I have had the good fortune to have been a hospital inpatient only once – as a five year old when I had my tonsils and adenoids removed. The experience sticks in my memory because in those days – 1946 – no parental visiting was allowed and even for a relatively simple procedure such as tonsillectomy and adenoidectomy inpatient stay was quite long. Since then I have been twice to accident and emergency departments but in both cases for relatively trivial conditions and the experiences were pretty unremarkable.
Since 1994 however I have had occasion to visit colleagues and relatives in hospital and this has allowed me to experience modern inpatient care at one remove as it were. As a doctor myself, to see modern healthcare in action from the receiving end has been particularly interesting.
In my early career I worked in three teaching hospitals where things were very different; but then this was over 50 years ago.
Surprises and causes for concern :
Lack of communication between medical and nursing staff. In my day the regular consultant’s round was the event when patient care was planned as a joint enterprise between the doctors and nurses. This practice seems to have died a death with the consultant’s round now being a rather low key uni-disciplinary affair. During one admission it was reported that the medical staff appeared from time to time, usually early in the day, seemingly rather anxious to avoid the nursing staff – skulking was the term used to describe their demeanor ! So, it was not unusual for the nursing staff to be operating to yesterday’s medical agenda. For example, insisting on restricting fluid intake on a boiling hot June day when this had been reversed two days previously by the medical staff. There were also several incidents of buck-passing where the nurses said the doctors would do something whereas the doctors said the reverse.
Lack of continuity of nursing care. During the most recent admission every day a new team of staff nurse and health care assistant was assigned to the patient. Inevitably with a lengthy admission he saw the same team several times but only intermittently. There is an argument, I know, for having fresh pairs of eyes looking at patients and inevitably the rostering of staff will have an impact, but I think having a daily change of staff is taking this too far and is at the very least confusing to the patient – and relatives – and almost certainly inimical to optimal care.
Staff operating as independent practitioners. With each admission it was noticeable that the staff nurses seemed to operate as independent practitioners doing things their way. Although the ward where one relative was treated recently was managed by a very experienced and confidence – inspiring sister her writ did not seem to run far with the staff nurses. One example of this involved the regular redressing of an infected wound – the cause of admission. Although a tissue viability specialist nurse had specified how it should be dressed and had written this in the notes most staff nurses seemed either not to have read it, or to ignore it, preferring their own judgement and experience to that of a specialist in the field. When this variation in practice was brought to the attention of the sister she responded that she did not believe it to be the case; but in the event she redressed the wound herself paying strict attention to the written advice of the tissue viability nurse. It was expected that things would change after this event but they didn’t.
Misrepresentation of prescribed actions. A practice discovered by accident on studying the case-notes was that sometimes the nurses signed that particular prescribed medications had been given when in fact they had not. This was reported to one of the pharmacists who visited daily to oversee the drug regimen. They were shocked and indicated that this was a serious and potentially dangerous breach of discipline and should be reported to the ward sister. In order to avoid a fuss and causing bad blood no action was taken; but on reflection it should have been reported for the benefit of other patients.
Substandard care at weekends. We all – fellow visitors and patients – came to dread weekends. Nothing happened unless it was a serious emergency. Patient care moved into the slow or stop lane. It almost appeared as if the staff who volunteered to work at weekends did so because they knew they would not have to do much. On occasions we noticed that senior nursing staff were on duty at weekends in order, we assumed, to ensure that standards did not fall too far.
Substandard care at night. On many nights staff who also worked days on the ward took their turn. But on other occasions night staff were agency staff or staff who only worked nights. It has to be said that many did not inspire confidence in their competence. We quickly formed the view that if a patient was receiving potentially dangerous treatment such as intravenous therapy or nasogastric feeding, for example, they were in real danger of things going wrong or not being done during the night shift.
One night there was a serious life-threatening complication and emergency measures had to be taken to prevent a possible fatal outcome. Fortunately, as well as a very clued up young doctor being on call that day there was a very competent staff nurse, part of the regular ward team, who was responsible for the patient’s nursing care. I have no doubt that her presence contributed significantly to his survival and recovery and that with some of the other night staff who appeared from time to time, he might not have been so lucky.
Inappropriate resuscitation question. During this same incident, in the course of the remedial action taken by the attending staff, the patient was asked whether or not he wished to be resuscitated should the need arise. Needless to say, he was rather taken aback by this question in these circumstances – there had never been any previous suggestion either that he was in danger of death or that his quality of life was intolerable.
Non communication with relatives. An extraordinary feature of the above incident was that none of the near relatives including the spouse were informed about what was happening and how serious the situation was. This was consistent with a seemingly prevailing attitude that only the patient had any right to information with relatives – even medically qualified ones – having none. Not that communication with patients was perfect. It would appear that the issues of patient autonomy and confidentiality have been carried to absurd lengths.
The “part of the furniture” or “familiarity breeds contempt” syndrome. In the course of one long hospital stay there was, it was felt, a danger that the patient would become part of the furniture as it were and through familiarity the standard of his nursing care would suffer. To be fair I did not see any evidence of this but it occurred to me that to avoid this it was necessary to engage actively and positively with staff by being friendly and helpful. With most staff it was easy to do this but not all. Another benefit of such behaviour I felt was that this encouraged the staff to give more than the professional minimum to the patient’s obvious benefit. The importance of patients and their relatives trying to promote good interpersonal relations with all staff cannot be overstressed in my view. After all they are human too, not robots.
Fear of retaliation by offended/reported staff. On one admission the patient was transferred to a ward where during one of my visits the staff were so unhelpful – refusing to give the required intravenous injection at the appropriate time because it was not convenient – that I was minded to report their action to a higher authority. I did not do so because I felt that if I did the same staff on another occasion might take some form of retaliative action that would not be in the patient’s interests. This feeling was based on both their negative and flippant attitude to my intervention and reports of how they had behaved to other patients in the ward.
The medical staff. My overriding impression with all the admissions was that the doctors operated in a different world to the other staff particularly the nurses. Many nurses did not know the names of doctors working on the wards, and vice versa, which I thought spoke volumes.
I expected to notice the fact that junior doctors now do shifts unlike in my day when we did continuous care. In fact I did not do so. The junior doctors seemed to be on duty during normal working hours with on call doctors – often different doctors – being available as needed during the evening and night.
The relevant consultants appeared regularly on the wards – usually twice weekly – which more or less mirrored my experience as a houseman in the 1960s. They were evidently available to the junior staff for consultations at other times which was reassuring though I did not discover how available they were at weekends.
The weight of paperwork. The amount of time spent by healthcare staff, particularly the nurses, on paperwork seemed excessive. I estimated that the staff nurses spent 25% of their time on paperwork. Some paperwork is inevitable as a component of auditable healthcare but I find it hard to believe that the current paperwork load cannot be lightened considerably. It almost seemed as if documenting what one did was more important than doing it – this may explain, in part, the case described above where a particular medicament was written up as having been given when in fact it hadn’t.
Lack of coordination of care. A major feature of one admission for an orthopaedic procedure was the lack of coordination of care. The only person who seemed to know who was doing what and when was the patient himself. Perhaps not too unacceptable with reasonably fit and educated patients; but totally unacceptable with ill patients and those – increasingly common these days – with evident cognitive deterioration such as dementia.
Disinterest in patient nutrition. I have read stories about patients becoming malnourished during their hospital stays and not believed them. I do now however. One patient’s nutritional state deteriorated considerably in the course of the first four or five weeks of admission. In the end he seemed to be subsisting on three peach slices and a small tub of ice cream each day. The catering staff noticed this and expressed concern but neither the doctors nor the nurses seemed to care until the fact was pointed out to them. In the end nasogastric tube feeding had to be instituted to ensure an adequate nutrient intake.
Lack of trainee nurses on the ward. Very different to my time where most of the staff on the wards were trainee nurses, there were no trainees on some of the wards, only registered nurses acting as staff nurses and health care assistants. It is difficult to believe that the absence of motivated trainees eager to learn and to challenge current practice and thinking does not lower the overall standard of care.
Staff too busy to provide proper personal care. Waiting for bedpans, commodes etc was normal, sometimes for very long times. This I believe was in part a reflection of the sheer volume of tasks to be undertaken; but it also suggested that attending to a patient’s excretory functions was seen as a low priority. The truth is, of course, that on a patient wellbeing scale, being able to exercise these functions in a timely manner rates rather high.
So, my hospital inpatient experience at one remove over the last 21 years gives no cause for complacency. At the very least it suggests significant underfunding, a lack of discipline among nursing staff, acceptance of poor standards of care at weekends and nights, a clear imbalance between the focus on technical healthcare and a concern for patients’ wellbeing, a lack of clear leadership on the wards, and a willingness seemingly to employ staff of doubtful competence to make up shift numbers.
One has to ask of course whether my experience was representative of the NHS hospital service as a whole. It comprised admissions to only three hospitals – one major teaching hospital, one highly reputable regional specialist centre and one a general hospital in a prosperous part of the country with an educated and empowered catchment population – but all three are likely to provide a higher standard of care than the standard district general hospital. It is reasonable to posit therefore that my experience probably under-represents the scope and scale of problems with modern hospital inpatient care.
Were things better in my day? Almost certainly not in many respects including the “risky weekend” syndrome. But in one respect they were in that nursing was then a disciplined service and that much of nursing care was provided by trainee nurses working as part of the ward nursing team, not as now, as super-numeries if present at all.
Something I had not fully appreciated before my very close involvement with the most recent admission was the importance of nursing to the whole healthcare process. A sensitivity analysis of episodes of healthcare would demonstrate, I am confident, that without good nursing there is no good healthcare. It is a necessary though not necessarily sufficient element of good healthcare. So getting nursing right must be the priority.
Apart from a radical rethink about nursing practice, recruitment and training there are some other obvious courses of action that would improve matters :
Increase the level of funding for hospital inpatient care. My guess is that the level of understaffing of nursing is at the 20% level. It is clear that other cadres of care staff such as physiotherapy, are also understaffed but possibly not to the same exent. The one group where this did not seem to apply was the doctors!
Wards should be staffed at all times including nights and weekends by the same team of nursing staff in rotation. Bringing in strangers such as agency staff is a recipe for accidents.
Each patient should have a single key worker most appropriately a nurse, to ensure that all inputs to care are coordinated and that there was a good channel of communication between all care staff.
The acute hospital service must be put on a 7/7 care basis. It just is not acceptable any more for standards of care to be allowed to plummet at weekends with measurable adverse consequences for patients who happen to be admitted or become ill then. It is a major indictment of the two major healthcare professions – medicine and nursing – that the “risky weekend” syndrome has been allowed to continue for so long.
The obsession with patient autonomy and confidentiality needs to be revisited. It is not satisfactory for patients to be asked to deal alone with important information and decisions such as the resuscitation question that was put to my relative. It is not actually in their interests.
The importance of patient wellbeing and what this means needs to be included in the training and continuing education of all healthcare staff. The current focus is too much on the technical aspects of healthcare. The fact that nurses have taken on more of the technical aspects that in my day were undertaken by doctors has clearly had the effect of diluting their traditional concern for patient wellbeing.
An interesting insight into management’s view on relative’s feedback such as this critique is that following one of the admissions I wrote a critique of the care received and included it in my application for a senior post with the Trust responsible for the hospital in question making the point that, were I appointed, I would make it my business to try to tackle the issues of concern raised in it. I was not surprised not to be called for interview but I was dismayed that those responsible for making the appointment showed no interest in the critique. At the very least I expected to be invited to talk about it but there was total silence. This may have been a unique example of management blindness to informed criticism, but I doubt it.
As a postscript it is only fair to report that in the course of the admissions described I came across some exceptional staff, particularly nurses and health care assistants, whose competence and caring attitude were exemplary. But such individuals can only do so much to counteract the systemic problems outlined above.