Direct nursing care for our elderly folk has most definitely taken a turn for the worse. Common sense and basic skills training have flown out of the window and the ward sister is no longer allowed to manage the ward without interference/intervention from others who are not familiar with the needs of the patients in her care. Dr Peter Carter states that families should be encouraged to assist during mealtimes and to toilet their relatives.

Would they be expected to complete a nutritional assessment chart or manage them if they fell whilst mobilizing? The Registered Nurse would most definitely be held responsible and accountable if something untoward happened on her shift. We have always encouraged the help and support of relatives where appropriate. On occasions the assistance of a relative - or even another patient has been the only way we could manage the work load, the difference is we never expected non-clinical people to help, nor did we 'put them on the spot' or make them feel obliged to help. One patient with dementia process or challenging behaviour (or both!) can disrupt the whole service for many hours. Extra nurses are not available from other wards and on-going use of agency nurses as a back fill is not the answer to this so called 'no time to care' situation.

Once relatives are seen to be willing to help it will be expected of them and nurses will assume that the help will continue to the degree that they may actually exclude a person who is being assisted by a relative from their handover stating that 'her sister will be in later to help her'. Staffing levels are constantly low despite the fact that demand remains high. Staff numbers may appear adequate on paper, but the actual number of nurses on a ward delivering direct care can be greatly reduced once non-clinical duties have been addressed. A Registered Nurse can be lost from the numbers for a whole shift doing seemingly constant medical rounds, administration and management tasks or attending meetings outside of the ward area.

Protected meal times is not a new concept. It was introduced (albeit not properly) to ensure patients were not disturbed during mealtimes. Non-urgent X-rays, blood tests and endless admission criteria questions interfered with the need to eat. Registered Nurses are invariably doing a medicine round at all mealtimes and so cannot oversee who is eating and drinking and more importantly who has had a tray taken away without the lid being taken off the plate!

Time constraints imposed by employers who have no idea of individual needs, especially those of the elderly, are unreasonable and inconsiderate and can contribute to a persons deteriorating state of health. On the average medical ward, in my personal experience, the time 'allowed' for lunch is 3/4 hour. This includes serving up, talking to the patient, time to eat the food, collect in the trays and return them to the trolleys for removal from the ward. 

Contractors have little or no insight into the care needs of the individuals for whom they provide a service. I have seen boiling hot beverages, filled to the brim, issued to elderly people with confusion or Dementia with an instruction to 'wait 'til it cools down' (if indeed this is told to them at all).

Ancillary staff are left to cope with mealtimes whilst the Registered Nurse is elsewhere, probably 'doing the meds'. It will be this same nurse who will commit to writing a nutritional care plan for a patient she has not observed herself. The same can probably be said for mobility, personal hygiene, communication, fluid intake etc etc.

A solution to the nutritional problem is for the registered nurse to take charge of their shift and manage it according to the demands and needs of the patient. Rather than going straight to the medicine trolley or cupboard after morning handover from the night shift it would be sensible to walk around to see the patients and to assess the whole bed space for clues as to the sort of night they have had, e.g. cold tea still in cup from night before, a full and untouched water jug, half eaten, dried up sandwich, a granny smith apple with some evidence of an attempt at biting it, soiled pillow cases/sheets, full drainage bags, empty intravenous bags - I could go on.

It really makes good sense to do this before medication is offered as most older people want to empty their bladder first thing and will ask to do so as the nurse is about to give them water tablets! These tasks cannot always be allocated to someone else and so the nurse will have to return the medication to the trolley, lock it up and help the patient with a basic need which was not addressed in a timely way - i.e. first thing in the morning.

The system is failing our older and elderly people. If nurses do not grab the nettle in the name of patient care it will fail absolutely and there will be no going back. Personhood, individual needs based assessed care and planning, are words which are bounced around the system in the name of improved care, when in actual fact it seems that it is the 'squeaky gate that gets the oil' and those who cannot and dare not ask don't get a thing.

The person as a patient need the same in this day and age as they did in 1975 when I began nursing - rest, w warmth and treatment, food and drink, inclusive care and the chance to recover in an environment of same gender wards staffed by nurses who genuinely want to be there and are competent to care properly - it really is not difficult.

From

Kaye Steel

Portsmouth