We should see acute hospitals as places for healing

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Part of Frontline clinical care in acute hospitals

Jocelyn Cornwell is chief executive of The Point of Care Foundation. Here she shares her thoughts on what would change if clinicians, managers and boards shifted their focus and placed priority on making hospital wards places of healing and caring.

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.

Comments

Dr Umesh Prabhu

Position
Medical Director for 16 years in NHS,
Organisation
www.bidaonline.co.uk
Comment date
12 May 2017
Very well written Jocelyn. As a Medical Director for 16 years in two Acute Trusts I fully support you Jocelyn. Sad reality is there is no accountability in our NHS for bullying staff or bullying managers or leaders. The culture of bullying, harassment, victimisation are rife. Just look at many Whistle-blowers life, Francis report and BME doctors and staff plight and you notice how far NHS has to go!

Today 45% of doctors in the NHS are BME and 25% of other staff are BME and one has to look at the King's Fund speakers, HSJ journalists, CQC, Monitor, NHS England, NHS Confederation, NHS Employers or many Medical and Nursing leaders throughout the NHS and head-hunters or lawyers and so on; all we see is White and mostly men!

Same old leaders saying same old thing will not make NHS safer or better and patients, staff and NHS suffer!

It saddens me such an important point is missed even by the King's Fund and HSJ! I know Simon Stevens want to get this right and this is why he has funded Work Force Race Equality!

Unless we get leadership and governance right in NHS for all leaders, managers and also to clinical staff, NHS will not be safer or better and we will keep on wasting NHS money!

Hope one day King's Fund will invite me (They have only once) to debate this important issue of governance, values, value based leader and its relation to patient safety and staff well-being!

In a culture of bullying even good staff become indifferent to human suffering!

Paul Walker

Position
retired,
Comment date
13 May 2017
There is a LOT of good sense 'spoken' here.

Pearl Baker

Position
Independent Mental Health Advocate & Advisor/Carer/DWP Appointee/Deputy to COP,
Organisation
Independent
Comment date
17 May 2017
Sadly those of us working in the Voluntary Sector and particularly Carers strive for improved Services, and are constantly ignored when we DARE to question NEGLECT or 'wrong doing' forced to take our concerns through a COMPLAINTS system 'not fit for purpose', and eventually the OMBUDSMAN equally USELESS. In the meantime your concerns regarding Health & Social Care delivered to your 'loved one' continues in the same 'fashion'.

The GP in my case refuses 2 speak to me, on the grounds of CONFIDENTIALITY, despite NEW recently issued GUIDELINES from the GMC 'speak to those you know are involved in their care'. escort to visit Consultant, clean, launder, provide food, still ignored. only option is a Complaint to the GMC re: failing in her 'duty of care'.

All Carers want is for somebody to listen to our concerns, nothing more or less.

West Berkshire Council say 'you are NOT a CARER' it's 'CONFIDENTIAL'
'Safeguarding' issues no food in fridge, dirty cloths everywhere, vacuum cleaner in bits. I use my own vacuum cleaner, change 'bed linen' pick up dirty cloths, take home launder. LGO have upheld a complaint similar to mine, why should we be forced down this route.

I was a 'whistleblower' where people were living in 'filth', London & Quadrant Housing Association admitted 'not up to their Standards. yet without my input the 'slippery slope' would return.

L & Q charge Housing Benefit extortionate RENTS to this particular one bedroom flats complex on the grounds these vulnerable residents are supported, claiming EXEMPT status. West Berkshire Council say some do NOT need support, and my personal experience has shown others are NOT getting the support they need. Will NOT speak to me on the grounds it is 'Confidential'? this has to be taken to the DWP PHSO.

I have provided three EXAMPLES of Insufficient Health & Social Care provided to this one person alone, and there are plenty more.

CARERS are 'propping' up a system, because others continue to delude themselves their CONFERENCES on'Leadership'? is the way forward.

Listen to the EXPERTS by EXPERIENCE you will learn a lot.






















Donna

Position
Sauce cook,
Comment date
26 August 2017
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