Who cares?

From time to time, I am "invited" to take part in selection interviews for student nurses. At some point in the interview some one on the interview panel will ask THE question - which is, of course, "why do you want to be a nurse?" To which the interviewee inevitably gives THE response "Because I want to care for people". I struggle a bit with this answer I have to be honest - why is nursing still primarily associated with caring rather than say, a satisfying career, the opportunity to do health care research or a fulfilling academic challenge? If people are so keen to care why not become lollipop ladies/men. They also care, they have a cool uniform and they only work about fours hours a day!

These individuals clearly have a view of nursing that is predicated upon the concept of caring, even thought they often have only the vaguest notion of what that may mean. They come into nurses education keen to care, nurse educators invest a great deal of time and energy in encouraging caring but once such students make it into the stress filled world of clinical delivery...guess what is the first thing to be subsumed?

This is why, in the UK at least, we have things such as the North Staffs enquiry, continuous reports about poor care for older people and only last week the report that doctors are now having to prescribe water to patients in hospital in order to prevent them dehydrating. This is shameful. Its not what potential students mean when they say they want to care, it  isn't what universities are teaching  so what is going wrong?

My friend became a grandmother for the first time earlier this year and found her daughter in such an appalling state post delivery that she signed her out to take her home. Not a bad idea, mother and baby were perfectly healthy, if not being washed, fed or being relieved of an  over flowing bed pan that had been used two or three times but not removed. On top of these indignities, the final words of the "caring professional" as this distraught first-time mother was helped from the ward by her family were "If your baby dies tonight - that won't be our problem".

That's a damning anecdote, but what it is worse is that every one who has fallen into the hands of organised health care, even briefly has a story that is similar or worse. My friend is a strong, assertive woman (wouldn't be my friend otherwise) but she didn't feel that it was worth her while to complain. If we as nurses and unaware that our caring attitudes are eroded by practice and our patients are not encouraged to be the custodians of our caring skills - then what hope is there for caring in health care?

Where are the maverick ward leaders of yester year?

Reluctent though I am to turn into one of those annoying people-of-a-certain-age who start every rant/blog with " When I was in clinical practice.."  but.....


When I was in clinical practice if I considered my leadership skills at all (and I didn't) I would have assumed that because I was willing to bend the rules for my patients and support my staff if they did the same I was a good leader. I ran a trauma ward in an area with a large elderly population, often we admitted elderly women whose husbands had never had to cook or shop for themselves so we would 'fiddle' the menus so that we could feed them. We would allow people to have their pets bought into to visit them (although not small babies!). We'd let people visit outside of visiting hours, in fact as a ward team we did all sorts of things that I suspect ward leaders theses days are too scared or too down trodden to contemplate and as a consequence we were a team that had a strong sense of both our professional identity and our professional responsibilities.

I wonder why we see very little evidence of leaders like this in modern health care. Ward leaders seem less willing to go the extra mile for their patients, whether this is because they are less caring (I don't think so) is it because they are frightened about maintaining their registration or have other hospital become places in which the individual has not place? I hope when I fall into the hands of organised healthcare, somewhere to care for me

Continue the discussion this Thursday on #healthcarechat at 8pm GMT+1

Poor pain management? I blame Margot......

Without doubt the most significant development in pain management in the UK was the publication, in 1990, of the College of Anaesthetists and Royal College of Surgeons working party report on pain after surgery. It was this report that lead to the creation of Acute Pain Services who would take the lead for improving pain management in hospitals.  Since then analgesic drugs have improved, we have better delivery methods and awareness of the importance of good pain management in a patients recovery has been fully emphasised. So, the question remains – why are patients still experiencing poor quality pain management?

Personally I blame Margot McCaffery. She it was who coined the annoying phrase “pain is what the patient says it is and occurs when the patient says it does”. On the face of it, there is little wrong with this, it raises the importance of believing patients when they say that they are in pain and that can only be a good thing, furthermore it’s catchy and easy to remember – and that is the bit I object to. It seems to me that one could walk into any clinical area in any hospital in the UK and say “Complete this sentence. Pain is what the patient says it is and.....” then brace yourself for the noise of all the staff finishing it off in loud and confident unison. The problem is that although every nurse in the UK knows and believes this statement, hardly any of them act as if they believe it. I think the difficulty if that this short statement has a nice bouncy rhythm, like the old drinka-pinta-milk-a-day or clunk-click-every-trip, to it that makes it easy to parrot and trot out at appropriate time. It has the advantage of sounding clinically empathetic without having to invest a great deal of intellectual effort. Nobody stops to consider that often pain is more than the patient says it is and occurs more often than the patient says it does.  It also implicitly excludes those patients who, for whatever reason, will have difficulty communicating their pain to the health care profession. Thus, despite parroting this annoying little phrase at every opportunity, there is little evidence that patients are believed when they report their pain, significant evidence that certain sections of society and not only disbelieved but labelled as drug abusers when they report their pain, and no evidence at all that a patients previous history of analgesic use is taken into account when prescribing and administering pain killing drugs.

It seems to me that despite all those better drugs, better delivery systems, enhanced prescribing practices and more supposedly patient/practitioner partnerships, pain management is still poor in the UK and it’s all down to McCaffery and her annoying little phrase. Time, I think, for educators and nurses to leave it behind and move on towards genuinely believing what patients tell them about pain and using their not inconsiderable resources to alleviate it.

Curated Chats

Our curated chats can be viewed by following these links:

5th May - Assisted dying

12th May - The role of government in healthcare 

19th May - Pain Management

26th May - Leadership in Healthcare

2nd June - Caring

9th June - Patient choice - open mic 

16th June - Meetings 

23rd June - Genetic testing 

30th June - Online learning

7th July - Professional Idols - are they up to scratch?

14th July - The medicalisation of normal

21st July - Involving patients in their care

28th July - Paying for healthcare

8th September - How do we measure quality in healthcare?

15th September - Should we refuse care based on a patients lifestyle? 

Time to choose?

Ali Handscomb argues that ".. the role of government in healthcare is to balance what is affordable with best quality and outcomes for the people it serves" and that seems to be a point of view that it is difficult to argue against. However, the divided nature of politics in the UK - especially in the present coalition situation would suggest that large proportion of the people will not be so served. Whilst the government feels the need to tinker with health care provision and attempts to sell such tinkering as providing extra choice  to service users, they seem to be missing two key points and they are these...when has increased choice ever been an issue and how does increased choice NOT translate into greater cost ( not less as proposed) Most people of my acquaintance want access to good health care, when they need it and they want it locally.
Many are not equipped to exercise any so-called choice since they don't consider different types of healthcare until they are in a position to need them. My fear is that by offering "choice" the danger of removing large elements of society from healthcare provision is extreme. I live in a fairly diverse neighbourhood where the middle-aged, (say those over 50) tend to be well educated professionals with small families and the younger element... not so much. It is clear that should the government sponsored choice materialise it will be driven by the vocal middle-aged. Good news for people like me who will need hip replacements one day, not so great for those who need teenage pregnancy midwives or  drug addiction services. Cheaper though!
The choice that is being held up as the key outcome of the new NHS reforms seems to me disingenuous. Reform should not necessarily be the role of government, monitoring and auditing of service driven reform that is informed by all of the members of local communities should be