Reviews Personal views

What's wrong with the wards?

BMJ 2007; 334 doi: (Published 11 January 2007) Cite this as: BMJ 2007;334:97
  1. Katherine Teale, consultant anaesthetist
  1. 1Salford Royal Hospitals NHS Trust, Manchester M20 3JS

    One of the more depressing moments in my week came when I overheard a conversation between two surgical trainees. “I'm covering the ward today,” said one disgruntled young man. “I always get the crap jobs.” His colleague was suitably sympathetic at this terrible misfortune. When I teach the medical students they seem fired up with the desire to help people. When does this become limited to wanting to cut bits out of people, send them back to the ward, and forget about them?

    It's not just the doctors' problem. The Royal College of Nursing recently warned that cuts in nursing jobs are putting patients' lives at risk. Certainly understaffing is a serious issue—but my experience of many wards is that there seems to be an invisible barrier between the nursing station and the patient areas. Nurses only cross this to do a specific task, and then scurry back to the paperwork as quickly as possible. Recent figures show that three of the four commonest causes of delayed discharge are associated with inadequate care on the ward: pressure sores, healthcare acquired infections, and medication errors. Although the news is full of stories about high technology surgery and expensive new treatments, perhaps what we should all be focusing on is the poor care that patients often receive on the wards.

    Friends and relatives who have been inpatients recently all have similar complaints—never seeing a nurse except when drugs were being handed out, no one offering reassurance or information, days going by without any contact with senior medical staff, having to beg for help moving up the bed or getting to the toilet, repeated requests for analgesia. Two elderly relatives developed pressure sores after straightforward surgery, and one lost 6% of her body weight after a joint replacement because of prolonged nausea that was inadequately managed. It's these experiences, and not the skilful surgery, that patients remember and tell their friends about. And it's these that make patients, especially elderly patients, dread being in hospital.

    Ironically, this is happening at a time when great emphasis is being placed on communication skills. Hours are spent teaching medical students this art, and our problem based learning cases are packed with “social cues.” Yet both doctors and nurses spend less time than ever actually communicating with patients. Part of the problem, of course, is the change to medical training—trainees, now working shifts and covering many more wards, have less time to spend with individual patients. Many of the tasks that would have brought trainees into contact with patients (taking blood, performing electrocardiograms) have now been delegated to nurse practitioners. Similarly many of the tasks done by trained nurses (“turning” rounds, handing out meals) are now done, if they're done at all, by auxiliaries. The result often is that the only people whom the patients regularly see are completely untrained—and all the valuable information about patients' progress which used to be gained has been lost, as have the opportunities for patients to use these casual contacts with staff for reassurance and asking questions.

    It's easy to blame the nurses, but we doctors have to take our share of responsibility. I've worked on wards where care is excellent; the difference is mainly good leadership, both from the nursing hierarchy and from the consultants. If the senior medical staff are rarely on the ward seeing what goes on, if they don't act as role models for their trainees, and don't make themselves available to support the nursing team then patient care suffers. Ward care is just as important as complex surgery—and can be just as difficult—but unfortunately it is not so glamorous, nor is it appreciated by peers. No one ever got a merit award for looking after their patients well. In fact, it seems that the less time you spend with patients, the more likely you are to be rewarded. This is tragic, not only for the patients but also, in the present climate, for the future of the hospital. It's madness to spend thousands of pounds on fancy surgery if the patients are then allowed to develop avoidable complications.

    The crisis on many wards is the result of lack of trained staff, lack of continuity of care, and poor leadership, and it is directly harming patients. Many of these changes are out of our control, yet they have created a problem that we must recognise and deal with. Doctors often complain that they feel helpless in the face of NHS reforms; this is one area in which each and every one of us can make a difference—simply by making time on the ward a priority, reviewing patients, guiding the trainees, and supporting the nursing staff. If providing care on the ward continues to be the “crap” job, the experience of those unfortunate patients will continue to be lousy.

    We should all be focusing on the poor care that patients often receive on the wards

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