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Limits to Nursing?

December 5, 2014

“I couldn’t believe it when I first came here” said an overseas student to me recently “and they told me the nurses had to wash the patients. In my country, that’s the family’s job”. I remembered those words at the weekend, as I read Nicci Gerrard’s heartbreaking description of her late father’s last stay in hospital. For anyone who hasn’t read it, Gerrard’s father had an existing dementia diagnosis – but despite that, when he was admitted to hospital with infected leg-ulcers, he was ‘strong, mobile, healthy, continent, reasonably articulate, cheerful and able to lead a fulfilled daily life’. Five weeks later, he emerged – ‘skeletal, incontinent, immobile, incoherent, bewildered, quite lost’ and unable to do anything for himself.

Gerrard is careful not to blame the alarming alteration in her father’s condition on those caring for him, almost all of whom ‘treated him with respect and genuine kindness’. Instead, her anger (or sorrow) is turned on the hospital’s limited visiting hours, exacerbated by an outbreak of norovirus, which restricted access still further. ‘I am certain’ she writes ‘that if he had not lain in hospital for five weeks, with no one who loved him to take care of him, he would not have descended into such a state of incapacity’.

The article ends with a heartfelt plea for relatives of confused patients in hospital to be granted unrestricted visiting. ‘It should’ Gerrard writes ‘not be a duty but an inalienable right, a matter of moral decency and simple human kindness’. Personally, I couldn’t agree more: anyone who has ever witnessed a confused and upset patient lighting up with joy at the sight of familiar faces coming through the door, will be well aware of the instant comfort and relief that the arrival of loved-ones brings. It’s like a blood transfusion for the soul.

Constant presence isn’t practical for everyone of course. Some elderly people have no close family, or none nearby. Grown-up children have work commitments. And exhausted partners may welcome hospital admission as their chance to get some well-earned rest and relaxation. Even so, a far better solution is surely to keep confused patients out of hospital altogether. Common sense tells you that abrupt removal from normal routines and environments will just add to the problems for someone who’s already prone to getting muddled as to time and place.

But what if admission is unavoidable? To my mind, Gerrard is way too forgiving of staff who looked after her father. Among the things they – for unspecified reasons – ‘couldn’t do’ for him were ‘brush his teeth…shave him and comb his hair’. And while Gerrard seems to think these failures are understandable, needless to say – I don’t. Why couldn’t staff do them? They’re the foundations of good nursing for God’s sake! If we can’t even get these right, what hope is there for everything else?

Because there is plenty else. Also on the list of things staff couldn’t do for Mr Gerrard were ‘read poetry to him, do crosswords, play chess, talk to him’ – all those personal pleasures, in other words, that made him the distinctive human being his family knew and loved. And while I can’t accept that staff were unable to attend to universal hygiene needs, I can well believe that they had little time to devote to those person-specific activities that turn us from just another face into precious and valued individuals.

Mr Gerrard’s experience, as his daughter so eloquently puts it, was ‘as if all the ropes that tied him were cut…and slowly he drifted from us’. But if the services we are providing are not allowing people to maintain their unique identities – are robbing them of their personalities in effect – then what is the meaning of ‘person-centred care’?

A recent (October 2014) publication from the Health Foundation says the concept of ‘person-centred care’ is ‘still an emerging and evolving area’ with no firmly-agreed definition. In talking about it however, their clear focus is on issues of care provision: building relationships, working in partnership, identifying what’s important to the service-user, professionals as enablers rather than directors and so on. But what we learn from Nicci Gerrard is that for care to be truly ‘person-centred’, even this is nowhere near enough. The question is: can – should – nurses be expected to provide care to the level Gerrard suggests is necessary? Is ‘reading poetry’ a nursing activity?

There’s no easy answer to this. If reading poetry (or similar) is a nursing activity, then we need to ask why (in hospital at least) is it not just almost never done, but rarely even considered? And if it’s not a nursing activity, are we then saying that the gentle, compassionate labour of holding together a fragile personality is beyond nursing’s remit? Are we admitting there are limits to nursing?

My personal feeling is ‘no’ – there are no limits to what nursing can achieve in the right circumstances. But we also have to be realistic: in the current climate, we need all the help and support we can get. So why not use the debate about visiting rights as an opportunity to re-negotiate our contract with the public? What’s the key? The Daily Mail of course! Get them to persuade their always-ready-to-be-righteously-indignant readership that visiting arrangements in some hospitals are ‘inhumane’. They’ll soon get a bandwagon rolling.

The important thing is for nursing to be proactive here. We need to act as our own insurance against the DM taking the opposite view: that families are being ‘obliged’ to care for relatives because staff think it’s ‘beneath them’. What we don’t need are headlines like ‘NHS meltdown! Hospital visitors told: look after Granny yourselves!’, plus interviews with disgruntled relatives who claim that ‘heartless nurses told me I HAD to take time off work to stay with sick mum – pardon me, but isn’t that their job?’ and yet more mutterings about the failings of degree nurses. What we do need is a sensible solution to this. Brothers and sisters: let’s do it!

  1. RGN007 permalink

    Thinking of my own experience as an SEN on a “lung” ward in 1995. I was helping out from my own ward “the heart ward”. I felt overwhelmed. Even then there were insufficient staff and although the “sister” spent a couple of hours trying to do the drugs round and it was also my job to do the “obs” on around 26 patients, there was still a number of patients who needed supported washing etc. I had a choice to make. I either did them all superficially or spent concentrated time doing 2 or 3 intensively. Working on my own I spent what seemed like half the morning on one man. It was very time consuming to do what he needed as he stated he had not been thoroughly helped for several days. As I left to go home he whispered “Thank-you”. I guess the others thought I was neglectful to them as it was an impossible task to attend to everyone.

    I understand the staffing has become worse. There are bad nurses who do not care but I do not believe they are all that common. The problem is accusing good nurses of lacking in compassion when those employing and managing the nurses are lacking in compassion for the workforce who are now falling on their knees under the strain.

    I no longer work in a hospital, but the same applies. It is about time “the powers that be” learn to treat the nurses and clinicians with compassion so that compassion can be passed on to those they care for.

    For far too long nurses are being told to do “more”, work smarter, but there is only one wheel left on the wagon and the passengers (the patients) are at risk of falling off and the wagon may be irreparable.

    I didn’t complain when my own mother was dying in our local hospital. It was painful to see her amidst a packed ward of dependent patients with so little staff. How could I complain about the nurse who was already on a 15 hour double shift, one with no time to even get lunch?

    Nursing has been cut back to bare bones, and like the old bones of the poor horses in Dickens’ times, being whipped until they fell dead on the street. Nurses are being whipped as dispassionate when really the problem is too much to do in insufficient time.

  2. Hi RGN007. Thanks for commenting. I do agree with you that it’s very frustrating to hear nurses accused of lacking compassion when what they really lack is time and enough people to provide the high standard of care that everyone who comes into nursing wants to be a part of. The trouble is that, for a number of reasons including poor workforce planning decisions in years gone by, more staff are not going to be forthcoming – or at least, not any time soon. The question is: what can we do about it?
    There are a number of ways to answer that – and I’ve examined most of them in other blogs. What I’m asking here is: should nursing look at admitting that we can’t do it all, retreating from certain tasks and handing them over to relatives? Or is this the thin end of the wedge, which would soon lead to demands for relatives to assume responsibility for ‘core’ nursing activities like patient hygiene? As I indicated in the quote at the top of the piece, this is commonplace in other cultures, so why not ours?
    The former would require a huge cultural shift throughout society. Would we, for example, need to recognise the special status of dementia by enshrining in law the right to time off work for employees caring for confused relatives who had been admitted to hospital? And as I also indicated, nurses would need a willingness to counter the accusations of’ laziness’ and ‘over-education’ that such a move would inevitably invite from some quarters. We would need to utilize proper evidence too, if we want to show that outcomes are better when relatives spend more time on the ward.
    In spite of all this, I think it may well be the case that in years to come, we will look back at the situation we have today, where distressed elderly people are allowed to spend only an hour or two a day at most with the people they most want to be with, and wonder how on earth we could have been so heartless.

  3. Kelly permalink

    Dear Grumbling Appendix,
    I had my eyes opened to the plight of restricted visiting through the power of twitter as a student nurse and I have long been a supporter.
    I am now a qualified staff nurse and fortunately the trust which I work for has reasonably good visiting hours 12-8 (officially) but people are always asked to leave at meals times. This is where my passion kicks in….
    In society and culturally we recognise the importance of eating and food as a time to reconnect with family and friends; a social activity that binds us and yet as soon as we enter a NHS hospital this value and belief system is stripped.
    Whilst I recognise the implementation was part of protected mealtimes I personally believe it’s time to re-think. People still leave hospital malnourished so the current system is clearly not working. I found plenty of research whilst doing my dissertation on this very subject which proves the benefit of social eating and family interaction.
    Radical I know but perhaps this should be the way forward; or at least judge each patients needs on an individual basis; we are good at using the “buzz” words but not so generous at implementing the individual care…..or at least not during the golden hour of meal times.

  4. Hi Kelly, thanks for commenting. Grumbling Appendix is always up for radical ideas!
    I think I’m right in saying that protected meal times were introduced in the first place because research had suggested that hospital patients eat more when their visitors are not around to distract them. I have no idea whether there has been any evaluation specifically of the effects of protected mealtimes on patient nutrition (perhaps you know the answer to that), but as you say, it plainly isn’t working for everybody, because many people are still leaving hospital in a malnourished state. This is speculation on my part, but perhaps the original research did not differentiate sufficiently between ‘all patients’ and ‘those patient groups that are most likely to be malnourished’ – their needs might be quite different from those of the generality.
    Years ago, I worked on an medicine for the elderly ward that had an enormous day-room. We used to take the patients up there for both mid-day and evening meals (they could stay by their beds if they wanted to, but in practice, few did) and make a social occasion of it. I couldn’t really tell you whether they ate more under this regime, but it did make the day more enjoyable, as well as give it structure. It would be out of the question now of course because large day-rooms (or indeed any day-rooms) are a thing of the past. Eating in isolation, off a tray by your bed, always seems rather sad to me.
    One thing I’m really glad to hear that you are drawing on research to inform your views of what needs to change. This is a tangible benefit of degree nursing. There is so much that needs re-thinking. And don’t forget that the most radical move of all would be for staff to eat with patients!

    • Yes indeed now that would be a can of worms actually eating with the patients, and how sad it is. I have worked in one area that clearly had taken their courage pills when they deemed meal time interaction and engagment with patients to be key to results from care. Why not combine the two? Surely the rationale of ‘it isn’t right’ should be laughed out the water if ever it is used but still here we are. In a culture where it is ok to go and sit with strangers in a public dining room to rush down whatever is readily available with no awareness of the patients you are responsible for or indeed a culture where it is accepted to lock yourself in solitary confinement of a stray office whilst attempting to eat in between a million distractions heightened through sheer human nature dragging you back so you can continue to care for your patients? It is even deemed acceptable by society to risk ones own health and wellbeing by not being able to switch off the responsibility of care thus resulting in no lunch breaks taken a lot of the time. Yet still it is deemed ludicrous to actually have staff eat with patients allowing for therapeutic relationships to form, vast amounts of assessment to be witnessed, minimised risk of any issues with the patients not being assessed and managed, Risk reduction of any detrimental effects to staff and patients alike. So why can’t a simple change in practice be considered let alone implemented when so many potential benefits are clear?

      It appears that unwritten rules and old age routines and practices have allowed for belief to form that this is just how it is. Well it won’t do, it’s not rocket science or a top class confidential secret nor is it acceptable to sit by and do nothing when potentially patient benefits could be achieved with relevant ease.
      We appear to have many of these practices that make little sense when compared to uptodate research/ guidance/policies and the impact these could have if actually acknowledged.

      I just remind myself upon challenging any of these such areas of care (or lack of care) that I can do. There is no doubt in my mind that if I was explaining why a patient had been harmed through poor dietary intake so to speak; i would be expected to outline everything I had done to try to help not which rooms I had sat in away from my patient for key areas of possible assessment etc. I challenge every nurse in the universe to deliver meal times in the individualised patient focused way that all care is encouraged to be currently. Yes shockingly I personally believe the numbers which would report being reprimanded for such unprofessional practice would be outstanding. But hey least your patients will have eaten!

      Rant over!

      Really looking forward to seeing you at our conference too in January,
      yours truly
      Maria Davison
      Proudtonurse – brave enough to deliver

  5. Hi Maria! You can rant as much as you want here! I like ranting!
    As I was writing the last sentence of my reply to Kelly’s comment, I was thinking ‘at least that way we’d be guaranteed the chance to have something to eat’! I personally would be quite happy to dine with patients. It’s an ideal opportunity for staff and patients to be humanised in each others’ eyes, and, as you say, to assess. It’s unfortunate that some parts of the NHS seem to be going full steam ahead in the opposite direction – see this news item for example.
    I did like your observation that ‘if I was explaining why a patient had been harmed through poor dietary intake…I would be expected to outline everything I had done to try to help, not which rooms I had sat in away from my patient for key areas of possible assessment etc’. It made me laugh because it’s so true, and so representative of the absurdities we are up against too often in nursing.
    I look forward to meeting you in January.

  6. RGN007 permalink

    Mmm…a couple of issues by previous comments would create problems. The first, relatives washing patients, or even eating with them would not be acceptable by me. The first suggestion is analogous of tradesmen coming to my home to do work. Even in the age of feminism, many jump to the conclusion, being a woman, I’ll be home for them to drop by. “No”, I say. I tell them I work full time and on the day they want to drop in, I leave the house at 7:20am to get to work and arrive home 7pm that evening.

    I recall the social worker’s conversation with me shortly after my mother’s admission to hospital. My two older sisters frail themselves being considerably older than myself, implying how I would “care” for my mother should she be discharged. It was awful, my mother was there listening. She always had wanted to live with me but our personalities meant it would never have worked. As much as I loved my mother and were close in many ways, I would have found it impossible to have such close bodily contact with my mother that I cannot go into here. Also, I had to explain to the social worker, that hidden behind being the youngest daughter attending the hospital every day, was also a carer of three adult children, two on disability benefit who depended on my holding down a job to provide a roof, pay a mortgage or 4 adults could be rendered homeless.

    Nurses used to not be able to be married and had to “marry” their career like a nun, but in today’s society most nurses have their won families and need to work family friendly hours.

    Regarding to meals with patients. I do think nurses need a break from the space of work. I resent the increasing assumption and acceptability that it is OK to abuse nurses or other health workers by condoning not having a break. I have an unpaid hour in a 10 hour day where I often need to get a nap in my car and regenerate. I vigorously avoid meetings during lunch as it is “my” time to think, wind down, make a phone call to see how my daughter is, get a bit of shopping.

    I think new ways of working are always worth considering but as much as the patient should be at the centre of care whilst nurses are within their employment hours, I feel it is a big mistake in an already feeling burnt out group of care givers to expect them to give what little time they have left to also care for themselves and any additional time outside contracted hours should be in emergency short term situations, not a long term solution to managers putting as little resources as possible into a system that is increasingly imposing on those already giving more than they have to give.

  7. Hi RGN007! Thanks for coming back at me – debate is great! Also thanks for sharing your personal experiences.
    Responding to your comments about nurses eating with patients, my thinking was definitely not that nurses should sacrifice precious time away from the demands of patients and the wards. It was more that normal social interaction with patients over a meal or a cup of tea could be recognised as part of the process of nursing, and be mutually beneficial. It has the potential to bring home to us more clearly that rather than ‘staff’ and ‘patients’, we are all people. At least, we all have to eat and drink! Official breaks would still be taken at other times.
    On the subject of families washing patients – I could take you to wards where this already happens quite a lot, but the important thing is that it is what the patient and relatives want, is agreed in advance with the staff, and does not impact on acknowledged nursing activities such as pressure area assessment – plus no one thinks any the less of families who can’t or don’t want to do it. As I said in the original piece, what we need to avoid at all costs is a situation where families feel ‘obliged’ to carry out certain tasks, or to stay all day. To carry these ideas forward, nurses to own them: to highlight the benefits, but also be clear that it’s a choice, and one not everyone can make. To avoid difficult situations like your own, perhaps we need to dump ‘person-centred care’, and look more towards ‘family-centred care’.

  8. Basket Press permalink

    To add some views on eating with patients:

    I worked for over a decade on adolescent psychiatric in-patient units (so quite a different area from the start of this discussion) and eating with the young people was part of the culture, in order to “normalise” meal times as we had many people with eating disorders, a number from chaotic backgrounds and the like.

    There were many advantages to this, as setting breakfast and lunch tables with a couple of the young people, then clearing up after, gave more opportunities for “normal” interactions and allowed working relationships to be enhanced.

    Even better for this was cooking the evening meal with a couple of the young people (we were only allowed to do this on one ward), which went further towards making it a “normal” experience, allowing the young people to practice life skills, and allowing more time for relationships to build.

    Staff breaks were still taken at other times.

  9. Hi Basket Press – thanks for bringing a different angle to the debate! Goes to show how much of what we think can’t be changed is actually just ‘culture’.
    I have always thought that a lot of complaints could be forestalled or avoided altogether if nurses spent more time being ‘normal’ with patients. Of course it’s not the answer to everything – there are still staff shortages, unrealistic workloads, clinical errors and more – but if nurses give patients and families the opportunity to like and respect them as people, those same patients and families are more likely to be understanding and cut the nurses some slack at times when times get tough.
    The original debate about visiting should, I think, be seen in this light: not about nurses trying to hand over care to someone else (because they ‘can’t be bothered’ or whatever), but rather, about giving all parties the chance to know and understand each others’ situation a little better. It should then be easier for everyone to work together to do the right thing for patients.

  10. RGN007 permalink

    Hi all, interesting debate. I do however sometimes like to be “Devil’s Advocate”. I am also under pressure in my present job to not take my lunch break because I have a car to go to do my own thing, and sadly, the health centre was built with nowhere for other staff to socialise and eat away from the reception and working desks.

    I would think in an ideal world we could strive for an “admission care plan” where families can confidentially write their circumstances should they so choose, rather than being confronted in front of their loved one to look after them in hospital or at home. Although I have a degree myself, I don’t think anyone needs to have done a degree to come up with innovative ideas. I am an advocate for nursing to not have gone down the degree route. I think it was a big mistake. I think we, as a society, should recognise more diverse forms of intelligence rather than just relying on academic certification.

    I do get the point about sharing meals, especially in the adolescent centre afore mentioned. Perhaps patients recovering from clinical and medical interventions, could have the choice to have their meals in hospital restaurant?
    I think this does happen in some places these days, but not sure how it works if a nurse needing a break is joined by the patients!

  11. Hi RGN 007. I’m sorry to hear about your problems with taking your break. If the Health Centre doesn’t have a staff room or anywhere for you to have a bit of r&r, I wonder if you’d be within your rights to go to a cafe, and put it on expenses! Does your union have a view?
    I do think nurses need degrees – I cannot see how training in critical thinking is an impediment to good practice – but I certainly don’t believe that people with degrees have the monopoly on innovative ideas; you are of course right to say that good ideas can come from anyone. However…if you’ll forgive me, I don’t really have the stomach for another round of the degree/not degree debate just now. I’ve already said everything I ever want to say on this subject ad nauseam on the blog and on Twitter, and I’ve no desire to start repeating myself. If others want to contribute their views, feel free – but count me out…Sorry.

  12. The Millers Tale permalink

    We need to re-label ‘basic care’ as ‘fundamental care’. These staff who do not wash or feed patients properly or carefully- have they not heard of Maslow?

  13. Hi Millers Tale – thanks for commenting. I think I may have missed your comment when you originally posted it, for which I apologise. Washing and feeding the patients in your care is of course a non-negotiable aspect of nursing – there should never be any excuse for neglect.In this piece, however, the focus is firmly on those strata at the pinnacle of Maslow’s pyramid, namely love/belonging, esteem and, most importantly, self-actualisation.
    Are there limits to what nurses, hard-pressed enough in trying to fulfil the ‘fundamental care’ everyone has the right to expect, can achieve in these areas? Is it realistic to expect nurses to spend time reading to patients, for example? If it is realistic, then we are going to need A LOT more nurses. But if it’s not realistic – then whose job is it to ensure that personalities and abilities are maintained and given the strength to survive a spell in the challenging environment of the hospital? If it’s not realistic, then what is nursing? A more visible family presence could be the missing link here – not to do the nurses’ work for them, but to support vulnerable patients through what may be a frightening and bewildering experience.

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