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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Nursing in today’s hospitals is a very different task from nursing 20 years ago

Filed Under (Nursing) by Paul on 23-07-2012

Dr Foster – the informatics company – has an ethics committee which holds a number of discussions. Last week I went to a session on the role of nursing in the modern hospital. These take place under Chatham House rules which means I can say what was said but not who said it.

There was much debunking of the idea of a ‘Golden Age’ of nursing which has been talked about as having been between 1950s and the early 1980s – and I will return to that issue later.

But the most important issue was a discussion about the changing nature of the patients that are actually in hospital needing care.

The changing nature of what goes on with inpatients in hospital over the last 30 years is very dramatic.

At any one time in the early 1980s most patients in hospital were stable and quite well. Crucially most were in hospital for some time with lengths of stay being long. Patients were also younger then – with a female life expectancy of 77 in the nation as a whole.

2012 hospitals are very different places. In the last ten years A and E attendance has increased by 46% and the number of outpatient appointments has increased by 42%. This means that the number of patients going through hospitals has increased enormously.

For a nurse working with outpatients and in A and E this means that the increased efficiency of the hospital organisation has led to many more patients passing through your hands.  It is very difficult to construct a ‘personal’ service when you don’t have time to get to know anyone because there are so many people coming and going..

But it is inpatient care that attracts the major criticism of current nursing style.

But inpatients are similarly different from 30 years ago. Patients are in hospital for much shorter times and they are much more ill and older. 80% of medical beds hold patients who are over 80 – and 25% of patients are cognitively impaired.

Think what this means for a nurse who is caring for a 10 bedded bay ward. Most people will be very old and can do little for themselves as they are quite ill. In a week there will be about 30 patients going through the ward, and 7 or 8 of them will be cognitively impaired.

Compare that to a similar week in 1982. A dozen patients who are younger and fitter – the job is very, very different.

I can conceive of creating a relationship with a dozen people in a week. But I am not sure I can understand how to make 30 relationships with people who are coming and going after 3 days – and who are more ill.

I have written previously about how difficult it must be to work with a ward of people who are so cognitively impaired that they do not respond to names or show any recognition, but my point here is that the pace of throughput – essential to the modern hospital – and the older sicker people with whom we are working makes it much, much harder to form the human relationships that we need at such times of crisis.

The real point is that our hospitals are, over the next decade, going to be working with more and more patients with quicker throughput. Patients will get older and more ill. So the issue will get bigger and bigger.

Training and support will be needed to help nurses cope with many more older and more vulnerable people during a week’s work. Getting to know 50 different people in a week and making them all feel exceptional when they are very sick and vulnerable will not be an easy task. But it is the task that modern health care sets for hospital nursing.

Of course it was different in the 1950s and there was some discussion about the fact that there wasn’t a ‘Golden Age’ of nursing. The point I made at the discussion was that those people that believe in the ‘Golden Age’ don’t believe that the past was so wonderful in any rational way. They believe it because they want to hate the present and the future. They feel better about today if they can convince themselves that yesterday was so much better.

The Daily Mail, amongst others, depends upon the past being so good in order to demonstrate how the present is failing. Nothing, no set of facts, will change that.

What is necessary is for modern nursing to make its case about its tasks in tackling the real world of hospitals today and demonstrating how it can better work with an increasing number of older, sicker people in a week with dignity and safety.

Comments:

3 Responses to “Nursing in today’s hospitals is a very different task from nursing 20 years ago”


  1. In addition to the change in patient profiles and lengths of stay, there have been major changes in nursing training, and job organisation – both in nursing and in the rest of the team with which nurses work.
    It is arguably easier to function if you are part of an identifiable multidisciplinary team – probably ward or department based – than if you have a large number of ever changing medical, health care assistants, cleaners and other essential team members forming temporary teams and not necessarily relating to the same group of patients.
    Did anyone offer any solutions or possible solutions?
    Nursing and nurses cannot be taken in isolation…


  2. As a nurse who trained in the late 70s and who has recently worked as a Bank nurse, I welcome these observations. I would add that the problems are around complexity of care rather than acuity. In 1980, most patients had a single illness wheras in 2012 they have multiple co morbidities and this increases their needs (and the risks) exponentially. Current workload measures do not capture this and so staf numbers and skill mix do not reflect the actual care requirements. It was interesting to note in the draft mandate that high quality nursing was mentioned a few times but we need to take a long look at what that measn in 2012


  3. I find the above comments somewhat amusing.

    20yrs ago was at the time of the
    ‘nursing process’. Now that was a waste of time! In theory, it appeared a valid approach to care. As it has since developed, it has resulted in the nurse
    role being akin to that of an essayist and confectionist [with the admin’ of medicines. Please don’t say the patient hasn’t been forgotten in all this!

    Thirty years ago, they were the days of
    60+ on non-mixed sex wards. They were also the days when SEN’s [State Enrolled Nurses on night duty were responsible for 180+ patients. They were NOT the ‘good old days’ nevertheless they were pleasant with standards of care very much higher than they are today.

    In my later years I was asked by a consultant regarding the changes I had seen in care [of the Elderly Mentally Ill]. My reply was that the furnishings had improved as had the wages. Other aspects including the standards of care were in decline. . . . .and still are today!

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