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Elderly care takes centre stage

Marilyn Eveleigh
Nurse Adviser and Independent Trainer
East Sussex

The media glare is once again directed at hospital nursing staff following the CQC's report on the dignity and nutrition of older people. What does this mean for community nursing staff?

The wretchedness of being old, ill and dependent has yet again been highlighted in another damning report. This time it was the Care Quality Commission's (CQC) unannounced visits made to 100 hospitals between March and June 2011 that provided the basis for the latest debate The regulator visited two wards for the elderly in each of the hospitals, looking at standards of dignity and nutrition. The results? 20 hospitals failed on either one or both standards.
One in five.

The reasons? For dignity shortcomings: call bells were found to
be out of reach, staff addressed patients in a dismissive or condescending way, and staff shortages with insufficient skills were identified. For the nutrition failures: interrupted mealtimes with patients not given help to eat and no assessment of dietary needs were reported.

The implications? Nursing, the bedrock of caring, has failed to ensure basic patient needs are met. Following three previous reports in the last year that outline similar themes, the media has had a field day on the risks of hospital admission, instilling fear in the vulnerable patient and carer, and shame and anger in a frustrated profession.

The irony? In many cases, the best and worst of standards were found in the same hospital, despite having similar staffing levels. It appears staff attitudes and consequent culture are key to preserving patient dignity and nutritional standards.

The most interesting fallout? For me, it was the suggestion that some wards were so busy and nurses sorely stretched that relatives should consider feeding and providing basic care to their loved ones. A subsequent exchange identified some relatives would like to feel useful in this way - and there are those that have already stepped up to the task through dire necessity. Yet this is the norm for the vast majority of very elderly and sick that remain in their own homes.

The literature on nutrition makes for interesting reading. There is a significant number of studies highlighting that three million people in the UK are malnourished. Furthermore, the number of malnourished patients discharged from English hospitals over the last 10 years has increased by 85% and poor nutritional status has negative outcomes for pressure area development, wound healing and prolonged hospital stays. Fortunately, nutritional assessment tools has empowered the profession to objectively target those at risk. Patients must be clinically assessed - but being supported to eat and drink cannot be restricted to the nursing role.

The majority of the studies on malnutrition have been in hospital or institutional settings: as are the measures of dignity towards patients. It is easier to measure in such environments. Teams working closely, covering 24-hour care and continually observed by peers and relatives, establish a role and culture of behaviour that becomes the norm - be it positive or negative.

This is not the same for patients nursed in their own homes. Entry to the home and participation in care regimes is a patient choice. Indignity can be challenged and lack of privacy is rare. Cooperation and mutual interdependence generates a different power balance in the patient/nurse relationship.

Could community nursing be equally criticised by the CQC, Age UK and other researchers if we were under the spotlight? I'm certainly not aware of any shaming reports of poor nursing standards and care in the community. Yet the same issues are there - appropriate training and competencies, staff numbers and skill mix with HCAs, compassion and workload, burnout and accountability.

Have we been lucky? The CQC is there to measure outcomes not procedures - one day it will ask our patients and their carers about their experience of our service. We cannot be complacent.

1. CQC [2011] Dignity and Nutrition for older people. dignity-and-nutrition-older-people