Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Caring for, and about, patients.
- Ghislaine C Young (13 January 2007)
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What is wrong with the wards
- Patrick G Beauchamp (14 January 2007)
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Knowing the patients
- Roger A Fisken (15 January 2007)
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Re: What is wrong with the wards
- Hannah E King (15 January 2007)
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Its the same in so many fields of endeavour
- Jim Page (15 January 2007)
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Ego dystonic or syntonic
- Stephen Workman (15 January 2007)
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Excellent article
- Ashley D Southall (16 January 2007)
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Not my patient!?
- Sam Norton (18 January 2007)
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Nurses, doctors and patients on wards
- Richard F Gunstone (18 January 2007)
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An FY1 view - team based doctors produce better ward care
- S G Ninan (18 January 2007)
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positive feedback
- Katherine F Teale (19 January 2007)
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Good nursing care and technical skills are not incompatible.
- Lesley A M EVANS, TA24 8HD (23 January 2007)
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Whistleblower
- Clement Lee (23 January 2007)
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Everythng iis is wrong with the wards!
- Zaheer Mangera (27 January 2007)
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Patient care is suffering in Psychiatry too
- MYOORAN CANAGARATNAM (1 February 2007)
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The Wards
- margaret williams (9 August 2007)
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Ghislaine C Young, Nurse Practitioner BD183EE
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Thank you Dr Teale for writing a thought provoking though disturbing Personal View. As a nurse myself, and with one daughter a junior doctor and another a nursing student I feel well placed to comment on modern day health services. I totally agree with Dr Teale's comments that all the technology and complex treatment modalities cannot replace the essence of nursing or medicine: the art of communication with our patients, and the "being there" for them. Steve Wright (Professor of Nursing) said a long time ago that the aim of good nursing care is not simply that patients get better but feel better! When I was a first year student nurse I was exhalted to help my patients to live, and not just prevent them from dying. Aspirational maybe- but what a wonderful ethic to try to follow! I refuse to believe that current nursing and medical students don't aspire to these same ideals, but maybe they need to be nurtured and rewarded. When we analyse outcomes of hospital care maybe it is the patient satisfaction questionnaires we need to take most notice of, and when implementing "Choose and Book" perhaps the hospital of choice will be the one not just with the shortest waiting list or best mortality figures, but the one where the nurses are most empathic and responsive to need.Finally I want to quote Dr Haslam (BMJ 2007 334;47) whom I wanted to cheer out loud when he said: "they taught us how to care for patients, but rarely mentioned caring about them"! If I have one wish it is that nurses and doctors work with each other to improve the patient's experience of their illness, because this is what medicine and nursing should be all about! Competing interests: None declared |
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Patrick G Beauchamp, Retired GP No longer at work HR2 8AL
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I feel that unless and until junior staff have the habit of doing daily rounds with their patients and not merely attending if called by the nursing staff there will be a problem. There will not be the habit of making that relationship with the patient which is so crucial to good practice and which is so richly rewarding to the doctor. I cannot but feel that extra seminars on communication skills do not replace this experience or is as good a training for a life in medicine. Competing interests: None declared |
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Roger A Fisken, Consultant physician Friarage Hospital, Northallerton, DL6 1JG
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Dr Teale deserves our heartfelt thanks for highlighting a problem which has become progressively more serious in recent years. When I do a ward round as a consultant it is the exception rather than the rule for the nursing staff to actually know about the patients' background, current health or progress. Often the most basic questions such as "who has he got at home with him?", "does he still have diarrhoea?" or even "does he have a fever?" are met with a shrug or an embarrassed silence. Dr Teale is absolutely right that the chages in nurses' working patterns have led to a disengagement with the patients' everyday care. Yes, it is true that similar accusations could be levelled at doctors, but the fact is that doctors have never been on the wards all the time - most doctors of SHO grade and above have commitments to theatre lists, out-patient clinics, etc. The one group of doctors who, historically, have always been on the wards were house officers; now their modern equivalents (FY1s) are increasingly pulled away to attend teaching sessions, as though listening to someone talking about evidence-based medicine for a whole afternoon is going to make them better doctors than seeing the principles which they have spent so long in learning being put into practice. Competing interests: None declared |
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Hannah E King, Clinical Fellow in Intensive Care Royal Surrey County Hospital, GU2 7XX
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I wish to respond to Dr Beauchamp. In particular to his comment, in his rapid response, that junior doctors need to get into the habit of doing daily ward rounds. Since starting as a pre-registration house officer in 2001 the only time I have not taken part in a daily ward round was when I was working in the emergency department. It is difficult to find the time to build a relationship with all your patients when you have thirty of them that you see everyday. Baring in mind that you also need to organise investigations for them, chase results and plan discharges before the 5 pm deadline when you can only organise things through the on call. As well as attending if called to see patients by nursing staff and other allied health professional who have concerns that a patients condition has changed. Competing interests: None declared |
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Jim Page, Dental Practitioner and Dental Tutor TN4 8BG
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What a great article - I would think one of the most important single pages in the Journal this year! I'm afraid that the problem is the same in so many other fields of endeavour. As a dentist with over forty years at the toothface I know that most of us do not spend enough time personally helping patients to keep themselves healthy - showing them how to clean their teeth and how to eat sensibly.We would much rather be doing the "advanced treatment" - fixing the teeth that should have been kept healthy in the first place and making them more beautiful. The simple things we delegate to others. This is all very well - it takes less time to train a hygienist than a dentist - but because it costs less to see a hygienist than to have a tooth fixed by a dentist both patient and dentist come to believe that the simple care - the "crap job" is less important than the complex. Unfortunately it is a well know feature of human behaviour that the expensive is seen to be more worth while than the less expensive - it has ever been so. Dr Teale is absolutely right - it is leadership from the top of the professions that is required. Good leaders in all fields know that you have to make your presence obvious regularly and from time to time get in there and do the "crap jobs" yourself. I hope she gets a lot of positive response - not just from Doctors but from all who have a responsibility to look after the NHS - I suspect that it is not more 'Management' that is required but more leadership. Competing interests: None declared |
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Stephen Workman, General Internist Halifax Nova Scotia, QEII HSC
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I agree that ward based care does not receive enough attention or respect. Recently when I asked medical students what they most like about medical practice I was offered one answer "Discharging patients"! Ward based care is a challenging and rewarding aspect of medicine, indeed general medicine patients generate more identifiable problems per admission I suspect than any other group. Unfortunately the concept of patients as burden is becoming deeply but needlessly entrenched in a health care system that values independence and intervention over interdependence and acceptance. Osler nailed it when he said it is just as important to know what kind of patient has a disease than what kind of disease a patient has. To know one's patients is a distinct pleasure but usually overlooked. In an increasingly litiginous and blame based society, the goal of medicine has become consumer satisfaction, great for angioplasty, not so great for nursing home placement or end of life care. Consequently, very important problems that cannot be fixed to the satisfaction of both the patient and the physician are viewed as illegitimate and unworthy. This hiearchy of glory and reward is quite distinctly reinforced by fee schedules that reward mechanical interventions and pay almost no heed to the many complex social dimensions of medical care. This unfortunate value system is then reinforced many times over by the tendency of the human mind to regret inaction much more than action. A considered decision to refrain from intervening, perhaps the most difficult type of decision physicians are routinely asked to make, will always have a greater potential for regret or blame. Competing interests: None declared |
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Ashley D Southall, Clinical Fellow in Medical Education Hillingdon Hospital, UB8 3NN
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Thank you so much for highlighting this problem. As a recent ex-surgical trainee I am incredibly disillusioned by the situation in most hospitals I have worked in. Due to the European Working Time Directive cut down on hours, the increasing inexperience of surgical registrars, and the practicalities of the Hospital at Night, the training opportunities for surgical SHOs have dwindled. Continuity of care has all but vanished and patients are no longer clerked in properly because they will become another team's problem in the morning. I found myself constantly torn between going to theatre to gain cutting experience and looking after patients properly on the wards. Unfortunately for my surgical career I chose the latter. Only once was I ever thanked by a surgical consultant for doing this. The rest of the time the consultants mostly keep quiet as by looking after the patients well, their figures improve and the patients write less complaints. Also they are able to cram more operating in without having to train the slow SHO, and come under less flack from other theatre staff who, it seems, are becoming increasingly intolerant of SHOs learning to operate as it means the list occasionally overruns (no-one books a training list anymore). During visits by the Deanery I have been asked to bend the truth about the quality and quantity of training opportunities in return for a good reference. I recently heard of a house officer getting the top surgical rotation in a region through neglecting his ward patients and making his face known to the consultants in theatre on a regular basis. The other PRHOs frequently had to do his ward jobs and it is rumoured he didn't know how to take blood or put a cannula in. Being a "nice" surgical SHO is difficult in that you are more likely to be called by the nurses about other people's patients because they know they won't stand a chance with the SHOs who drop everything to go to theatre. Experiencing the patient side of things recently, my wife had a caesarean section. The consultant, who had met me in clinic and knew I was a doctor, never showed his face once. The SHO performing the operation (to my astonishment) didn't introduce himself to my wife or myself until 2 days later when he was reluctantly called to write the discharge letter. The registrar supervising the operation had no idea which consultant my wife was under nor any idea about her previous history of a near fatal post-partum haemorrhage. If that's the care you get as a doctor's wife I despair for the rest of the public. Thus, in the current climate more so than ever, those kinds of conversations between surgical SHOs are likely to become increasingly common, as adopting that kind of attitude (if you didn't have it already) is the only way to progress in surgery. Competing interests: None declared |
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Sam Norton, SpR Plastic Surgery Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY
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I agree with Dr Teale's assessment of the current ward-based mindset and am grateful that she has brought it into the public arena. It seems a rather sad reflection of how the NHS has "evolved" to see such a great change in staff attitutes compared to my first ward experiences as a medical student over a decade ago. I feel a great deal of the problem lies in the lack of responsibility/accountability that exists in day-to-day patient care. With junior doctors on shift work patterns, a consequence of the European Working Time Directive, the individual burden of care a doctor used to have with their consultant's patients has dissolved. Patients are now exposed to multiple medical staff during an admission under the umbrella of the admitting speciality or specialised ward with no junior actually being allocated to the individual's care. Regularly patient don't know who their doctor is and the shared care they receive results in an all or nothing type response. If an investigation is not requested, for example, it's nobody's fault in our no-blame culture and it is only the patient who is subject to the consequences. Equally, for the same reason, their is no longer any pride generated in a patient's ward care and ward duties become seen as merely chores. A different attitude exists within nursing care where the opposite approach has been adopted. Patient allocation to nursing staff is tightly adhered to. The readily used phrase " Sorry, they're not my patient" when attending referrals on peripheral wards emphasises the point with the words patient and problem being seemingly interchangeable. Here responsibilites are restricted to only an individual's allocated patients at the expensive of general ward care. Perhaps, I admit, I am a little old fashioned in my views and approach but there is a lot to be said for the wealth of experience and satisfaction that can be gained from working in a busy ward setting. It is likely that only patient dissatisfaction will see a change in the modern trend. Competing interests: None declared |
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Richard F Gunstone, retired physician;part time lecturer in undergraduate medicine University Hospital Coventry and Warwick, Coventry CV2 2DX
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One minor contributary reason, I believe, why nurses don't see their patients, is that, on many wards, the nurses station is invisible to patients on their beds and vice versa. Bring back Nightingale wards with the nurses' desk in the middle. Competing interests: None declared |
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S G Ninan, FY1 House Officer Leeds General Infirmary, LS1 3EX
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As many have already said, thank you Dr Teale for an excellent article. I have to agree with many of the points you make. You are right to point out that it is sad and bizarre that we have been taught so much in communication skills yet many of is do often put these to good use. You are right to point out that poorly managed problems on the ward are well remembered by patients. The converse is also true. In my first FY1 posting in surgery, I worked in a team based system where the senior surgeons spent most of their time off the ward although I have to point out that I have found that the surgeons in the hospital I work in were actually quite good at spending time on the wards with most teams doing twice daily ward rounds. Despite my novice's skill in venepuncture and cannulation, I found myself to be well-like by patients for explaining diagnoses and keeping them updated with their management progress "your endoscopy could be any time. Some of the machines are broken" This is ultimately rewarding for patients and myself - patients are happy if they are kept well informed, my team was happy that I knew what was going on with my patients and I was happy that I felt appreciated by my team and patients alike. I have now moved from a team-based jobs to a ward-based job. Although my new ward is very busy, it is not as busy as my old job and bizarrely, despite spending all my time on the ward, I spend less time with patients. The nurses and the other doctors I work with are all excellent and hard working. However, instead of my old - ward round, jobs, problems and review routine, there are three separate ward rounds each day by each of the teams and a consultant ward round on most days (6 a week) which means i miss out on many ward rounds because they often overlap and I spend much less time with patients. All of this leaves me with a list of disconnected jobs to do from patients I may not have seen, so I don't even know why they need these investigations in the first place (reading the notes doesn't always explain doctors thinking). I don't see all of my patients every day, so I don't know them well. I spend very little time with SHOs or registrars (who total 11 in number)and thus learn less from them , all of which is detrimental to patient care, my personal learning and job satisfaction. For good ward care, you need team-based doctors. Competing interests: None declared |
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Katherine F Teale, consultant anaesthetist Hope Hospital, Salford, M6 8HD
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I've had lots of positive response to my article, which I wrote with some trepidation. Some interesting responses have come from trainees, concerning how best their role can be organised on the ward - ie ward- based or team-based, and this is a debate which we are currently having at my own hospital. I'm not sure what the answer is. It's very sad that several trainees have confirmed my assertion that spending time on the ward is often neither noticed nor rewarded by seniors - this is something consultants need to address. My own experience is that wards function best where all the professionals involved take their fair share of responsibility - nurses, trainees and consultants. Sadly this is not always the case. Lack of organisation on the ward has multiple effects - not only are patients not cared for as well as they might be, but they are often not prepared for theatre in a timely fashion, and complications lead to delayed discharge. All of these are bad news for NHS hospitals if we wish to compete in the current climate. Competing interests: None declared |
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Lesley A M EVANS, Retired Consultant Physician No longer working, TA24 8HD
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I heartily agree with all Dr Teale has written, and it saddens me greatly to hear that the situation on the wards is now even worse than when I was working as a Consultant in Geriatric Medicine until 12 years ago. Why is it not possible for nurses (and doctors, come to that) to be skilled at the personal, hands-on bedside care which all ill, dependent, vulnerable people need, as well as being able to read ECGs, and acquire all the technical skills which modern nursing and medicine require? Why should it be either-or? Why not BOTH? There is nothing more important to the patient, and nothing more satisfying to a good nurse, than to be able to make the patient comfortable and reassured in mind. To be washed and turned regularly and competently is surely basic to good care. A patient who is not washed properly and frequently is at far greater risk of developing pressure sores, and infections, which will delay recovery and prolong hospital stay. A patient who cannot feed himself must be fed patiently and properly or he will not recover as quickly, if at all. It is surely not just compassionate and good nursing care to do these things, it is also good economic sense, as there is so much pressure on bed availability. I feel one problem is that so few young people today have any personal experience of illness, weakness and vulnerability, and seem unable to put themselves in other's shoes. My mother, who was a superb practical nurse, always said the professions of nursing and medicine are not in competition, nor is one better than the other. They are sister professions. I could never be a nurse, and I have enormous respect for good nurses. In Geriatrics I was privileged to work with many excellent bedside nurses, who did far more for the patients than I ever did. We were also extremely fortunate to have our own dedicated hospitals, where we knoew all the staff, including the porters, the gardeners, and the hairdresser, and we worked together as a team. I always did my word rounds not just with my SHO (I had no other juniors) but also the Physio and OT who were allocated permanently to my team, and who knew all the patients, as did the nurses on the ward. After the round we met the Social Worker, who worked exclusively for that hospital and knew everyone. This team work was crucial to the efficiency of the system, and it worked. Unfortunately, and wrongly in my view, our old Geriatric hospitals were closed, and the patients moved onto wards at the DGH where we lost our own therapists and social workers, and the nurses had little interest in the elderly. The stiuation has changed since then,in that dedicated wards for the elderly have been opened since I left, but I still think the old system worked best. I also covered peripheral hospitals, in one of which I had 45 mainly rehab patients anad no junior doctor, and no ward clerks. I took all my own bloods, wrote the request forms myself, saw every patient at least once a week, and held multi-disciplinary meetings. The nurses and I worked together as a team. I was also first on call every third night for that hospital for some time as the GPs did not want to do it. I took all the OP clinics myself. Personally I loved the hands-on medicine and being so close to the patients, and my particular interest then was palliative and terminal care. This changed when so many patients had to go to Nursing Homes. There is nothing more satisfying that the one to one relationship with patients, and coming to know them as friends. I would not want the high tech side of medicine and the administration to destroy that precious relationship with ill people, which is what nursing and medicine should be all about. Lesley Evans. Competing interests: None declared |
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Clement Lee, SHO in Surgery London
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Dr Teale thank you very much for your article. As a surgical trainne, I throughly enjoyed reading it with a lot of mixed feelings. Without a single doubt, the quality of patient care within the NHS is deterioating very fast although I must give credits to those of us who still try our very best to maintain the expected standard. I recently discussed the problem with my colleagues who had previouly worked in America and Australia. Our conclusion is as follows: 1) The NHS concentrates too much on target figures and patients are often treated like commondities. Hence, their quality of care suffers. 2) The NHS is currently under a lot of financial strain. This leads to massive cutting of resources and staffing. The morale and disappointment among staff are at critical point. My current trust is going to downband my post in February becasue only 1 surgical SHO will be covering the whole hospital at night as opposed to two in the past. Despite every trainee and consultant crying out loud the foreseeable danger associated the new arrangement, the hospital management team decided to go ahead. 3) Due to the EWTD, doctors now rarely look after their patients right from admission to discharge. Patients and nurses often get confused with the treatment plans because different teams might approach the problem slightly differently. This simply makes the general public lose respect and confidence in the profession. 4) There is far little communication between doctors and nurses. I can hardly recall doing one single ward round with the presence of a nurse since I started the rotation. The high patient turn-over rate and shift- work pattern makes nurses very difficult to follow their patients, especially a lot of them work only 3 and a half days per week. Given the current situation in the NHS, I don't expect nurses to do the daily ward round with doctors but it should at least happen during the consultant round. 5) Team based medicine may be a good solution to the problem. In Australia, surgeons spend a similar number of hours in hospitals like us. However, the team is responsible for the care of all their patients even when they are not on call. Registrars or residents will be called in to see their patients if they become unwell. Admittedly, this idea is quite tough on surgeons but excellent from the patient care and training point of view. In the US, interns and residents are given much more responsibilies. Interns have to do their prerounds and sort out the patients on their own before their residents and attendings come in. This is again tough on the juniors but their reward is to learn and get involved in the care plan of their patients very quickly at a much earlier stage when compared to the house officers in the UK. Competing interests: None declared |
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Zaheer Mangera, FY1 Basildon Hospital, Nether Mayne, Essex SS16 5NL
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At Basildon Hospital most junior staff (FY1s and SHOs) openly admit to hating having to cover the wards when they are oncall and I am sure it is the same at most hospitals. This is not because there is a lack of desire to care for our inpatient's but because we are simply overwhelmed with the number of patients and wards that we are expected to cover and the fact that our bleeps never stop bleeping. However this does not mean to say we hate covering wards when we do our normal 9-5 shifts where most of my colleagues would not dare to leave hospital without seeing all their patients. There are of course many occasions when we do all we can do avoid having to see patients outside of the ward round, trying to solve problems over the phone or simply looking at observation charts and fluid charts and prescribing without even looking at the patient. My own opinion is that all too often as FY1s we never build up a rapport with the patient, as the time to build that rapport is in A+E/medical assessment unit when the patient is first clerked and there is sufficient time to build a relationship. Once a patient care is transferred to our consultants opportunities to build rapport are few and far between, patients being referred to by their bay and bed number. Without this foundation a caring attitude is undoubtedly much more difficult to generate. This can be blamed on European working time directives, the fact that ward rounds go at a rate of knots or simply because we do not do enough medical procedures that give opportunities for patient contact. Whatever the underlying reasons, from an FY1 point of view this requires careful attention by those modernising medical careers!!! Competing interests: None declared |
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MYOORAN CANAGARATNAM, SHO Psychiatry St Annes Hospital, London, N15 3TH
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Dr Teales article clearly has resonance with health professionals of various disciplines and specialities. As a trainee doctor in psychiatry, I believed I was entering a speciality which, above all others, valued empathy, communication and seeing patients as people rather than illnesses. I regret to report that, all too often, my experience in this field has been that my only scheduled time on the ward has been during the consultant ward round, where my primary duty has been keeping notes, and where there is little scope for developing rapport with in-patients. Much of my other working life is taken up by outpatient clinics, community assessments, and required attendance at teaching programmes. This is even before considering the demands of completing audit and research, which have become vital for career progression in the modern NHS. The problem is not so much the attitude of medical students and trainee doctors, rather it is the value the system places on providing concrete evidence of activities which must look increasingly impressive in the current competitive environment. Furthermore management appears intent on squeezing the most in terms of service provision of every doctor, with little regard for quality of care. It is little wonder that in this climate, patients become jobs-to-do lists, and the subjective experience of being a patient has deteriorated. Competing interests: None declared |
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margaret williams, Asthma nurse Child Health, Croesnewydd Rd. Wrexham LL137TD
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Thank-you Dr, Teale for your brilliant observations on life on the modern ward.It is a sad reflection on our training and priorities. The focus must return to the patient with a revival of the therapeutic nursing and medical contact being valued more than words and acaedemia.The latter would then fall back into it's rightful place. Competing interests: None declared |
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