The institutional and physical design of improved nursing care
Like Peter Watt (also trained as a nurse), I acknowledge readily that there are deeply embedded problems in the NHS, and that standards of care are often poor, and probably getting worse. Mid-Staffs is indeed just the tip of the iceberg.
Unlike Peter, but like Chris, I regard these problems as institutional (and therefore power-related) rather than those of a “cult” (or rather than cultural). Consequently, I believe that it is primarily through institutional change (i.e. changing power structures) that NHS care will be changed for the better, rather than through increased managerialism, or through hanging effigies.
If I were (a socialist) Lord Francis, I’d make three central recommendations on how to change the NHS to make it more ‘caring’: one short-term, one longer term, and one – the main focus of this piece - to do with the physical status of the hospital institution.
1) Short term power change
Instead of loading the issue of safe staffing levels on to NICE, I’d recommend the imposition of weekly management/staff side meetings at Trust level to review the past week’s levels and trained/untrained mix, and allow staff side to argue why the levels/mix were not enough, if that’s what they think, with management side able to agree increase or defend their position. In the event of no agreement, the matter should be referred immediately to a CQC adjudicator. Repeated ‘losses’ for management side by the adjudicator would result in prompter inspection. This puts the power in the hands of frontline staff, but institutionalizes it more than the current whistleblower stuff.
2) Long term power change
2) Instead of suggesting that trade unions split their ‘terms and conditions’ function from their ‘work standards function’, which will be counterproductive, I’d recommend to the TUC and the broader union movement that it should redevelop and revitalise its existing structure of local Trades Councils, brining together all unions in a geographic area with public service users to come to their own conclusions and action plans about those services. This is obviously about more than hospital/care home, but these discussions would be a core feature. Such action plans might include use of the Foundation Trust governors (whose role Francis wants to bolster, but in an ineffective way as it stands) to push hospital management into change demanded by both staff and users, but it might also include community-wide consent to industrial action if management don’t listen or respond.
3) Physical change and nurse power
This one may seem a bit odd, but I think our hospitals are now designed wrong, and this is contributing directly to reduced quality of care.
From the early 1980s onwards, most hospitals replaced their old ‘nightingale’ wards, which were long rectangles with beds down each side, numbering 26-32 in total. Generally there’d also be two or three side rooms, reserved generally for people with infections who were being ‘barrier nursed’ or for shouty/aggressive/confused people who were really disturbing the other patients. The nurses’ desk, which was separate from the nurses’ office, was smack bang in the middle of the ward. Shift handovers generally took place in the office (though I often preferred to do it bed to bed if I was in charge).
Nightingale wards were replaced with ‘bayed’ wards, with each bay containing 4-6 beds, and the nurses’ desk moved to next to the office, somewhere between but not in the bays.
Nobody, as far as I know, has ever done any proper research into whether this major physical change to the way nurses had to go about their work changed the quality of care. Reflecting the emerging market-driven ideology of the time, anything that was done was around ‘customer experience’ and such, and there was an in-built assumption that the new wards were better because less people less meant less noise and more privacy. The anecdotal evidence – that nurses found it easier to work effectively, and that many patients felt security in numbers – was dismissed as resistance to change.
But in fact what little research there is does suggest I may have a case. Pattison and Roberston, writing in 1996, when both types of ward were still around, concluded that, even in gynaecological wards (where care needs around the ‘activities of living’ like drinking tend to be less than in medical/elderly wards) :
The aim of any ward layout at its most basic level is to provide a safe environment for patient care. This involves the nurse in charge of the ward being able to observe junior staff and monitor their activities, as well as being able to see the patients In turn the patients should be able to contact a nurse at all times. The results show that there is no doubt that patients feel these aims are better fulfilled on the Nightingale ward. On the bay ward, the lack of information on nurses’ whereabouts and the activity of the rest of the ward (e g the progress of ward rounds), is a major area of concern.
With the benefit of Mid-Staffs hindsight, the authors’ ensuing recommendation that the safety issue could be resolved by “[m]ore sophisticated information systems… for bay wards , and that “[m]ost patients (75%) expressed a preference for the bay ward layout, and on this criterion alone there appears to be no reason not to encourage their continued introduction” seems strangely glib, but this perhaps reflects how much worse things have got in the 18 or so years since the research was done. In 1995, bay wards were the way to go, standards (and staffing levels) would only increase, and a bit of concern about the new wards not being at all conducive to patient care could be dismissed in the Advanced Journal of Nursing Care.
Give this background, I do increasingly wonder if this is the nursing equivalent to the belated discovery that smoking causes cancer, caused by the continued determination of those with a vested interest to promote other possible causes, such as the early 20th century tarmac-ing of roads (this 1956 article provides a fascinating insight into the contentions of the time).
That is, are we ignoring a pretty obvious correlation between big changes in the way nurses have to carry out their work because of walls in between patients and the decline in standards, which appears to have taken place over roughly the same period of time (I nursed in the 80′s to early 90s, and again in the early 2000′s when I came back from overseas and before my back gave out, and I can attest personally to that decline, for what it’s worth)?
Are we ignoring the possible ward labour-poor care link, because, as with smoking-cancer, there are possible, though unproven explanations which fit better today’s dominant right-wing narrative: ranging from not enough ‘leadership’ to ‘too posh to wash’ and onto the more generic ‘broken society’ stuff (while this is dominant, I don’t discount the ‘leftie’ explanation that it is all to do with understaffing, though I do think this is contributory)?
I am not, I should stress, arguing that declining standards may be solely down to the ergonomics of nurses’ movements and visibility. It’s probably more complex than that, and to do with the way in which some of the feeling I used to experience when I walked onto a ward for a shift – that I was joining my team for a new day’s battle – may have been lost, and with it the inbuilt solidarity around keeping up standards. You don’t have to be a believer in the principles of the Panopticon to acknowledge that, when everyone can see what everyone else is up to for most of the whole 8 hours, then everyone’s going to stick the effort in. On an open ward, my team developed an almost telepathic understanding of when a colleague needed a quick hand – for example, when Mr Jones, the heavy left-side stroke patient, needed the two of you to pivot from bed to chair, and this sense of teamwork extended to the physios, the OTs, the cleaners, and even the odd junior doctor.
Put more simply, when I see nurses walk down a ward nowadays, they seem to do it more slowly than I did. There must be a reason for that.
So where to go with this? Of course, this may be no more than the hunch of an ex-nurse, desperate to resolve the apparently conflicting beliefs that it was better in his day and that today’s nurses are just as good as we were. But I also think, with all due humility, that it’s something worth checking out properly. It seems to be that this is absolutely the kind of thing that Ben Goldacre and his Innovation Unit mates should be developing a Randomised Control Trial for, to see if a return to the physical old days really does create significantly better care. Of course, a Trust would have to be persuaded to knock through a wall or three first, to create a new Nightingale, but I suspect that’d be much better investment than implementing some of the managerialist crap that Lord Francis has come out with.