The Tooth Inspector

Argus title : Nurses’ duty is no longer to their patients but to their line manager

I’ve known the ‘Tooth Inspector’ for over 15 years. She isn’t really a tooth inspector. She’s a nurse.

We call her that because when our daughter was very young she used to examine her new milk teeth and congratulate her (and us) on every gummy arrival. We still have the little pink and white tooth mug she bought her to keep her first tooth brush.

She has a name, of course, but for the security of her employment, I won’t use it. I’ll call her ‘T.I.’

T.I. began her career as a Registered General Nurse some 30 years ago. When she moved to Sussex she decided to specialise in ‘elderly care’.

Over the past 10 years, she has worked in 2 Brighton hospitals, mostly for what is now the Brighton & Sussex University Hospitals NHS Trust. In the wake of the Panorama documentary about an elderly care ward at the Royal Sussex County Hospital, I asked her to talk about her work.

T.I. spoke quietly about the need to value elderly people and the clinicians who work with them. She described the diagnostic skill that is required to identify the medical problems of a patient who may present with dementia or delirium – and the overriding need to see “the human being, not just the body”.

She described the satisfaction which comes from relieving the pain and humiliation of an elderly patient, who may be appalled by incontinence and terrified of the possible imminence of death. “It’s so important to reassure people. You have to take the time to talk to them, look into their eyes and build a relationship. Sometimes it’s like detective work to find out the problems and identify solutions”.

She expressed passionate pride in her profession, pointing out that it is probably unique in requiring its members to exercise high levels of skill and carry out tasks which are often considered menial. I asked her whether this should change, but she forcefully rejected this, saying that nurses need to have time to clean and feed frail patients because “it is a way of building a relationship which will reassure the patient and help the nurse identify symptoms.”

“Feeding, cleaning and dealing with incontinence are essential if patients are to be comfortable. You cannot separate infection control from cleanliness and patient well being. They’re all part of the same thing.”.

She said she was “glad” the Panorama documentary had been made. “It was needed to kick things off, but hopefully it’s just the start of a process. The important thing is to make sure that discussion isn’t closed down. All the anxiety and pain will have been worthwhile if something good comes out of it.”

She added: “Elderly care services in Brighton & Hove have had some excellent consultants and nurses, but it’s always been under-resourced and under-valued. ”

I asked her whether this meant that nurses could not meet patients’ needs in the way she’d described. She was silent for a while and then I noticed she had tears in her eyes.

She said very slowly “When I go into work each day, I consciously think ‘which of my patients can I neglect today?’. I choose one, usually someone who’s a bit stronger, that I’ve worked with intensively the day before, so I’m fairly sure that the unqualified assistant can manage, with less back up than I’d like to give them. “

“I work late. I come in on days off. And still I can’t nurse properly as I was trained to do”.

She composed herself and continued: “Of recent years, the staff to patient ratio on these wards has been half what’s considered safe and would be unacceptable in any other ward. Despite the complex needs of the patients, there’s only 1 qualified and 1 unqualified nurse to 9 or 10 patients”

“Agency nurses are supposed to cover staff absence or vacancies, but they are not employed to do a full 8 hour shift. Where we work from 7- 3, they work from 8 – 1. So the hospital saves some money, but the regular nurses have to cover the other 3 hours and do 2 ‘handover’ briefings.”

“And, while other wards can select which patients they take, we can’t. Though you find elderly patients on all wards, those who pose greatest challenges – for example with dementia or serious incontinence – come to us.”

“We’ve been stretched to breaking point. And when we were at our busiest, trying to do the drug round, dealing with incontinence, knowing that several patients still needed to be fed their breakfasts and that the caterers were desperate to clear away so they can meet their targets, administrators would turn up, insist the senior nurse left her duties to help them answer queries about discharge figures. I’ve known them stay for an hour, with patients desperate for care.”

I asked what would happen if a nurse refused. She replied “You can’t refuse. They can be very rude. Some of them seem to have no respect for anyone who works with patients, especially elderly patients.”

“The worst thing of all is the effect on patients of obsession with targets. For example, because of the 100% bed occupancy rule, patients are shoved around, from bed to bed and ward to ward. They never develop a relationship with nurses, there’s risk of infection and a danger vital information isn’t passed on. They lose their possessions, even their false teeth and their spectacles. It’s degrading”

TI spoke about her belief in the NHS; “When I joined the Health Service, the principles of the NHS were fully consonant with the professional standards governing nursing. The codes of conduct governing nurses’ practice still require us to put the well being of patients first, but the NHS has changed. Meeting patient need is often very difficult.”

“The problem came in the 1980s when the market entered the NHS. That was when the Government said that managing a health service was much the same as managing Sainsbury’s. Suddenly, instead of having an overriding professional duty to our patients, our duty was to our employer, to our own particular Trust.

Administrators began to dominate the service. And they have no professional code of practice to put the interests of patients first, still less to respect the advice of clinical staff.”

“A climate has developed in which everyone watches their back. Now, if a nurse sees anything which concerns them, their only obligation is to inform their line manager. If they do more, they can be disciplined. That’s one reason why nurses don’t speak out. People fear victimisation.”

She said “In a system in which you are devalued and can’t express a view, you eventually become demoralised, get out or resort to concentrating on this, here, now – because you’re not listened to. So all I can say to myself is ‘just do the best you can for this patient now’. That’s all I can do.”

“People have asked me whether I’d like to work in a hospice. But I don’t want to. I like seeing elderly patients get well and go home. And any patient who approaches death should receive a hospice standard of care in the mainstream health service. To help someone to achieve a peaceful and pain-free death without fear is achievable, but only with enough staff.”

I asked T.I. what advice she would give local NHS Trusts. She said:

“I’d point out that midwifery has begun to be turned around because mothers and midwives have worked together. It’s a model of what can be done when patients, their families and health professionals work together to plan services. “

“But managers would have to really listen to patients and families, learn from complaints and make patient need the focus of the service. They’d have to employ more clinicians and fewer administrators.”

“The quantum change would be for senior managers to demonstrate that they value clinical staff working with elderly patients, that they have respect for their expertise and are committed to solving problems together.”

As the anniversary of my father’s death approaches, I can’t help wishing T.I. had nursed him. And that she could sit on the Trust’s Board.

I’d feel safer, somehow.

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