Contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’
Ann Farenden, National Professional Advisor, Care Quality Commission
Nurses play a pivotal role in the delivery of health care today. Our responsibility at CQC is to regulate health and social care across England and monitor whether providers are complying with the Essential Standards of Quality and Safety (CQC 2010). In the course of our work we see standards of care provided by nurses that go across the spectrum from high quality, safe care to poor quality, unsafe care.
There are many examples of good quality care in which nurses engage positively with patients, by providing encouragement, reassurance, and by being attentive to each individual’s needs. They give patients information they need to make choices, take account of their preferences for diet, form of address and meeting hygiene needs. They explain care and are readily available to answer questions. They undertake risk assessments for developing pressure ulcers, falls and malnourishment and provide care to address individuals’ needs. In addition they audit the care they provide and take action to make improvements. Such examples can be found in all sectors where nurse care is delivered.
Recent inspections have also highlighted aspects of poor care provided by nurses, such as patients not being given any information when they arrive at hospital and having to make their own discharge arrangements as no-one spoke to them about their needs. Other examples include patients’ care needs not being met, not getting help with eating or drinking or having the opportunity to wash their hands before eating meals as well as their records being inadequately completed. There are also examples of staff not following their own policies on hand hygiene and ensuring that the environment for care was clean and free from hazards.
There are many factors that influence the quality and safety of nursing care. In all the investigations and many reviews and inspections CQC have undertaken so far, issues around leadership, staffing levels, education, training, supervision and appraisal have all presented as factors underpinning the compliance with regulatory requirements. Having insufficient numbers of nurses, with the right training, on duty can lead to poor care. In the review of dignity and nutrition (CQC 2011) we found that in half of the non compliant hospitals, inadequate staffing levels and lack of training were common factors. We have also found that when there are not enough nurses to deliver the level of care required they have to prioritise care and they may not have time to get people out of bed or have time to talk to relatives and tend to needs promptly. Patients may also be at greater risk of falling when they cannot be adequately supervised. Most nurses will be disturbed and upset by such events but will also understand that they need to be addressed.
Poor and ineffective leadership has also been present when failings have been found. This results in nurses being unclear of what is expected of them. They lack understanding of their roles and responsibilities. There is often poor team working, ineffective relationships and low expectations about what they can achieve for patients.
Sometimes there is a culture of impotence and complacency with a reluctance to raise concerns about standards for fear they will be ignored or reprimanded. They are unwilling to report incidents and there is therefore little learning about how to improve. Compliance with the essential standards of quality and safety requires sufficient numbers of nurses with the appropriate qualifications, skills, knowledge and experience to do the job and they must be up to date with current practice. They should be able to understand the physical, emotional and communication needs of the patients in their care, be able to respond to their changing needs and know when to seek more expert advice.
In order to be competent to carry out safe and effective care nurses must understand what is expected of them and have the right support in terms of training, professional development, supervision and appraisal. They also require clear standards and policies to guide their practice. The work environment needs to provide an open culture in which staff feel supported and are comfortable to raise concerns and know that these will be addressed. In addition, they must have access to properly maintained and suitable equipment and be adequately trained in its use.
Strong and effective nurse leaders at all levels are critical to achieving improvements in nursing care in the future. They need to foster a culture where patients are the priority and where everyone is alert to potential risks and harm; where abuse is not tolerated; where learning from mistakes is the norm and where people are confident that when raising concerns they will be listened to and action taken. They need to ensure that systems are in place to ensure safe care and that they are universally adopted, such as standards for good practice, processes for assessing risk, for raising concerns, investigating incidents and taking action, monitoring actions debriefing staff and learning lessons. Nurse leaders should also support their staff in continual growth and ensure they have opportunities to develop and keep up to date and be supported supervised and appraised. In addition, they should facilitate effective team working and partnership.
They also need to ensure that they measure and monitor performance by making use of the information that is available to make improvements which last. However, in order to be successful there must be ongoing investment in nurse leadership development, together with support to do the role and a manageable portfolio of work.
Further, the culture should be such, that it will enable leaders to develop the confidence to use their initiative and be innovative in their practice.
The Care Quality Commission, 2010, The Essential Standards of Quality and Safety Guidance about Compliance