Nursing by numbers - sorry, wrong number

In a rare idle moment, I saw this article on the BBC news website http://www.bbc.co.uk/news/health-11097822 It's all about fears that elderly people getting malnourished in hospital. I'm afraid it got me rather angry. This is simply a different manifestation of what Mencap found in their 'Death by Indiference' report on people with learning disabilities in hospital. What really got my ire up was the perennial assumption, seemingly by all concerned, that this could be solved by monitoring and procedures - introducing red trays etc. for people at risk.

Monitoring and procedures are not a substitute for care. People's conditions change, procedures don't always get implemented accurately, individuals fall through the gaps - and die. You'll be aware of my abhorrence of nursing by numbers and how hospitals are bad for people with disabilities. I don't blame the individual nurses - bless them, there are precious few around these days. The people visitors and patients take for nurses are actually nursing assistants in the main (or care staff in the community) who, because they have limited training, need the procedures to do their job. We've actually had one agency nurse say to us that she 'didn't do care - she had the nursing assistants for that' - she was only used to manning the nurses station, dispensing medication and ward/nursing home management. Our own package uses nurses precisely so that they have the skill and judgement to use their discretion, but they are now working under so many protocols, procedures and guidelines that we have to intervene when the rules work against his best interests.

Example - protocols state that if he has a fit lasting over 5 mins. give chloral hydrate. He almost always has a fit on waking. At present he has a chest infection. Result of chloral being given is that he was knocked out for over 12 hours - no coughing. Physio and PEP attempted by nurses but as it caused his O2 to fall initially, not proceeded with. He would have re-consolidated and ... draw your own conclusions. Upshot is that we had to go round and do physio and PEP ourselves, result lots of gunk removed from chest - all's well, (not quite all) with the world. Everyone knows the protocols don't work but they have to follow them or their nursing PIN number is at risk.

I know it's about resources - but that doesn't make it acceptable. There was another situation last century where the defence 'I was only following orders' was deemed unacceptable - it seems now to be the normal and only basis for action in this context. Mencap and others have raised this issue already. It isn't more rules that are needed - it's more people giving care. I wait in apprehension for the headline 'Old lady dies because she was given wrong colour tray.'

Rant not over - it's not over until the thin lady dies.

Doing it by the book

Epilepsy is a very individual thing to manage - and we currently have a bit of an issue around his epilepsy rescue medication - when to intervene with what. The protocols we've had to work up run to about six pages and cover a series of escalating drug interventions and are designed to keep him out of status (continuous, intractable fits). He's never been fit free but on an average day has about 5 to 7 fits that we don't react to. It used to be that the nurses used their training and clinical judgement to assess when he'd had too many fits, or they were getting too close together to become a problem. But in these days of 'nursing by numbers' it's all spelled out in fine detail, so that if he has one fit lasting a certain time, or a series of 3 in a fixed period, they use drug A, and if that doesn't stop them in a set time, they go to drug B etc.. Things have got so complex and prescriptive that the nurses are now questioning whether the specified times include just the fit itself or also include the recovery time. I think it's far too prescriptive but have a lot of sympathy with them, as they are at risk from CQC and the PCT, and potentially could lose their registration if anything goes wrong. CQC and the PCT insist on everything being protocoled, taking away all the clinical judgement and the nurses ability to act in his best interests. I'd be far happier with a real 'no blame' culture where the nurses could decide for themselves what treatment was right for him, balancing out control of his fits with his quality of life. We could stop him fitting tomorrow - he just wouldn't be awake or have a life, and he'd probably succumb to a major chest infection quite quickly. But to be 'safe' they have to keep to the protocols - so now we have to have another meeting to fine tune, micro manage the trigger points on paper, rather than seeing how he really is. It seems more important to be seen to be doing it right than actually doing it right in practice.

His epilepsy protocols are just one set - he has similar things for gastrostomy (feeding direct through stomache wall), oxygen, various PRN (as necessary) medications, hospital admission, antibiotic use etc. etc.. We wouldn't trust a nurse with him unless we (and they) were happy doing his care. The paperwork seems to exist largely to cover the back of the PCT. They say its because they have a 'duty of care' but the reality is that we don't actually have protocols for airway suction because ' it's still with the solicitors'.

I'd be much happier if the nurses could be allowed to nurse and we could concentrate on giving him a life - as it is we'll all have to spend even more time making up forms so that they can tick boxes in them and the PCT has someone to blame if it doesn't work.