Delivering good care without increasing the cost; why quality matters

A contribution to the recent 2020health report entitled ‘Too posh to wash? Reflections on the future of Nursing’

By June Andrews, Director of the Dementia Services, Development Centre, University of Stirling

The greatest tragedy about the delivery of care by nurses is that so much of what they do is often futile. Nurses spend an awful lot of time doing things that don’t make any difference, and in some cases, they spend time doing things that are known to make things worse. In addition, when they are doing things that really can make a difference, they find themselves running out of time, usually because they are badly organised.

In a nursing team, or for an individual nurse, the only thing that is rationed is time. There is only so much that can be done in the time allocated for any one patient encounter, and there is a limit to the number of patient encounters in any one span of duty, or one clinic. The problem arises when the individual nurse cannot distinguish between unnecessary and pointless interventions and those that make a difference, or when the system makes it easier for the nurse to fill their allotted working hours with trivia.

In discussion with nurses they will often claim that they are held back in doing what ought to be done by paperwork, or routines that are demanded by employers and inspectors. They are harassed by phone calls and emails, meetings and unplanned interruptions into what they are trying to do. Of course there is a case for this. But when you look at the quality of the paperwork, and the effectiveness of the phone calls and emails, and the badly organised meetings, it is clear that they are not excelling at those tasks either. When challenged they will claim that these overwhelming jobs take a priority over other things that might demand their time and attention. In an apparently overwhelming tidal wave of demands on the nurse during any span of duty, it is as if the tasks choose their own priority. The nurses behave as if they have no discretion.

In reality the problem is sometimes that the nurse lacks sufficient authority and personal effectiveness to challenge the pointless activities that the system asks of them. At times this personal ineffectiveness could be mistaken for a kind of passive aggression. “I know that doing this stuff won’t help my patients, but the one in charge says I must do it, and so I will. It’s more than I can be bothered to do, to tell them how their routines and requirements are increasing length of stay, or patient cost, or adverse incidents or complaints. And if the relatives notice it and point it out, I’ll wash my hands of the problem and tell them I am too tired/busy/overworked to deal with their issue.” The damage is done and the nurse takes flight into being a victim.

A lot could be done to improve what is effectively a quality issue, by getting nursing staff to be more focused  “Recently my dad was catheterised at home by the district nurse. She was in the house for ten minutes and never washed her hands in that time. When I got to his house he knew that she was tired, her car was playing up, there were only three nurses on for the county, and that she thought errors might occur because they were so busy. He did not know that he could (in fact really must) take more frequent showers to keep himself clean and that the bag should always be lower than his bottom to keep the urine running out, or that he should drink a lot of water and aim to make the urine paler. She was busy and harassed, but she completely missed the chance to help him other than introducing the tube. But she was not too busy to share all her problems with him. He won’t complain in case he needs her again.”

The nurse needs some simple rules. Don’t talk about anything other than what is related to the patient’s care. Ask lots of questions about how they are and listen to the answer. Conceal from the patient as much as you can if the work is giving you stress. You need to tell someone, but don’t wreck the possibilities in the patient encounter by getting your own problems to take priority over that of the patient.

The best example of this no cost, high impact, quality improvement in a hospital setting is intentional rounding. If the nurses regularly go and ask how patients are doing, and listen to the answer every hour of every day, the unexpected and adverse incidents drop away, along with call buzzers and other disturbances. It is not rocket science.

The evidence is there. It is time for nurses to just do it.

About Julia Manning

Julia is a social pioneer, writer and campaigner. She studied visual science at City University and became a member of the College of Optometrists in 1991, later specialising in visual impairment and diabetes. During her career in optometry, she lectured at City University, was a visiting clinician at the Royal Free Hospital and worked with Primary Care Trusts. She ran a domiciliary practice across south London and was a Director of the UK Institute of Optometry. Julia formed 20/20Health in 2006. Becoming an expert in digital health solutions, she led on the NHS–USA Veterans’ Health Digital Health Exchange Programme and was co-founder of the Health Tech and You Awards with Axa PPP and the Design Museum. Her research interests are now in harnessing digital to improve personal health, and she is a PhD candidate in Human Computer Interaction (HCI) at UCL. She is also dedicated to creating a sustainable Whole School Wellbeing Community model for schools that builds relationships, discovers assets and develops life skills. She is a member of the Royal Society of Medicine’s Digital Health Council. Julia has shared 2020health's research widely in the media (BBC News, ITV, Channel 5 News, BBC 1′s The Big Questions & Victoria Derbyshire, BBC Radio 4 Today, PM and Woman's Hour, LBC) and has taken part in debates and contributed to BBC’s Newsnight, Panorama, You and Yours and ITV’s The Week.
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