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Taking action on poor practice

Researchers have identified how organisations can support better care, write Yvonne Sawbridge and Alistair Hewison

Although inquiries into care failures at hospitals may shed light on the circumstances of particular episodes and result in recommendations for improvement, further failures continue to take place.

A think-tank was convened at the University of Birmingham in September last year to enable national and local nursing leaders to consider the issues, share good practice, identify actions and contribute to the wider debate about how to halt the decline in care standards. This article sets out some of its conclusions.

There is no simple answer, but participants explored a range of considerations.

A fundamental issue is the content of nursing work. It has long been recognised that nurses face situations such as death and dying, for example, on a regular basis. An ageing and increasingly dependent patient population means that the demands on nursing are growing. Therefore, nurses require systematic support for the emotional aspects of their work, and yet it is rare to find this on wards.

Psychoanalyst Isabel Menzies showed how the emotional stresses of nursing leave those closest to patients exposed to emotional pressures that more senior staff do not experience. She said that in many organisations, aspects of nursing that are considered to be frightening, disgusting or distasteful are rarely discussed.

In addition, processes that helped nurses to manage the emotional side of their work have been removed. The move from task-based nursing to individualised care, while progressive, increases the expectation that nurses will build relationships with patients. However, the think-tank has seen few mechanisms in place to support this.

This situation can be contrasted with that at the charity Samaritans, for example, where emotional support systems are in place for volunteers to ensure they can cope when caring for others.

Providing care is often regarded as an easy task. This leads to assumptions that caring is simply about common sense.

Such views underlie much of the recent criticism of nursing and result in individuals or their education being blamed for a lack of care. Accusations of 'uncaring university-educated nurses who are too posh to wash' take no account of what it means to be a registered nurse in today's complex healthcare environment.

These criticisms ignore the evidence that graduate nurses achieve better outcomes. Most nurses want to care well and need organisational support to do so.

Board roles
A further prerequisite of care is effective ward and board nurse leadership. In particular, the importance of the ward manager in creating a climate in which staff are supported and developed cannot be underestimated. Yet the authority attached to this role has been diluted and its importance has diminished.

Most nurse directors have lost line management responsibility for nursing in hospitals and rely instead on influencing practice and standards, rather than directing them.

Some of these difficulties manifest as a conflict between being a good nurse and a good employee. For example, good nurses are expected to have a clear appreciation of which patients on the ward are the most sick and need the most care, how many need help with eating and how many are at risk of developing pressure ulcers.

A good employee may be more concerned with the bed availability and how soon a patient can be discharged.

While skilled nurse managers can balance these requirements, the interplay of demands creates a constant and inherent tension between system pressures and good nursing care.

Efforts to provide compassionate care that can be benchmarked against national standards may be undermined by organisational pressures to maximise bed use and meet other targets. Nursing priorities can be distorted and the personalisation of care can be overlooked in the pursuit of high-profile, externally imposed performance measures.

At a time of heightened public, professional and political concern about poor nursing practice, it may seem counter-intuitive to suggest that nurses need to be valued and supported. However, if we are serious about solving these problems, the evidence of experienced nurses suggests that this is necessary - along with a leadership that vests ward sisters and senior nurses with the authority to ensure care takes precedence amid the welter of organisational priorities.

If action is taken in these and other areas identified by think-tank members, nurses may be able to rediscover the care they want to provide and patients have a right to expect.

The RCN Publishing Company is a wholly owned subsidiary of the Royal College of Nursing, the world's largest organisation for nurses. RCN Publishing produces one weekly, eight monthly and two quarterly nursing publications. Nursing Standard, the flagship journal, is the UK's biggest selling weekly for nursing. It is produced by RCN Publishing Company along with a suite of specialist nursing journals - Cancer Nursing Practice, Mental Health Practice, Learning Disability Practice, Nursing Children and Young People, Nursing Management, Emergency Nurse, Nursing Older People, Nurse Researcher and Primary Health Care. RCN Publishing Company also produce the RCN Bulletin, a major source of up-to-the-minute information for RCN members in all specialities, grades and working environments. With the latest nurse vacancies from trusts nationwide, it has become the most cost-effective nurse recruitment magazine available.