The Care Quality Commission exposes…. nursing leadership fails …. but nothing will change.

Submitted by Chris Hiley on Thu 13 Oct 11 - 12:24
in

The Care Quality Commission has, once again, exposed the low standards of care inflicted on far too many elderly adults in the National Health Service. 20% of sites visited were failing to ensure dignity or nutrition for their patients, or both. One in five.

Criticism of care of patients in hospitals can only mean criticism of nursing and nurses. But they seem somehow absent or innocent in discussions. It’s old people who are affected. We are wrongly, dangerously, cruelly, ambivalent about old people. That's why nothing will change.
 
Let’s see. The usual, in terms of excuses will be coming over the hill ….. It’ll be the cuts. There will be acute effects, on top of chronic over work and under capacity. Too much paperwork and too little patient record keeping. Not enough qualified nurses and at the same time, too many qualified nurses, whom the Daily Mail will accuse of being too grand to get involved with patients. The wrong kind of patient or case mix on wards. The wrong service configuration or the wrong service reconfiguration. Off-hand distant medical staff. Or over-involved, interfering medical staff. A breakdown in working relationships amongst staff, or far too close, 'wall of silence' type working relationships. Professional disrespect in Trust cultures that bully staff. Then there’ll be the passive aggression at ward level – “There’s no point in saying anything, nothing ever changes…..”
 
The massive story that will be missed in all this is the commentary on the failure of nursing leadership. When will this be tackled? It keeps happening. The BBC page here doesn’t use the word ‘nurse’  anywhere and 'nursing' only appears in a comment from the Royal College of Nursing, though Andrew Lansley does mention nurse leadership in an audio file. From the mouth of a polictician this may sound like passing the buck, rather than a reasonable point and thus ignored. Wrongly, in my view.  
 
Failing nurse leadership is all over the CQC report.
 
The Today programme had a CEO from Sandwell NHS Trust who did not as far as I recall mention nurses. Care was mentioned, over and over by Jim Naughtie.  
 
Where is the assertiveness, confidence and leadership by any nurses as implied in their professionally registered status in these situations? Or are they really professional-lite? Girls got the look, but not the substance? Where is the influence of the nurse executives promoted into Director posts, to lead on nursing at board level, fully backed up by, and backing, their ward teams?
 
All nurses are registered. They don’t get more registered as they ascend the hierarchy of nursing. Or less registered. The nature or content of the registration does not change. Standards are immutable. The influence a registered nurse does slowly change in increasingly senior roles. At Director of Nursing level it has changed to influencing the wider cultural context for patient care rather than a proximal physical one, which is how ward based nurses exert their leadership.
 
Culturally, as well as physically there is a clearly a big problem with nursing leadership in the care of elderly people. The Care Quality Commission keeps uncovering it.
 
What are nurses doing? I’ve just lifted the following from the Nursing and Midwifery Council website
 
“If you don't do something, who will?
Safeguarding is part of everyday nursing and midwifery practice in whatever setting it takes place. You should have the skills to confidently recognise and effectively manage situations where you suspect a person in your care is at risk of harm, abuse or neglect, including poor practice. Do you know what to do?”
 
Plainly not. At any level. Or, if they do know, why don’t they do it?
 
Nurses are registered with the Nursing and Midwifery Council. They say 
  • We are the nursing and midwifery regulator for England, Wales, Scotland, Northern Ireland and the Islands.
  • We exist to safeguard the health and wellbeing of the public.
  • We set standards of education, training, conduct and performance so that nurses and midwives can deliver high quality healthcare consistently throughout their careers.
  • We ensure that nurses and midwives keep their skills and knowledge up to date and uphold our professional standards.
  • We have clear and transparent processes to investigate nurses and midwives who fall short of our standards.
Their standards are in "The Code: Standards of conduct, performance and ethics for nurses and midwives." The very first items are clear.
  • Make the care of people your first concern, treating them as individuals and respecting their dignity
Treat people as individuals
  1. You must treat people as individuals and respect their dignity
  2. You must not discriminate in any way against those in your care
  3. You must treat people kindly and considerately
  4. You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support
It goes on….
  • Work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community
  • Provide a high standard of practice and care at all times
And then, later, on managing risk…..
  • You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk
  • You must inform someone in authority if you experience problems that prevent you working within this Code or other nationally agreed standards
  • You must report your concerns in writing if problems in the environment of care are putting people at risk
And finally, “be open and honest, act with integrity and uphold the reputation of your profession”.
 
Oops.
 
This is not rocket science and that is the CQC problem uncovered. Not Big. Not clever. Not at all grand. Basic nursing standards but blasted to pieces.
 
At ward level the ward managers (ward sisters in old money) may feel they can’t raise concerns because “no one listens to me anyway” – typical nurse passive aggression that helps no one or, worse, this is a sign of a bullying culture that has worn his or her professional identity to wafer thinness. Or they may have voiced concerns with no effect, higher up the line, running aground on a senior nurse who doesn’t want the Director of Nursing to know they have management problems or aren’t coping. There’s nothing more provoking to some nurses than other nurses ‘not coping’. So don’t disclose it, ever. Google ‘nurse’ and ‘bullying’. It’s out there. 
 
A Director of Nursing should know about standards of patient care in their Trust. Should have an inkling. Should have a level of suspicion. I want to know what happens to Directors of Nursing when the failures of NHS care are so profound and so common.
 
I’ve just sent in a Freedom of Information request to the NMC, asking a) How many Directors of Nursing of NHS Trusts have appeared before a disciplinary hearing of the NMC (or precursors) [for work based disciplinary reasons rather than personal ones, like drink or drugs] in the last decade and b) What proportion of them received any kind of sanction, up to and including suspension or removal from the register?
 
I’m expecting ‘none’. I’ll let you know either way. 
 
You can make up your own story on what any NMC results might signify. Registered nurses on the wards are certainly culpable for their personal failure to care but the Directors are culpable for the cultural failing. I'd prioritise that cultural one as it'll directly relieve most of the personal professional failings at ward level. I do wonder if anyone in the nurse hierarchy - executive or ward - will be called to account by the NMC as a result of the CQC report?  I hope so. They advised the CQC during the report process, for hevinsake, so do will know all about it. 
 
I'll wait for the NMC disciplinary processes against multiple Nurse Directors. But I won't hold my breath whilst doing so. If there are none, what value does any nurse registration actually have?
  

Comments

in support of Chris Hiley

Submitted by anon nursing sister (not verified) on Mon 17 Oct 11 - 20:20.

I totally agree with the observations and comments you have made Chris. The care and safety of patients is paramount especially the care of elderly vulnerable people. Isn,t that why we all became nurses because we care.

I am a nursing sister with 30 years experience in a wide variety of settings including acute and primary care. I started as an enrolled nurse and have progressed myself professionally and acaedemically. I am totally devoted to my profession and have maintained my philosophy that if we cannot get the basics right nothing else will be .

This devotion and my actions to highlight poor standards have recently resulted in me being the subject of what i can best describe as a witch hunt. Following a lengthy disciplinary process I am now about to go to tribunal. Incidently I have found the NMC to be very supportive. Sadly in the area I worked in managers used reporting to the NMC as a threat to staff to discourage full disclosure.

Your comment regarding the directors I can absolutly relate to how can we respect these "leaders" when as my own expereince has demonstrated they
fail to act with honesty and integrity. Instead these positive human element are replaced by protectionism and dishonesty. Yes because exposure is the last thing they want. I can only speak of my experience where i observed many senior nurses and managers contine in what i refer to as the emporers new clothes syndrome. I spoke out and the result was a very targeted witch hunt.

I will not for obvious reasons relay the details of the allegations that were made against me. In essence I suppose I fit the new model of advanced practitoner able to do the Job at the coal face clinically and to lead and manage change. A major threat to managers whose roles in the very traditional hierarchal systems of the NHS are threatened by nurses like me.

You are absolutely correct that what is missing is leadership. Leadership needs to be defined. Leaders such as ward sisters can only lead if they are supported and empowered to make the decisions and changes needed to keep patients safe. Managers need to work with not against these change agents.

A year on I am now very happily working for a wonderful OOH provider. Do I regret speaking out absolutely not. To fight the system is tremendously hard and often comes at great personal cost . What made me keep going was the thought that the little elderly lady or gentleman could be my mother or father. They deserve respect and to be treat with dignity. If these essential human elements are not displayed within the professional team to each other, what chance do patients have or recieving basic care.

Hello Anon Nurse. Thank you

Submitted by Chris (not verified) on Tue 18 Oct 11 - 10:06.

Hello Anon Nurse. Thank you for your comments. We are as one on this. There was a delay getting your comment up because I moderate them. I don't want to, particularly, but if I don't I'm plagued by a Ukrainian spam bot who loves to advertise knock off handbags and porn. All well and good in a liberal democracy but not right HERE.