asked her if she’d like me to buzz on her behalf (although I did this reluctantly because, by this time, I really thought this might work against her, such was my reputation for what probably had been deemed my overuse!) She thanked me and said yes please. I did so.

A nurse came in the fullness of time and spoke to her rather patronisingly in language littered with ‘sweathearts’ and ‘darlings’ and then disappeared again for ages. It sounded caring but actually what this lady needed was someone with her. Her drip monitor spent more time screaming it’s ‘I’m not working’ alarm than it did doing it’s job. Various staff came and pressed buttons muttering things like ‘it needs flushing really’ and walking away, in the full knowledge it would start it’s alarm again within 5 minutes or so. I could not believe the lack of concern shown for the function or not of the apparatus itself, the patient’s physical well being and anxiety levels, let alone other people in the ward!!!  Extraordinary.

On a final note relating to communication. Since my homecoming, my husband has told me that the surgeon had told him that the operation had gone well, that the bones had shown no sign of osteoporosis, that I could go home anytime and that the high levels of pain I had experienced during the 38 hour wait had been due to a huge blood clot that had formed in the waiting period. Post op., when I ‘d been visited briefly by a consultant on the ward, he’d simply said ‘perfect, that’s perfect, good’. He’d seemed concerned only with his performance. He told me nothing of the above. Was I supposed to have asked for more? Probably. I doubt very much if any of the nursing staff knew either, so extremely busy they were with fire fighting. Who knows?

Incidentally, I have just met someone in outpatients who told me that she’d waited 4 days for her broken hip to be operated on in this hospital! Enough.

So that’s it really. Biq questions. If through the obvious lack of effective leadership and properly systematised management of resources, practices and data, all staff and patients are all now completely dependant on good relationships for good communication, accurate assessment and good practice, how is it that time spent with patients is soooo…… de-prioritised and subsumed by task orientated systems and values?AND how is it that a patient’s needs are determined not by their personal reality but by the conditions/risk levels of the other patients who happen to be in the system at that time?

Our politicised need to continually demonstrate improved clinical outcomes appears to have led us to over-focus on those factors and practices that are perceived as measurable. We have been drawn to those interventions that are technical and pharmaceutical over therapeutic because the former can be more easily quantified, recorded and analysed. This has resulted in nurse practitioners core values becoming stripped of personal/relational qualities. The time has come to re-evaluate the benefits of the therapeutic relationship in clinical and managerial outcomes.

In my recent experience, I realise that, although I now have a wonderful new knee, I also needed appropriate, reliable, actively caring attention to ME while I managed physical and psychological trauma. Diazepam was helpful but did not alleviate what were probably symptoms of shock as well as pain. That nurse’s consistent, reliable, visible attention after surgery was invaluable. A good chat with another ‘old-style’ nurse, her offering to help me when she spotted I needed help washing (I didn’t have to pressurise anyone for help), being actively listened to and being warmly hugged by another nurse and the anaesthetist made a huge difference to my approach to my own situation and undoubtedly therefore my overall ‘outcome’:  a speedy, possibly cheaper, healthy, recovery.

We all have a serious problem here. Nurse what nurse? Patient what patient? I remember a wonderful sketch from what seems long ago (20 years?). John Cleese (I think) was a consultant leading a team of staff, dignitaries, stakeholders and journalists around a new, gleaming, high-tech ward telling everyone how wonderful it was etc., etc. One small journalist piped up from the back of the line of people and said “ When does it open to the public?’ The manager said  ‘Oh no, we don’t want any actual people in here. It’d be a frightful waste of resources ….get messed up in no time at all!!

Nothing’s changed then. In fact according to some experienced nurses, it’s much worse! They long for the days when there was a practitioner leader, everyone knew what was what and the best outcomes depended on valuing and supporting the nurse/patient relationship.

So what is stopping the NHS investing in and promoting the value of the healthy, mutually respectful, responsive nurse/patient relationship?

We seem to have invested in scientism and managerialism over empiricism, financial and material assets over human currencies. We need to look at how capitalism and market forces affect our attitudes and how we design our caring organisations. I notice on the Circle (commercially/John Lewis principles driven healthcare provider) website that they refer to all their staff as ‘clinicians’. From ‘clinical’, the definition of which is: dispassionate, analytic, antiseptic, cold, detached, disinterested, emotionless, impersonal, objective, scientific, unemotional (www.thesaurus.com)! Speaks volumes.

Who is doing the difficult bit, the therapeutic bit, the daring to care and demonstrate compassion. Or is it true that we don’t need this anymore? That if we increase efficiency, bleed the life out of every pound, turn a blind eye to tears and fears, hustle and bustle our way through our daily lives, we’ll all be happier, healthier? No, of course it’s not. All we’ve got to do is face up and accept that without formally recognizing the true value of our human currencies as being fundamental to the whole, we are missing a huge (and free!) trick.

So if the decision was to be made to make the nurse/patient relationship KEY to the success of caring healthcare organisations/providers, not only on the basis of tons of anecdotal and empirical evidence, but because it’s an infinitely sensible thing to do, what would need to be addressed?

Leadership and Management Style

According to my experience the unit/ward in this hospital appeared to suffer from a lack of cohesive spirit, evidenced by inconsistent delivery and practices. This suggests poor team management.  I also noticed a tendency to partisan behaviour and either ‘close buddy’ relationships or a ‘best to work alone’ approach.

I was told by a number of nurses that they were short staffed. On one occasion 2 nurses for 26 patients. The negative implications of this to clinical outcomes and morale are obvious.

The general sense of being in a pressured, task orientated rather than a caring environment, led to patients feeling neglected and frustrated, along with their visitors and all staff feeling disempowered and undervalued.

Waste

Non-standardized data collection and recording methods means that what there is, is not reliable and sometimes actually depends on patients’ memory: black plastic files with lots of different coloured bits of paper in them, left on lockers, lost.  Electronic tablets and probably communal white board scribbles.

It appears, in this hospital, there are too many hand over’s. So, without reliable coordinated records, too much time is spent handing over, leading to duplication. Less time available to improve relationships with patients to ensure good communication!

The current ‘buzz the nurse’ system in this unit is clearly leading to a vast waste of both nurse (finish what you’re doing, prioritise who to respond to next, walk to them, find out what they need, walk away to get it, walk back with it, feel pressurized, feel inadequate) and patient time ( wait, buzz, wait, suffer, feel bad, feel guilty).  It is also open to abuse by staff (selective response) and patient alike (bring me some champagne). Undermines mutual trust and respect. Is there time or inclination to make accurate records?

Values and attitudes

An over dependency on patient choice, ‘patient led’, ‘patient as a consumer’ thinking: ‘ Here’s the information, it’s your choice’, ‘you decide what you want’ ‘ ‘you call us’ etc. (despite the infra structure not actually being there to provide it for example here: toast, dedicated nursing and good pain management). The patient is nearly always vulnerable through their injury and circumstance (physical pain, psychological distress, out of their comfort zone and fearful) and not a medical expert.  They need help to make the best decisions. They need a partnership with someone they can trust and rely on, clinically and emotionally. Not giving them that can only undermine all objectives and outcomes.

Perhaps there is also a recruitment problem. If our training of nurses and managers doesn’t include or demonstrate (hard curriculum stuff not lip service) the value of relational, self-giving skills or behaviour and errs on the side of ethics and rights, responsibility and accountability over personal skills and values, it follows that they are unlikely to figure highly in the recruitment criteria/process. Are the best people being recruited?

Suggestions

To improve morale, relationships (nurse/patient and nurse/nurse) and reduce waste:

  • Re-write the website for NHS nursing to reflect new values and beliefs:

That nurses and good nursing (care and compassion as well as clinical excellence and integrity)  are THE most important factor in every patient’s well being and clinical outcome. No matter how brilliant the clinical intervention it’s how each patient responds to it and how that response is managed that makes the real difference to any outcome.

Nurses are not an incidental support cog in the ‘greater machine/hierarchy’. Nor are they simply the gophers of the ward at the beck and call of patients and managers alike. The nurse/patient relationship needs to be seen as the bedrock for the management and success of all interventions. And that includes everything in the care plan from nutrition to bedpan, surgery to rehab. The dedicated nurse is the conduit for all successful outcomes.

  • Address and correct nurse/patient ratios and shifts to support, strengthen and sustain dedicated nurse/patient relationships
  • Change management and leadership style to cohesive whole team (including cleaners, chefs and consultants) patient-facing working over command and control.
  • Provide consistent, high quality, personal support, mentoring and coaching for each nurse.
  • Offer involvement to each patient in creating their own care plan according to their need.
  • Introduce a form of ‘joining the ward team’ induction as each patient arrives: A ‘contract’ based on partnership working (patient/nurse), mutual respect, honesty etc. with basic expectations and ground rules, how the ward functions etc., mealtimes, pain management, what’s available. Indicates commitment to a mutually respectful relationship.

Patient to take the responsibility for communicating needs and wants, nurse to consistently manage, listen, advise, direct and deliver, both parties being supported by infra-structure fit for purpose/ needs (nurse and patient) determined.

  • Obtain patient feedback on leaving. Provide copy of care plan.
  • Introduce new, but inexpensive, well-programmed personal technology. Apps?,

for example:

Patient: Hand held Nurse/Patient personalized communication system  Favourites (bedpan, pain relief, chat, champagne) Limited Texting?

Nurse: Personal technology for receiving and returning calls under Patient Favourites (as above) texts.  Also used for all log entries and accessible to all practitioners via a general database, for reference and to record any interaction with any patient.

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