30 July 2008

Starving to death in hospital

Dr Grumble was at a meeting the other day at which he was urged to recognise the problem of malnutrition in his patients. The allegation was that doctors often fail to spot the problem. The recommended solution was loads of supplements and, if necessary, feeding the patients with tubes either poked through their noses into their stomachs or plunged more directly into their stomachs through their abdominal walls. For some reason, like so many things these days, it's doctors that are to blame.

But Dr Grumble has another explanation. He thinks it's the nurses that are to blame. Nurses have become very good at paperwork and very good at doing work (though not the chores) that used to be done by doctors but they have become very bad at basic nursing care. And what could be more important than getting patients to eat and drink? From their voluminous paperwork nurses frequently tell Dr Grumble that patients are not eating enough. Dr Grumble asks why. Often the explanation is that the patient just won't eat. Around the bed of such patients invariably you will find a wonderful collection of expensive nutritional supplements of one sort or another. They cost more than a decent meal. Yet often they are untouched by the patient and more often than not they are just out of the patient's reach. After Dr Grumble has been told this, he will select the most appetizing supplement, usually a pot of yogurt, and pass it to the patient. Not infrequently the patient will snatch the pot from Dr Grumble and consume the contents ravenously. These patients are indeed starving. They are starving not because the hospital food is bad (ours is quite good). They are starving because the nurses don't even ensure the food is within reach of the patient. They certainly don't spend enough time feeding patients unable to feed themseves. Some patients need to be fed like a baby needs to be fed. It needs time. It needs patience. It needs kindness. It needs attention to basic needs. It needs nurses - good old-fashioned nurses. These nurses need to be supervised by senior nurses, proper ward sisters, not managers, who need to have pride in their work and be rewarded. These nurses need to be rewarded for nursing not for becoming quasi doctors. Running a busy ward is a great responsibility. It's not easy. Why is that never recognised?

The solution to hospital starvation lies not in criticising doctors for not appreciating the problem of malnutrition and being reluctant to assault their patients with tubes. Nor are the nurses themselves to blame. We should criticise the rotten systems we have created for training nurses. We used to have vocational nurses, people who had a calling to nurse, who trained in an apprenticeship based around caring for patient. But now we have too-posh-to-wash nurses with degrees who think that basic nursing care is beneath them. We should be spending money on nurses not to become pseudo-doctors or managers but to do, yes, nursing - basic nursing. And instead of those expensive but not always appetising supplements we should spend money on better hospital food and round the clock availability. There was a time when a nurse could rustle up an omelette in the ward kitchen. If this is no longer allowed we need decent alternatives. Who knows? It might even be cost effective.

Far too little attention has been paid to these issues. It was some years ago now that Dr Grumble noticed that those plastic teacher beakers with a spout that were used to water patients had disappeared from the wards. Young doctors have never even seen them. Before then nurses used to feed patients from enamel containers with a spout. All these things have gone and the only substitutes have been the doctors' tubes. Reluctant to resort to these, doctors are now having to do the watering rounds.

British nursing used to be the envy of the world. It's very sad to see the way it has gone.

This post was first published on 20th October 2007. It has been republished now in response to this.


jayann said...

You're right. Meals are just dumped there. Supplements may or may not be supplied to the patient's they're for, if they are, may not be fed to them. Patients are given (if they're very lucky and their need is realised..) drinks with a bent straw *that bends the wrong way for someone lying down* (who can't sit up or is not helped to sit up). Etc.. There are wards where patients who need help are given some and there are some good HCAs who help patients out; but I'm afraid I do think that's rare.

I do though have to say that some hospital doctors probably should know more about what's actually happening on wards. And doctors and nurses should look into why some patients refuse to eat (it seems -- and this fits a case I know well -- that sometimes they are afraid to because they will then need 'the commode' and they have reason to think they won't get any help with that; before I read about that I thought it was more of a protest against maltreatment, which also fit the case).

jayann said...

('patient/s' they're for!)

The Shrink said...

"Some patients need to be fed like a baby needs to be fed. It needs time. It needs patience. it needs kindness."

Totally agree. Nursing, whether wualified staff or healthcare assistants, often have to facilitate acitivities of daily living and personal care.

For managers to hassle doctors to pen Fortisip 200mls PO TDS (or PEG feeding) may well be expedient. But invariably it's not appropriate care.

Anonymous said...

I absolutely and wholeheartedly agree that patients are starving!! Instead of playing the BLAME the nurse game, ask your administrators WHY your nurses are so bogged down in paperwork and why there is not enough support staff to feed these patients???!!! Nurses want to be at the bedside feeding and nurturing their patients. That is why the vast majority of them became nurses. However, who would you like to assess the patient and hang their IV meds, change their dressings, communicate with their family and other departments to coordinate their care?? If you work with lazy nurses who don't even care enough about the patients to see that they are fed , then that really is a problem and should be addressed as such. Don't just BLAME the nurses!

Dr Grumble said...

Blaming the nurses was just a way of getting your attention about a serious problem. It's not the individual nurses themselves that are to blame; it is the systems that have been forced on them. And doctors can't be blamed for the nursing systems because they are not and never have had any significant influence on nursing matters. Nurses themselves have been responsible for the changes in nursing. In that respect very senior nurses are to blame. In any case a professional in health care should actually make sure that they give priority to feeding and watering their patients. That's why junior doctors are now plugging this gap as best they can.

Elaine said...

I do agree,


I wish you wouldn't show that obscene photograph.

Anonymous said...

If you want to see change, why don't you start a volunteer program or talk to administration about hiring more staff. It is so much easier to blame someone else. Why don't you spend a day with a nurse and see how much she has to do within the day. It is NOT that they think they are to good. I have been in numberous hopitals and shadowed many nurses and I have never met one that thought she was to good to wipe butts. It is their calling, but it is kind of difficult when you are responsible for seven patients medications, wound dressing changes, assessments, helping their families, getting them resources, education, and any other miscellaneous task (trach care, blood transfusion, tube feedings, collecting blood cultures and other specimens, and etc.) to do everything you want to. Especially, when they are understaffed. Why don't you stop bitching and do something! It is alot easier to blame it on your "underlings", then to do something to change it. Why don't you check on your patients and ensure that they have nutrients while you are doing rounds? Or fight for more staffing so there will be enough nurses or nursing assistants to get things done right.

Anonymous said...

The line that physicians have no power or influence over nursing matters is a bunch of junk. Physicians have a tremendous amount of power in hospital institutions because they bring in patients which translates to $$$! The nurses are who are powerless, they are merely considered a cost center and thus are constantly short-staffed. Yes patients are suffering but Dr. Grumble you are doing what most physicians do...they take the easy way out and blame the nurses rather than trouble themselves to fight for appropriate staffing levels and reduced paperwork for the nursing staff!

ayla said...

To the poster who commented on doctors bringing in money to hospitals and therefore having power, that is the USA not in the UK.
I go home from shifts knowing that I may not have stopped for 8 hours did my paperwork after i handed over and was not being paid that patient did not receive the care and attention that gives the best nursing care. In ways I was better During protected meal time we were told off for not answering the phone, we even had a customer service person(yes in the NHS) come down to tell us of as a relative hadn't had been trying to ring the ward. in the grand scheme of things the call was not essential and due to patient relatives not been bale to talk to each other.

Anonymous said...

I'll take the bait too doc. Take a look at the process.1970s food came up to wards from kitchen, sisters privilige to serve it out to each patients ie soft diet, the younger patients needed extra potatoes. Time allowed to feed those who needed feeding /help (+ the chance of sitting down) - seconds available for any who wanted. A kitchen with a cooker where a nurse could rustle up toast / scrambled egg for a late arrival. We had complan on wards and necessary utensils to feed those to weak to feed themselves 20011 NHS adopts business model.Kitchens removed other a kettle - dishwasher little else ( an illegal microwave). Ready prepared food comes up in red hot trolley no oven gloves reduced to using paper towels / airline packaged stuff jam etc normal people have trouble opening.HCA's were developed to deal with basic nursing care, ie feeding washing, toileting, however HCAs are now used to replace the Registered Nurse.Forgot to mention 30mins for patients to be fed and all collected and back to kitchen.The cleaner worries if trolley not back to kitchen in time it won't be collected. So you can see management numpty has applied their own numpty notions from the private sector has set up feeding patients aka airlines. Nope inspite of of being well educated nay even a masters have never been too posh to wash. The elephant in the room staffing levels - don't mean people dressed to look like qualified nurse. Check out the ratio of bedside Registered Nurses to patients?
1970s I worked in a London private hospital and the standard was 4 patients to one RN and looked after each patient totally.Guess those patient would be quick to sue.
On one occasion couldn't even rub cream on to a patient's sore bum because someone without being challenged decided that anything applied to a patient such as moisturising cream or sudo cream available from chemist must be prescribed - so no stock stuff available to apply. Dr. G the business model applied to clinical staff is designed to create Factory Hands. Clinical need to be facilitated to do their work instead are impeded at every turn. Don't worry doc NHS jollies abound they are trawling the planet for nurses and not investing in home grown staff 'cos they think the NHS is a car factory.

Nurse Anne said...

"Nurses themselves have been responsible for the changes in nursing"


It certainly wasn't the nursing profession who decided that the ward would run without qualified nurses and use care assistants. The nurses had no say in any of this. THe matrons, sisters and chief nurse have no say in staffing or anything else. They are figureheads.

Staff Nurse AMM said...

Despite what some lazy journalists and bloggers may think, the vast, VAST majority of nurses do not see themselves as "above" personal care. They are not "too posh to wash". They do not deliberately deprive their patients of basic sanitation, nutrition or any other daily essentials. They would, in fact, love nothing more than to be allowed the time to treat their patients as individuals, with dignity and respect, and ensure that they are adequately bathed, fed, nourished, stimulated and healing well.

If you'd care to observe one registered nurse trying to do all of this for ten or more patients, singlehandedly, across 12 hours, while simultaneously monitoring drugs, IV fluids, blood sugar levels, intake/output charts, catheters, IV cannulas, admissions, discharges, dressings, pressure areas and so on - with patients who can be elderly, frail, demented, unreasonable, grossly obese, abusive, etc, while simultaneously filling out the legally compulsory "voluminous paperwork", then you may gain more of an insight into the difficulties we face.