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Karen Sanders, Senior Staff Nurse at North Bristol NHS Trust, describes how, too often, frontline staff are at the sharp end of competing priorities.
This is one in a series of stories that the Point of Care programme is presenting on the issues that staff face in trying to ensure a positive patient experience. The views given in this series are of the authors and do not necessarily represent the views of The King's Fund.
A colleague approached me on the ward asking: 'This protected meal times thing for patients – does it cover requests for radiology? Waiting for the end of meals is making it difficult to achieve our scanning targets'.
Protected meal times were brought in to ensure patients' meals were uninterrupted. A protected time to eat your food, whilst it is still hot and looks edible seems a basic right. And protected meal times focus ward staff on the importance of meals and the people who need extra nutritional support. Patients should be able to eat in a timely and dignified way. Protected time reminds staff that other tasks on the to-do list can actually wait. The sanctuary of the meal time prevents everyone else (the occupational therapist, physiotherapist, pharmacist, doctor) from doing what they need to get done, just because it fits with their schedule.
Protected meal times were launched against a back drop of headlines such as: 'patients starve in our hospitals', 'nurses don't care', and patients now require 'water to be prescribed'. Isolated incidences they maybe, and perhaps gross generalisations, but protecting meals helps to slow the speeding juggernaut of hospital business blundering its way through patients’ meal times. We know that people who eat well get better sooner and leave hospital faster, and that those who get better quicker are at less risk of developing an infection, pressure sore or of falling over.
'So' I said, 'I'm afraid radiology will have to wait until after protected meal times to call for their patient. I’m sorry your tight schedule is even tighter as a result, but after all, the Care Quality Commission inspects on many levels for the adherence to protected meal times and grades us accordingly'.
My colleague understood the rationale for protected meal times, but radiology departments face a logistical nightmare every day – slotting outpatients and inpatients into their busy schedules. To her, waiting for meals to end seems insignificant compared to the patient’s need for a scan, X-ray or investigation to inform the diagnosis and plan of care. So, to her, the obvious solution is to allow the porters to call for the patient at any time: clinical need trumps nutritional need every time, and the dreaded breach of the radiological target comes with a hefty fine.
No one would question the fact that patients who need emergency radiology should receive it, irrespective of the meal time or time of day. But for patients who do not need urgent investigations, shouldn’t we respect their right to eat in peace and resist fear of breaching the target to dictate service delivery over respect and wellbeing?
For me, the story perfectly illustrates the fact that, as frontline staff, we are often at the sharp end of competing priorities. Too often, senior executives and board members do not seem to be aware of conflicts and trade-offs, and they leave middle managers to slug it out with us. Almost invariably, it is the most vulnerable patients who can't speak up for themselves, or the patients who don't have visitors, who lose out. They are the ones whose meal times are interrupted, and who get moved for non-clinical reasons, often in the middle of the night. This is why it is so important that the people who run hospitals carefully think through, and articulate to themselves and their staff, what the hospital is for and whose needs and priorities matter most.
Just as the radiologist and I agreed a reasonable solution, a new patient arrived on the ward from the Emergency Department. The meals service was totally disrupted, the domestic packed away her meal trolley, nurses scattered to deal with the new admission, tables, beds and chairs were moved to accommodate the porters and much noise and fuss was made. When I asked the nurse why she had brought the patient into the ward during protected meal time, she said 'Sorry but the patient was about to breach the four-hour Emergency Department waiting target. We would have been fined. I had no choice'.
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