I’m afraid I cannot agree with Marcus Longley’s conclusion about the Department of Health’s recent report Hospital Inspections – Led by Patients. He says: “At least they know what matters most to their patients”. I would say they only know what they chose to know about.
The DH work should be commended for having surveyed patients’ experience on what matters to them in terms of cleanliness, food standards, privacy and dignity, laundry, access, and ward and building maintenance – all managerial issues. But did they pose the really important questions about really important things which patients experience to their detriment or advantage when actually experiencing the care element of their time in hospital? My categorical answer is “No”!
I found myself reading the questionnaire very shortly after discharge, following a three day stay for a laparoscopic kidney removal in my local DGH: mentally, I answered the items, siding with the majority of other respondents, and assuming good managers would look after, and be accountable internally, for these matters. Incidentally, I was able to be complimentary across the board about my own experience. By then, though, it had struck me forcibly there were other items I wanted included, things that had really, really contributed both positively and negatively to my time in hospital. These all came from within the area of personal care.
A few of the best things first:
Top, because it has to be up there, the whole process (and outcome) of the operation. A preop visit by the consultant anaesthetist who shared with me his weekend, showing pictures of the Ganesh he had made for the festival. A long chat, both professional and personal, with the Registrar at a relaxed point in the evening. A cheerful theatre porter who knew what it was I was going to have done, and was genuinely encouraging. A post op visit of encouragement by the surgeon, and his smile. The welcome back by fellow patients as I came round, with an announcement of which one had the winning five hour ticket lottery ticket for the duration of my absence. And, joy of joys, a technically difficult operation completed without incident, and with no wound or other infections afterwards.
Equal top of my list, and perhaps strange to some, comes the bed bath provided early morning on the day after the op. To be handled firmly and with dignity engendered a feeling of great confidence in respect of my ability to self-manage movement alongside pain. The staff nurse talked about how the pain would progress –“worse before it gets better”: this bit of reality enabled me to feel less guilty about using the PCA (Patient-controlled Analgesia). He showed me the technique of using a rolled towel to press against the wound as I got out of bed or reached for water. Oh! And the feel of fresh sheets against a clean body.
Second, the ‘connection’ of a Health Care Assistant who took BPs, but talked to me as she did her work, not to other staff as was more usual. She also replaced a very uncomfortable pillow in moments, and checked out that the new one worked.
Third, my fellow patients who cheered and listened in equal measure, and who helped with the little practical things – “Could you push my water over, please?” “Where is the toilet?” One even challenged, in a friendly way, that I couldn`t be as cheerful as I looked – and he was right! The brief, although semi-public, conversation that followed provided considerable emotional relief. But might it have been expected to be a routine exchange with care staff if they had been equally observant? It`s a big thing physically and psychologically to lose a kidney after all.
Many might say the ‘worst’ things were not that disastrous, indeed not really reaching ‘bad’ on any scale, and they would be right. But for a person who was, for a time, totally (and unusually) dependent on others for the basics, this is my list:
Worst of all was failing to be able to ask the right staff member to do a particular thing for me, resulting in delays while the task was handed to another with often a miscommunication of my needs. Result: frustration, and then resignation; and ‘huffing and puffing’ by the staff concerned. But how were you to know who to ask? Sometimes you were referred to a name, but the individual was unfamiliar, and only one person had a visible ID of any kind over the whole stay.
Next, comes the failure by staff to do the right thing first time. A very common response to a request was ‘I’ll be with you in two minutes’, and myself or another patient would be left immobile for a long time on the side of the bed unable, for example, to carry out the normally simple task of putting on a slipper to go to the toilet. This is a big deal in a urology ward! Also, if I wasn’t able to closely supervise, the water jug and glass would be placed on the table far out of reach, with no attempt to check if I could pick it up. Another wait to spot the right person to make remedy.
Third, anonymity is unpleasant and unsettling in a hospital ward. I felt very much things were done to me with little or no preamble. I was supposed to understand what was going on. My faith in this casual approach was undermined, however, by the number of trained staff who asked me what I was to have, or had had done. They had no ID, and mostly did not address me by name. And it was disconcerting to have staff members come into the ward and tunnel their vision to avoid any other than the patient of their immediate concern. This was common and widespread. The ‘get well soon’ card I received might just be getting too close for comfort. A bald naked man is bending over in front of a uniformed older woman holding a clipboard, and she is saying: “Hmm, it looks alright to me, but then I`m just the secretary”.
Last, comes the clear division I felt between doctors and nurses. Both, quite reasonably, had their own observable hierarchies, but I could not see where they visibly came together to coordinate my care. They would refer me from one to the other, but never met together at the bedside. I had to become the care coordinator in effect. I thought I might be relieved of this function when ill.
One other item which deserves mention falls into neither the ‘best’ or ‘worst’ categories. This is the ever- more frequent likelihood of having demented patients in a multi-occupancy ward, requiring the close, almost continuous, attention of care staff. This was a real challenge during my stay; and both the staff and the other patients were kindness itself in helping to control the wandering tendency and prevent drip lines from being wrenched out. At night, however, with other patients asleep, insufficient attention was provided (or available?) and an incident occurred which raised the question as to whether a proper legal duty of care to both the demented person and another patient had been exercised. It left a ward of quite sick people very unsettled indeed.
Fortunately, as the patient in this instance, I do not have to form the questions to get at the softer issues in the above examples. But these are what counted for me. Perhaps patients could be asked, at discharge and by volunteers, for the two best and worst (it doesn’t have to be ‘bad’) things about their experiences of relating to staff, and that would suffice.
Hospital managers should, and most often do, have in place systems to answer the DH questions. This is what they are paid for! Patient’ time should not be wasted on this sort of thing. It is a sop for real patient involvement. But it is only patients that can provide the sort of information necessary to ensure good personal care. And it is up to all those coming into contact with them during their hospital stay to feel it is their duty to care (something beyond the legal duty of care), and to show this in ways that patients can appreciate and feel is of benefit to them. Speedy healing is to some degree dependent on it.
Currently, I might suggest, the situation is very well represented by the caption on another greetings card. Holmes and Watson are laying on the ground at night looking skywards, and Holmes asks Watson what he observes. Watson replies that he sees the stars and the heavens beyond, and the shimmering light from the moon; and he asks Holmes for his observations. Holmes replies that he wonders who has stolen the tent! If the DH is Watson, it remains for the professions to assume the role of Holmes.
Written by Morton Warner, Emeritus Professor