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What is the problem?

Concerns about the hospital care of vulnerable people has been an issue for decades. In 1969, the report of the inquiry into allegations of ill- treatment of patients and other irregularities at the Ely hospital, Cardiff highlighted serious failings in NHS care. More recently Graham Pink[1], a nurse working at Stepping Hill hospital Stockport, lost his job in 1990 for speaking to the media about the care that was being delivered in the hospital where he worked. Nurse Margaret Haywood has faced similar difficulties this year for whistle blowing to protect patients. She was initially struck off the register for breaching patient confidentiality and has now, following appeal, been re-instated on the nurse register[2].

In 1997 BBC Panorama[3] brought the issue to the public’s attention again and since then there have been numerous campaigns, Government policies and initiatives put in place, but little appears to change.

A Dignified Revolution receives numerous emails from members of the public and professionals, both working and retired, who give their accounts and their own views on why there are such problems with hospital care. They include concerns about:

  • the lack of communication and involvement in treatment and care
  • staff attitudes and behaviour towards older people
  • nurse education
  • the NHS environment
  • accountability and regulation

Attitudes,  behaviour and ageism

The concerns that the general public have about attitudes and behaviour are backed up in the literature. In 2007 The Health Service Journal[4] reported that many NHS staff are prone to ageism and reluctant to work with the elderly. The article reported that derogatory terms such as “gomer” and “crumble” are common terms used to describe the elderly, and a surgeon was quoted in the article as asking ward staff “how do any of you stand working with all these old people?”. Delegates attending courses that A Dignified Revolution runs also report often hearing their colleagues using such derogatory terms.

More recently in a review of the treatment of older people[5] researchers found that elderly stroke patients received less adequate care than younger counterparts and the over-65s lose out on mental health services. A poll found almost half of doctors who cared for older people believed the NHS was "institutionally ageist".

Those clinical staff, of which there are many,  who strive to provide compassionate care, can face significant barriers from their managers. One nurse emailed to say that she had tried to voice her concerns about poor standards of care to no avail.  The response that she received from her manager was:

your problem is – your standards are too high. Patients should be fed, watered and medicated - anything else is a luxury

Whilst it is interesting to view attitudes and behaviour from an NHS point of view many discussions in which A Dignified Revolution is involved draw attention to the fact that attitudes and behaviour towards older people are not specific to the NHS, they are widespread across society.  An example of this can be found in Nigel Slater's book ‘Eating for England’[6]. He comments that:

“feeding the elderly has non of the charisma of feeding children. There is no Jamie Oliver to improve the daily diet of old people. What celebrity chef wants to fill his cookbook with pictures of wrinkly people with no teeth? A child with a blob of custard on her chin looks cute; an old person with a blob of custard on hers simply looks demented”.

Hospital environment

Many of the issues that are cited as barriers to providing dignified care are:

  • mixed sex wards
  • lack of private facilities in which to have confidential conversations
  • lack of privacy for personal needs
  • staffing levels
  • lack of resources
  • pressure to meet targets

Whilst A Dignified Revolution accepts that the above issues can impact significantly it is also of the view that common courtesies i.e. a warm welcome, a reassuring smile, a gentle touch – a little empathy, takes little time and costs nothing.

Nurse education

Nurse education is often raised in discussions about dignified care. Nurse education has also recently been the focus of media attention[7] with the recent announcement that nurses in England are to be trained to degree level. All student nurses in Wales and Scotland already study to degree level.

Issues that are frequently raised in correspondence received by A Dignified Revolution include:

  • degree level nursing
  • nursing as a vocation rather than a profession
  • nurses being ‘too posh to wash’
  • lack of mentoring and nurse leadership
  • lack of training related to care of the elderly
  • recruitment of the right sort of person for nursing
  • nurses not perceiving that basic nursing care is their role

This last point is featured in an article in a recent Nursing Times[8] journal which reported that student nurses supernumerary status affects the way that they think about nursing.   Research findings showed that:

“there is an increased division of labour between registered and non-registered staff, so student nurses observe Health Care Assistants  performing bedside care and Registered Nurses undertaking more technical tasks. This leads students to reject bedside care as part of nursing. Our data suggests that being associated with such work in their supervised practice may lead to students feeling stigmatised. This can then leave them feeling unprepared for their future role as trained nurses who do not have time to perform such tasks. There is clearly a mismatch between trained and student nurses’ views of what nursing is and what student nurses need to learn”.

Supernumerary status also results in the “priming” effect.  The way you think, affects the way you behave.  If you think supernumery, then you behave as a supernumery.

Nurse education was raised in an article in the recent edition of the New Statesman. Concerns were raised that  “in order for nursing to be accepted as a degree – level discipline, the essentials of the job will be submerged in spurious academic theory”. The author made the point that “bedside manner has two sides to it: the bedside manner, which involves reassuring, cosseting and encouraging patients, and the technological side of drugs, surgery, kidney machines and so on”…….. doctors focus successfully on the technological side but most of us still value the ‘caring’ functions of nursing. Indeed while doctors are regarded with growing suspicion, nurses retain high levels of public esteem and trust. We should value their distinctive qualities, not turn them into people who have the same skill set as doctors but at a lower level”.

The author of the article finishes by pondering about what would happen to the driving test if academics ever got their hands on it. “The history of the motor care, the physics of the internal combustion engine, the chemistry of petrol, the psychology of pedestrian movement- all these and much else would be deemed essential for safe and competent driving and add upi to a three year degree course. At least the roads would be less congested. I cannot think of comparable benefits for nursing”

Accountability and regulation

There are concerns that there is a lack of accountability within the NHS. There is a view that there is a “no blame culture” where no-one is held to account. Also that the regulatory systems are not effective, particularly where individuals have reported nurses and medical staff and received the response is that there is no case to answer, and that they have no right to appeal against the decision.  A Dignified Revolution has joined the Council for Health Regulatory Excellence (CHRE) stakeholder network so that it can channel this type of concern into the performance review framework for regulatory bodies. Both members of the public and professionals can have a voice by joining the CHRE stakeholder network.  CHRE will cover travel expenses for attending meetings. 

Communication

Good communication between staff, patients and their relatives and carers is crucial if treatment and recovery is to be effective.  A respectful, thoughtful and considerate nurse who takes the time to talk to, and involve an individual in their care is of great importance to older people[9]. It not only enables them to be in control of the situation in which they find themselves, but also helps to maintain their independence and dignity.

Where an older person finds themselves in a vulnerable situation with no relative or carer to speak up for them then independent advocacy services should be available, particularly when subjected to complex processes such as those surrounding continuing healthcare. Sadly, such services are few and far between and vulnerable older people are often encouraged to accept care options that are not preferable to their needs or aspirations.

NB: Whilst the fundamental role of the registered nurse is to act as an advocate for vulnerable people to ensure that they receive safe and appropriate clinical care, independent advocacy is also needed when dealing with decisions about future care needs in the community.

Protection of Vulnerable Adults (POVA)

The Protection of Vulnerable Adults (POVA) is a mechanism designed to protect vulnerable older people from abuse. However, A Dignified Revolution has found that:

  • potential cases of abuse are being routed through clinical governance in some NHS hospitals
  • in some areas there appears to be a lack of POVA training available
  • there appears to be a lack of understanding on the part of some professionals of what constitutes abuse
  • the general public are not aware of POVA and the fact that they can report concerns themselves on behalf of a relative who might be suffering abuse

This applies to hospitals, care homes, domiciliary care and even abuse from a relative. Visit the how we can help you section of the website for more information.

Dignity and Respect are fundamental principles of the Human Rights Act. Maintaining dignity and respect is therefore a requirement of law, rather than an aspiration.

Dignity is everybody’ s business, not just the responsibility of frontline staff. It needs to be embraced and embedded throughout the whole of the organisation from the executive board downwards.

And…………….it is not only patients who need to be treated with dignity and respect, it is also necessary for patients and NHS organisations to respect and value staff in order to afford them their dignity. Sadly, the reported levels of sickness and absence through stress indicate that there is a long way to go before dignity can be successfully achieved for all in the NHS.

 

 

 

 

 


[1] Guardian Newspaper: Yours Sincerely, FG Pink http://www.guardian.co.uk/society/1990/apr/11/guardiansocietysupplement (accessed 16 November 2009)

[2] Royal College of Nurse: Margaret Haywood – court case settled  http://www.rcn.org.uk/newsevents/news/article/uk/margaret_haywood__court_case_settled (accessed 16 November 2009)

[3] BBC News: Policy on Caring for Older People  http://news.bbc.co.uk/1/hi/programmes/panorama/4700599.stm (accessed 16 November 2009)

[4] Health Service Journal (2007) How do you stand working with all these old people? 22 November 2007

[5] NHS to outlaw age discrimination http://latestnews.virginmedia.com/news/uk/2009/10/22/nhs_to_outlaw_age_discrimination  (accessed 16 November 2009)

[6] Slater, N (2007) Eating for England. Harper Perennial

[7] Guardian Newspaper (2009) All new nurses to have degrees by 2013

http://www.guardian.co.uk/society/2009/nov/12/nurses-nursing-qualifications-degrees-nmc-rcn (accessed 16 November 2009)

[8] Nursing Times (2009) How supernumerary status affects the way that student nurses think about nursing

     Wilby, P (2009) Nurses, cricket and anti-Semitism. New Statesman, 23 November 2009 p.8

http://www.nursingtimes.net/nursing-practice-clinical-research/acute-care/how-student-nurses-supernumerary-status-affects-the-way-they-think-about-nursing-a-qualitative-study/5007967.article (accessed 16 November 2009)

[9] Baillie, L (2009) Patient Dignity in an acute hospital setting: a case study. International Journal of Nursing Studies 46 (2009) 23-37