Imagine the scene.
Cameron visits a hospital in, let’s say, Barnsley. His advisers have been doing their homework and have told him that there’s a new opioid anaesthetic drugs, Remifentanil, which is very promising because it clears from the body very quickly post-anaesthetic, and doesn’t have any adverse effect on the excretory organs like the kidneys.
Cameron, enthused by this, asks to go to the operating theatres, not least because he thinks he’ll look quite dashing in the greens – a bit like George Clooney off ER. He has small talk with the anaesthetist delegated to show him around, and then asks him, as a supposedly surprise question, what he thinks of Remifentanil. The anaesthetist replies that it is, in his view, a useful addition to the anaesthetic armoury, especially for people with pre-existing kidney function problems.
Cameron thanks the anaesthetist and moves on. Half an hour later, he hold a press conference, at which he announces that he wants to see Remifentanil used as the anaesthetic drug of choice in future.
Anaesthetists up and down the country are bemused by the new announcement, but Cameron’s PM and he’s given the order. The use of Remifentanil is rolled out across the country, and within a year there’s a surge in people reporting severe post-operative pain because of inadequate pain relief, since other points in the prescribing chain have not caught up with the short-acting nature of Remifentanil.
There is uproar about how badly people are being treated in surgical wards. Cameron calls for an inquiry into what’s gone on, and says heads will roll…….
It may not be quite as dramatic but this is essentially the disgraceful, disrespectful behaviour Cameron engaged in this morning towards nurses, when he instructed that ‘hourly rounds’ should be introduced to wards.
Of course, had he made such an announcement about Remifentanil, he’d have been laughed out of town by the medical establishment. The point is that, because it’s the nursing profession he’ll ordering around, he thinks he can get away with precisely this level of disrespect.
Let’s just be clear about where we stand with ‘nursing rounds’.
This recent research overview is helpful [subscriber only, but just put “Intentional rounding: its role in supporting essential care” into Google”:
The idea of systematically rounding to ensure patients’ essential care needs are met is not new.
For many years, nurses carried out “back” rounds, where particular attention was paid to patients’ skin to avoid skin breakdown. While aspects of these were evidence based, anecdotally staff believed patients felt more comfortable after the round and it provided an opportunity to build relationships between nurses and patients.
With the advent of the holistic nursing care approach and the requirement for more technical skills, nurses began to move farther away from the bedside and began to view such task-oriented processes as archaic, preferring to focus on the provision of “individualised” care.
However, concerns about essential nursing care have refocused attention on the need to ensure fundamental aspects of care are delivered reliably, alongside individualised care.
The research overview provides a positive case for a return to “rounds”, with a particular focus on the certainty and confidence that they bring to patients.
Even so, the authors acknowledge that there are potential downsides to the reintroduction of ’round’ routines. There is not room here to cover the risks and unintended consequences in detail, but they include the obvious risk that rounding routines soon develop their own bureaucratic logic, such that patient individuality become ignored, and those patients who need to develop the independence in daily activities that they need when they go home are discouraged from doing so; the fostering of independence was precisely the reason for adopting new nursing processes in the 1970s and 1980s.
In general, nursing academics now encouraging a return to old routines are short-sighted in two ways.
First, they tend to use, as their baseline for the measurement of improved care, standards of personal care which have already dipped signficantly since the 1970s, principally because of lowered staffing levels. This gives a false positive when it comes to reviewing the effectiveness of the return to rounds.
Second, they are so ‘stuck’ within nursing literature that they fail to use the wider social insights of, say, Implementation Studies, which show very clearly how the routinisation of tasks leads over time to poor quality of service, whatever the initial success of top-down ordered pilot studies. In the face of continued staff shortages, it is perfectly possible to imagine scenarios where patients are told that they will “have to wait for the round” before they can be removed from their own shit.
The point of this article, however, is not so much that the nursing profession itself may be on a very slippery slope if it returns to old, trusted ways as a short-term solution to inadequate staffing levels borne of political expediency, and that they would be better off politicising the debate (that was the point of this article).
The point is that Cameron and his flunkies have failed to recognise that the debate about the best way for the profession to meet its aspirations to standards is still very much ongoing. That is, after all, why the nursing rounds that have been introduced have tended to be on a pilot basis – time is needed to see if they stay as effective as their proponents claim they will be.
In making this, off-the-cuff, prime ministerial order to a profession he knows nothing about - introducing on the basis of scanty evidence at best - nursing methods now deeply alien to many highly trained staff (just see the comments to the research overview), Cameron displays deep disrespect to half a million nursing staff.
It is not something he would have done to doctors, that’s for sure. But then perhaps he thinks nurses should be treated the same way as he treats women in the House of Commons.
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