What is an acute medical ward for? Who defines its purpose and value?
Instead of the prevailing definition of the ward as a medical workplace, it would be better defined as a place for healing, where pain and distress can be eased by caring professionals. When value is defined from the supply side alone, it tends to ignore the relational and non-clinical aspects of care that are critical to patients' mental and emotional wellbeing and recovery.
A broader definition of value would recognise how illness affects patients; it is unsettling, induces anxiety and fear, and makes us vulnerable. Carel, with experience of a life-threatening, chronic condition, observes, 'Illness changes everything. It changes not only my internal organs, but my relationship to my body, my relationship to others, their relation to me and to my body... In short, illness changes how one is in the world.'
Admission to hospital may bring relief, but it increases vulnerability. Sweeney and colleagues describe it in this way: 'Every patient that comes through a hospital is apprehensive. It's a strange place, you have strange sheets, you have odd tea in a plastic cup. The whole thing is vibrantly different.'
For patients, the hospital environment is always unfamiliar: on admission, they lose their autonomy, their right to move, eat and drink at will, to sleep or wake up, and to choose their own company. Adults find themselves dependent on others for help with the most basic issues of hygiene and personal care. As McCrum puts it in My year off: rediscovering life after a stroke, 'Being a patient is, as the word implies, totally passive. You are dependent upon the nurses; you are always saying thank you and falling in with nurses' jokey routines. If you don’t, you become a "bad" patient to be punished in all kinds of subtle but unmistakable ways.'
Feeling dependent and exposed in this way makes patients constantly aware of the power that (all) staff have over them and makes them acutely sensitive to the feeling and tone of all interactions.
A doctor who attended my father... was extremely rude. [We] had been told that my father needed hourly checks but this wasn’t happening on the Sunday. When my mum mentioned this to the doctor she snapped, 'there is no way anyone would have approved that.' It was very unsettling.
(Anonymous, daughter, The Point of Care Foundation website)
Staff do not intend patients to suffer, far from it, but patients are inadvertently exposed to shame and humiliation; to distress, when their requests are ignored or overridden; to anxiety, about being kept in the dark, and about discontinuities and contradictory information; and to fear, when they are unable to trust caregivers.
If wards were re-defined as places for healing, recovery and care, staff would aim to reduce and eliminate all avoidable suffering. The quality of relational care would have equal priority to clinical quality and patient safety, and changes in the physical environment, the conduct of staff and the organisation of care would follow.
Staff would be aware of themselves as 'on stage' when in sight or earshot of patients and visitors, and act accordingly. They would always introduce themselves by name and explain their role to patients. They would be curious about patients’ wants and needs, and would strive to have equal discussions about the goals of treatment. They would welcome visitors.
They would trust managers to support them when they made changes to benefit patients and to act on their concerns about anything in the physical environment, relationships with colleagues or resources that could be detrimental for patients.
The managers' primary task would be to enable staff to be at their best and to deliver the best care possible. They would be sure to spend time on the wards themselves to observe staff interacting with patients; they would look for evidence of human touches in patients' care and see their absence as red flags, signals that the team climate might need attention. They would make sure that staff had access to patient feedback and were equipped with the tools and techniques that would refresh their awareness of the patients' experiences and enable them to make improvements. They would help staff to reduce time-wasting activities and insist on them observing breaks.
Members of the executive team would not leave the quality of relational care to chance but would see their role as identifying and dismantling systemic obstacles to good care. They would aim to protect and increase the time that frontline staff spend with patients, by reducing the administrative load and culling top-down demands for information. Accepting that surveys have their limitations, they would seek multiple sources of intelligence about the quality of care and listen to the views and opinions of patients and staff.
They would invest in developing the people skills and offer all staff opportunities for reflective practice and self-care. They would constantly monitor staffing levels, staff engagement and staff wellbeing, and delegate as much control down the line as possible. Finally, they would invite patients and families to contribute to definitions of value, and ask them to collaborate in service design and improvement and to participate as equals, alongside the professionals, in the workings of the hospital.
This is a shortened version of an article that appears alongside perspectives from other clinicians, managers, patients and others as part of a report by The King’s Fund: Organising care at the NHS front line.