When I qualified I remember what was then called ” task-orientation.” We started in bay one and went, in two teams, up and down the ward with our care and our trolleys. With aprons on, we washed and turned, fed and hydrated our patients. Every chart was filled in, everyone seen, mobilised, toileted. Dressings were done,medication was given and when that was finished we went off to separate breaks ( one team at a time) and then came back and started it all over again.The ward sisters -there were two of them had an eye on everything. Nothing was missed and woe betide you if it was missed. The ward sister was the heart and the nucleus of everything. Doctors went to her, everyone went to her. She often took the phone calls. She managed everything. I was lucky as I was on a strict but excellent ward in terms of care. There was no shortages of nurses wanting to work on this ward.
However, task orientation was criticised. It was not giving personalised, individual care. People were not a set of tasks but with unique and differing needs. The regular “Kardex”, as it was called then, of writing up the care was changed. Up to this point it had been short and concise. An idea from America came to our NHS,it was shaped on the Roper’s Model of Care:it was called the Nursing Process. This was the first of the mountain of paper that emerged.It meant that all patients had to have an individual care plans for every activity of living. These were first hand written and then when I left nursing they were typed photocopies and had become little more than tick-boxes, another task in my opinion.
Then something else happened which changed our role. Doctors were working sometimes 80 hrs a week, being on call etc and this was rightly considered too much, something had to be done. With this concern came an increase in technological advances in care. Patients who might have died now lived with advancing medicines, diagnosis and procedures. Slowly, the nurse practitioner would be born out of all of this. However, in the mean time sisters were becoming bleep holders, budget holders and bed managers. Staff nurses became clinical shift leaders and I was told to take my apron off and start running the ward instead. There were still qualified nurses and nursing auxilaries doing the care, but what was once undertaken in a higher dependency unit was now becoming mainstream on the wards. This was very marked for me when I returned to acute nursing after working for four years in elderly care rehabilitation. The work load even by then was becoming more stressful.
So registered nurses paper-work increased, more advanced skill became the norm, including venepuncture, cannulation, IVI drug administration to name a few. Hotel workers replaced nurses both qualified and unqualified in giving out meals and drinks. The nurse mentor was born and he/she was now responsible not only for patients but for students as well. This was all happening when I left acute hospital nursing in 1993. I left and went into community after a particular night when one visitor came up to me and said:
” Hello again, there are two things I observe about you. One is that you are always here and two you are always writing out bits of paper.”
It is now 2013 -20 years has passed since then.
Now multiply what I have said a few times more, as demand for services, changing clinical roles, paper, stats, sicker older people, European Economic Community patients needing care, cuts in resources, cuts in staff and you can begin to see why we are in the current crisis situation. Also, crucially from the very top of the decision-making tree, our government and senior NHS management, who increasingly see patients as a entity of profit-making and not focusing on them first as someone needing care. No wonder the Government is stating that it is costing just all too much and auctioning the whole care parcel out to who ever can give the best price…..
Tomorrow: Let’s start to look at leadership within the NHS.