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Editor’s blog Thursday 27 August 2009: The basics of nursing

The new report from the Patients Association, Patients, not numbers … people, not statistics has cornered the headlines today. Cataloguing 16 incidents of appalling patient care reported to them (only one of which is anonymised), the report focuses repeatedly on incidents of bad basic nursing and ancillary care.

Using other data from the Information Centre, the report suggests that 2% of NHS hospital inpatients rate their care as ‘poor’: a figure unchanged between the start of data collection in 2002 and the latest set for 2008.

You should read the report. It is an assembly of stories, calmly written and obviously considered. One of the most cutting comments refers to “a lack of kindness, care, consideration and friendliness at both Barnet and Edgware hospitals, all the attributes a nurse should have if they join that very noble profession”. Inevitably, note recording and handovers between consultants and nurses as well as departments feature prominently.

Nursing getting it in the neck?
So is it open season on nursing and ancillary staff? By no means. The accounts mostly describe experiences of good patient care on different wards within the same trust, or in other trusts. (Interestingly, care given in hospices is rated consistently highly.)

More broadly: how big a problem are ‘bad’ nursing or low nurse-patient ratios? The report, being based on patient stories, cannot quantify this. It restricts itself to the 2% figure rating their care as bad.

It will therefore be easy to dismiss the report as a ‘greatest hits of anecdote’. The dictum that ‘the plural of anecdote is not evidence’ may even get wheeled out – and as ever, will score a point in the argument without understanding the problems more or making things better.

Perhaps it would be best to treat this report as a symptom. It attempts a diagnosis, but sadly ignores the issue of culture.

Great Scott
A few years ago, I worked alongside Helen Scott, a very experienced former NHS nurse who had gone on to edit the British Journal of Nursing.

Helen is a great character, though initially I found her catchphrase “well of course, it’s the death of nursing!” a tad offputting. Longer acquaintance, and repeated NHS scandals, revealed to me that Helen’s parents missed out on the opportunity to name her Cassandra.

Helen agreed that the move to turn nursing into a quasi-academic discipline with university tuition (which back in the day attracted tuition fees and grants) had been problematic for the former entrants to the profession who were by no means academically-inclined, but would be good at the interpersonal communication and ‘feeding and bum-wiping basics’ (Helen’s phrase) that are fundamental to good nursing care.

Helen also taught me how you could recognise a good nurse from the pre-alcohol-rub days: dry skin on both hands, from constant washing with soap and water.

While Helen was quite clear that there was a clear need in modern medicine for more academically-inclined nurses to handle the technical aspects of care, she despaired (and giggled) about some of the articles submitted to BJN about the ‘self-actualisation of the nurse learning experience’ and suchlike. I observed that it seemed that aspects of nursing education were as inward-looking and rectum-gazing as the postmodernist critical theories I’d been forced to graze as part of my humanities degree.

The sensible Dr Grumble posted something similar in 2006.

Will there be traction? Speaking on the BBC Radio 4 Today programme, CNO Chris Beasley agreed that a "small but very significant proportion" of nurses were to blame, and suggested the need for changes to make it easier for both patients and their friends and relatives – and, crucially, care professionals, to complain.

What might shift the culture?
It is important to be clear that the number of nursing staff involved in very poor patient care of the kind discussed is, as the report has suggested, small.

However, such few people as are the worst offenders are apparently surviving in the system at an consistent level year-on-year. It is clear that they do generate complaints. The efficacy of the complaint procedure in changing behaviours is, at best, unclear from the trusts’ responses at the end of the document.

What might work? There is evidence nationally and internationally that appropriate ratios of nursing staff to patients are a critical factor – Alan Maynard has even given it his benediction. This is nothing more than stating the obvious, in truth.

But what shifts the culture in such a way that this kind of bad and negligent care becomes unacceptable? Peer pressure should and may be effective, but even despite NHS resources doubling since the start of the figures cited in the report in 2002, the 2% figure of reports of bad care remains depressingly constant.

More to the point, not everybody complains. Some do not complain for highly-understandable reasons of fearing that their care may be compromised if they create trouble for staff. Ben Page of MORI observed at the Innovation Expo in July that older people in poorer northern communities complain the least.

There is a means for effective complaints by staff – the NPSA patient safety incident reporting system. This can be really useful, but may not be as central to board meetings as it might.

However, the procedure for patient complaints is slow-moving, and being locally-based, may encourage defensive attitudes.

Sticking in a new bureaucracy to solve this feels problematic. But one easy-to-use option would be to use something along the lines of Patient Opinion as a registration conduit for complaints – not a duplication of extant systems; just a logging mechanism, each with a case number. The idea would be to ‘weigh’ the complaints by number, and feed the information back to trusts boards and executives on a weekly basis, who would have to feed it back internally to ward level.

This would require very little management time; encourage trusts to sort the problems out themselves; and cost very little in relative termds to the potential benefit.

One day, it could be me in that hospital bed. Or you.