28 December 2008

Back to basics

For most of us it is difficult to complain. If Dr Grumble were to take the trouble to complain about something, which he rarely does, he would probably try and start with a compliment about the service. If you are going to complain it is nice to give credit for the things that went well and this might also lend some credibility for when you put the boot in.

Dr Grumble has just read an account by a patient referring to 'good care' at Leeds General Infirmary. By this the patient means the medical treatment was good (which it probably was) but the 'care' was plainly appalling. The patient refers to 'poor facilities' (which they probably were). It easier to criticise facilities as opposed to people. But Dr Grumble thinks there were staff failings. Full bedpans and urine bottles left everywhere may have something to do with facilities but whatever facilities you have these things do not empty themselves.

"Could we nudge them into doing better?"says Paul. No Paul. They need more than a nudge. We need a return to good old fashioned nursing. And we don't need to do away with hierarchies we need to bring them back. We need somebody with status in charge. Somebody who is revered. Somebody who is accountable. Somebody who takes pride in the ward and the staff and ensures that everybody does a good job. We need to do away with the endemic sloppiness that has insidiously crept into our wards. We need to do away with the no-blame culture and get people to do their jobs properly. We need to bring back the benevolent dictators who used rule the wards with a rod of iron. Good basic nursing needs to return. It needs to be valued. It needs to be respected. It needs to be rewarded.


Elaine said...

I absolutely agree.

One major issue is that a ward is divided into two "teams" and staff in one team do not know patients under the care of the other team.

That is problem 1

The second problem arises out of proposals for a grading structure for nurses to reward those with more experience and more responsibility with higher pay grades.

The inevitable happened.

I can speak only to hospital experience here, but hospital management twisted and tweaked job descriptions to save money and the ward sister (who would have been on a G grade) was no more.

And so it went on.

That is problem 2.

A further issue was the making of student nurses supernumerary thus losing active carers on the ward.

That is problem 3.

I am sure this list can be extended.

Dr Grumble said...

Thanks, Elaine for those knowledgeable comments.

There are clearly many causes of the rot that has set in. Amongst the most baffling to Dr G are the teams which mean that there is a 50% chance that if you ask a nurse about a patient you will be met with a blank look and a glance at a list. Was there some method to that particular madness?

Dr Aust said...

Not sure how relevant to the health-care context, but a trend that has been observable over the last 10-15 years among the technical staff in Universities has been the following:

A sharp decline in overall numbers has meant fewer "teams / groupings of under half a dozen people who work togeter over extended periods" (e.g. in a cluster of related labs, or a small department).

Therefore, there are less roles to be senior / in charge of three-four-five people who you see every day, who do the same job as you but at a lesser level of competence, and who you therefore manage and mentor.

Conversely, there are now more jobs to be "notionally" in charge of a dozen people or more, who the in-charge "line manager" type will now hardly ever see except by formal appointment. These new "chief technician" jobs are spread across multiple areas, or buildings, so other people rarely know where this person is. They also involve a lot of meetings with other people in simlar roles to discuss "policy" and "regulatory matters".

People who stay in the reduced number of technical jobs close to the labs get over-burdened as others leave. This is expecially true if they are experienced, as other workers nearby (of all types) rapidly learn that Joanne Bloggs is the person you can ask how to do things.


These "coalface" people cannot be promoted, as promotion now depends almost exclusively on "supervisory responsibility", defined largely as "how many people you are nominal line manager for". (Not, note, on "how many people actually depend on you for advice and help")

Result: supervisory people whose job is to whizz between committee meetings, appraisals, multiple buildings and paperwork, and who never see what really goes on in the labs, get promoted.

Conversely, people who stay doing a job where other workers find them useful don't.

Further result: the reduced number of technical staff left in this latter "doing things near the lab" category realise they are never going to get on or increase their salary, and either: (i) transfer to the supervisory caste / paperwork roles (more money) or: (ii) leave (had enough).

Anonymous said...

When it comes to doctors it seems that just as managers discovered team working they destroyed the traditional consultant firm structures and replaced them with evanescent teams which disappear as rapidly as they are formed.

the a&e charge nurse said...

If there is one MYTH that needs to be busted it is the perennial call to 'bring back matron' (or variations on this theme) - even NuLab latched onto it not that long ago.

Don't get me wrong, I'm not against matron, some may be very useful, but even the biggest/baddest pseudo-military type would have little effect on the financial and organisational forces driving the current health scene.

The trends are well established and do no seem to take into account the relationship between clinical demand and nursing resources/skill mix, etc to meet it.

Most days I go home with a dull to moderate headache, and only partial sensation in my feet.
Prn gaviscon is required to subdue the hastily ingested slops that passes for a meal in the hospital canteen.

In short, I can put my hand on my heart and say I've tried my best most days, yet phrases like pissing in the wind are invoked every time I see a fresh batch of elderly patients (complete with the obligatory oxygen mask) being wheeled into A&E by the paramedics.

Perhaps I'm just suffering trench fever but many dedicated nursing colleagues seem equally downbeat at the moment - if there are failings, it's not because nursing staff are not working our sox off.

Sad to report that it doesn't take too long before a significant proportion of nurses become focussed on self preservation because the system treats them as units to be replaced as soon as they burn out or break down.

Happy1 said...

Well said A&E Charge Nurse..you describe my department very well..in the description of yours.

I can honestly say (and i know I can't speak for other hospitals or departments)..that i have never seen really sloppy nursing care.

I've definately seen self-preservation and burn-out...along with sheer frustation at not being able to provide adequate care due to patient overload, staffing issues, lack of beds and equiptment, government targets and management interference...

We can only dream of the difference we could make to NHS patients without these damaging obstacles.