Nursing Standards

226. We have already made a number of criticisms of the standards of nursing at Ely. They are not the only criticisms we feel compelled to make. It is important that our observations should be read in their context and that the whole matter should be kept in proper perspective. We do not doubt that most, if not all, members of the staff have been trying hard to discharge their duty properly by their own standards. And it must be acknowledged that they are having to do so under conditions which are very far from ideal. The shortage of staff—and above all of staff who have received proper training in modern methods of caring for the sub-normal—is a chronic feature of this, as of many another, mental hospital. Many senior members of the present staff have given years of faithful service, having been brought up under a tradition and in conditions which date from the old Poor Law. A medical member of the HMC had all our sympathy when he asked what more could be done with “the awful building here. It gets a bit boring,” he sajd, “solving the impossible”. A member of the hospital’s medical staff expressed the same sentiment when he said: “In our hospital it is very difficult to do anything new because we are short of staff … I could not inspire enthusiasm for things I want to do and produce, because the people here are overworked”. We are far from unmindful of these difficulties. But the physical conditions and staffing difficulties at Ely are, unhappily, far from unique. It is the function of leadership in such a setting to involve itself in constantly challenging the difficulties. Without such leadership the difficulties will never be overcome, nor even mitigated.

227.Even, therefore, when allowance has been made for all these things, we are in no doubt that standards of nursing care at Ely fall short, not merely of the ideal which is attainable in the 1960s, but of a standard which is obtainable and practicable even in the hospital as it stands today.

228.The matters which have caused us most concern (not listed in order of importance) may be summarised under the following heads:

(a) Seclusion

229. The patient, Byron (in Ward 17A, see Paragraphs 38 to 43 above) was undoubtedly secluded for unduly long periods and there was complete laxity in reporting the periods when he was so secluded.

(b) Dentures and toothbrushes

230. There was, as indicated in connection with the patient, Dryden (see Paragraphs 49 to 56 above) insensitivity and laxity in the care, provision and control of false teeth and toothbrushes. It is plain that the shortcomings in this respect which came to our knowledge were not exceptional: for when Mrs. “Z”, a nursing officer of the Welsh Board of Health, visited the hospital on 30th May, 1967, her attention was drawn to the same topic by her discovery of a pot of unlabelled toothbrushes in a sluice room on one of the wards.

(c) Death of patients

231. The way in which the patient, Flecker (Ward 17B, see Paragraphs 80 to 83 above) was “disposed of” without any apparent examination by a member of the medical staff is indicative of an unduly casual attitude in this respect.

(d) Suturing

232. The case of Housman (Ward 21, see Paragraphs 89 to 96 above) illustrates a situation in which nurses are, as a matter of practice, permitted to administer sedatives and to deal with wounds by stitching without any or sufficient reference to or supervision by the medical staff. Moreover, it seems probable that in this particular case the accepted practice of the hospital (which, in any event, provided for insufficient medical supervision or participation) was not itself complied with.

(e) Incontinence

233. Incontinence is, of course, a major problem in a hospital like Ely. It is as much to the benefit of the nursing staff as of the patients themselves for the problem to be mitigated by undertaking the habit training of the patients affected. Yet we were told by the Chief Male Nurse that this had never been attempted. Until very recently, no use had been made of disposables in connection with incontinence. The matron told us that she had “asked and asked” for disposables to be introduced—but, apparently, without any effect until the latter half of 1967.

(f) Role of patients on the ward

234. In the old era of custodial care, it was customary to keep the patients occupied by giving them menial and domestic work to do on the ward. This pattern of activity is not compatible with more modern views about patient care. Moreover, as was noted by visiting members of the HMC, on 27th April, 1966: “Owing to the reduction in the number of high grade patients and the subsequent increase in low grade patients, the help previously available from the former has now ceased”. The recruitment of 12 additional cleaners was accordingly recommended. In fact only four were taken on—one in each of the male wards, for approximately 36 hours per week. At weekends the domestic work still has to be undertaken by members of the nursing staff, with the assistance of patients. Patients have in addition continued to do domestic work at other times. One consequence of this (see Paragraphs 114 to 117 above) is that one patient has been engaged in supervising other patients to an extent that is undesirable, having regard to his known capacity for violence.

(g) Handling of patients

235. The basic tasks of cleaning, changing and feeding the patients and of attending to such conditions as the prevention of bedsores appear to have been conscientiously attended to. But, in other respects, patients seem to have been treated with a degree of roughness and lack of sympathy. This comment is exemplified by the cases of Addison (Ward 17A, Paragraphs 30 to 37 above), Byron (Ward 17A, Paragraphs 38 to 43 above), Housman (Ward 21, Paragraphs 89 to 96 above), Masefieild and Newbolt (Ward 23, Paragraphs 109 to 113 and 123 to 134 above), Rossetti (Ward 21 by night, Paragraphs 184 to 187 above), and Masefield (this time by night, Paragraphs 188 to 190 above).

236. Similarly, the conditions which we have described as existing in Villa 2 (Chapter 4 above), although no doubt partially due to sheer shortage of staff, appear to indicate a willingness to accept standards of patient care, which fall substantially below those which could reasonably be attained.

(h) Reporting of incidents

237. We have identified (in Paragraphs 73 to 83 above) an undue casualness in the reporting of sudden death and of the necessity to stitch wounds or administer drugs. There seems also to have been a lack of clarity about the necessity to report incidents on the ward, or complaints made at ward level by the relatives of patients. This last matter has been considered by the HMC since the appearance of Circular HM(66)15 and, more particularly, since the Permanent Secretary to the Ministry of Health wrote, on 28th June, 1967, specifically about “Conditions of the Elderly in Hospital”. At a special meeting organised by the HMC on 26th October, 1967, it was agreed that each Hospital Secretary or Matron should register any complaints which they considered sufficiently important to be brought before the relevant house sub-committee.

238. The foregoing recommendations, although still leaving a great deal to discretion, may be sufficient to deal with the more important complaints. The evidence given before us suggested, however, that there was less certainty that complaints made at ward level would necessarily come to the notice of the appropriate senior nursing officer. Thus the Chief Male Nurse explained that there was, at the material time, no system for ensuring that he received notice of complaints of the kind made, for example, about the cutting of Newbolt’s toenails (Ward 23, Paragraphs 131 to 134 above). Although we did not have to investigate the female side in detail, we were told by the Matron that such complaints would, on her side, have been recorded in the ward report book and thus have come to her notice.

239. Laxity about reporting on the male side appears also to be evidenced by the fact that there had, for some years, been no ward night report book; these were only re-introduced with effect from 4th October, 1967. We have referred (in Paragraph 197 above), to the danger inherent in a system of using ward report books whose pages are unnumbered, and which accordingly lend themselves to the treatment suggested by Night Charge Nurse “U “, whereby ” offending ” pages may be removed from the book.

(i) Hand-over arrangements

240. It appears that hours of duty are so arranged that the night staff are due to come on at the same moment as day staff are due to go off duty. Good sense on the part of the nurses, who arrange to arrive on duty some minutes before their official time, has mitigated the difficulties which could possibly arise from such a system (although we heard of at least two occasions when acrimonious disputes arose between members of the night and day staff because of the late arrival of the oncoming staff). Such a system is, however, not conducive to a proper hand-over of ward responsibilities. Similar difficulties appear to arise when the nurse in charge of a ward proceeds to take his/her three days off duty. It is clear that proper consideration needs to be given to the actual times of duty, so as to ensure an adequate overlap between night and day staff and adequate reporting by one Charge Nurse to his/her successor.

(j) Ward management

241. We have indicated in Paragraphs 29, 58, 88 and 99 above that, so far as their physical condition is concerned, the patients in all the wards appeared to be well cared for. We did, however, observe (particularly in Ward 23) many signs of poor ward management. Thus, for example:

(i) Soiled linen was being sluiced in open sanitary annexes on the wards;

(ii) In some cases, “sterile” equipment was either not sterile, not in use (see Paragraph 100 above) or being used for the purpose of storing materials, such as dressings, which were not themselves sterile;

(iii) Medicines were untidily or carelessly cared for (thus, for example, in one ward cupboard there was an unlabelled and uncovered cup containing paraldehyde);

(iv) There were insufficient towels and face flannels—so that, throughout the male wards, such things were being used on a communal basis;

(v) Particularly in Ward 23 (see Paragraph 100 above) stores and equipment were untidily disposed of and often muddled together. In several wards there was evidence that stores had been “stock­piled”.

242. When one comes to consider the causes of the nursing deficiencies discussed above, the following matters have to be taken into account:

(a) Nursing establishment and the extent to which staffing falls short of establishment;

(b) Qualifications of nurses in post;

(c)Training;

(d) Supervision;

(e) Status and organisation.

243. A general insight into these matters is afforded by the circumstances surrounding the making of the report by Mrs. “Z “, to which we refer above. She paid an official visit to the hospital, accompanied by an assistant regional nursing officer of the RHB, on 30th May, 1967, specifically in connection with a planning matter. As a result of the conditions which she observed, she felt that she had a duty to the nurses and patients at Ely to prepare an additional report on more general matters. In a contemporary note, accompanying her report, she wrote: “While being distressed and perturbed by this state I am anxious to improve the situation. I would stress that help is what I would wish to give, not apportion blame. It is difficult to evaluate a situation on a first visit. … We have staff shortage, old buildings, financial stringency and have inherited problems of management, that cannot be laid at any one’s door, but which nevertheless need to be speedily overcome.” Mrs. “Z’s” report eventually found its way, on 31st July, 1967, via the RHB, to the Group Secretary of the HMC On 30th August, 1967, the Group Secretary (having discussed the report with hospital officials and representatives of the HMC) replied to the RHB’s Senior Nursing Officer.

244. Mrs. “Z”, having observed conditions similar to those set out above, concluded, amongst other things, that:

(1)”The nursing staff require all the help and guidance from all sources to attempt to improve the standards of nursing care ;

(2) “The whole matter of laundry arrangements and linen issue must be examined very critically. It is quite untenable for nurses today to count and sluice dirty linen. Equally every patient must have his own towel and tooth brush”;

(3) “In-service training ought to be instituted and the authorities made aware of modern methods of nursing the sub-normal”. The reply by the HMC Group Secretary to Mrs. “Z’s” criticisms was defensive in tone and made the following points:

(1) “The matron and head male nurse claim a high standard of nursing care at Ely within the limits imposed upon them and their staff by the Victorian type of accommodation. . . . The Committee and its senior officers are well aware of modern methods of nursing the sub-normal. The shortage of trained staff in appropriate grades hampers our work in this direction”;

(2) “The laundry arrangements and linen issue are being looked at, as well as the provision of individual towels and toothbrushes”;

(3) “With regard to in-service training the possibility of developing a training school was explored several months ago but, without school facilities and better wards and other departments, we had long ago realised that recognition of Ely hospital by the General Nursing Council would not be forthcoming”;

(4) ” Her report has given us the opportunity of paying tribute to the staff of the hospital in all grades, who carry out a very good job of work under the most trying conditions “.

254. The contrast between the two foregoing views of conditions at Ely is made all the more striking by the fact, that, at the time of our inspection, a number of the deficiencies of which Mrs. “Z” complained were still evident. “One lives”, as she put it, “with a situation so long that one no longer sees it”. In this setting, we are equally reluctant to apportion the blame to individuals because, again to quote Mrs. “Z”, “there is something wrong really with a system in which this can be perpetuated, this inertia, because this is what is wrong”.

246. The responsibility in terms of system, for the continuance of the affairs which distressed Mrs. “Z” and has concerned us is something which we discuss more widely below. In this context however, we will now turn our attention to the particular matters listed in Paragraph 242 above.

Establishment

247. The minimum establishment of nurses for the hospital was last reviewed by the Nursing Officer of the RHB on 8th July, 1965. On the female side, the recommended figure was 119; on the male side, 58.

248. We do not here propose to consider the female side, save only to notice that the female staff was five short of establishment on 1st January, 1968, with almost all the deficiency concentrated in the posts designated for trained staff nurses: there was only one such in post, as against an establishment of 14; numbers were made up with additional nursing assistants.

249. On the male side, staff in post on 1st January, 1968, totalled 48 against an establishment of 58. The whole of this deficiency was in the nursing assistant grade, where there were only 32 in post against an establishment of 42.

250. Considered as a whole, the establishment represents a ratio of 1 nurse to 3.4 patients overall; and the number in post represents a ratio of 1 nurse to 3.6 patients overall. We were told that the Board’s nursing ratio for sub-normality is 1 nurse to 5 patients; by this standard, the establishment appears not unreasonable. The Board’s nursing officer was, however, said to be aiming for a ratio of 1 nurse to 3 patients overall. This ratio, although described by various hospital officers who gave evidence before us as their “pipe dream ” or ” ideal”, should be regarded as a reasonable minimum.

251. When one analyses the establishment, by reference to the male and female sides considered separately, a rather different picture emerges. The male establishment of 58 nurses represents a ratio of 1 nurse to 3.9 patients overall; and the number of nurses in post on the male side (48) represents a ratio of 1 nurse to 4.8 patients overall.

252. When the staffing position is expressed in this way, it is not surprising that visiting members of the HMC, on 15th October, 1965, recorded that: “The staffing situation is deteriorating and calls for urgent attention “. The visiting members suggested a review of the establishment at that date. No such review has apparently taken place. Establishment on the male side thus remains too low; the number of nurses in post is, of course, even lower.

Qualifications

253. With the exception of one Charge Nurse, who is a State Enrolled Nurse by virtue of work done, all the senior male staff (Chief Male Nurse, Deputy Chief Male Nurse, Assistant Chief Male Nurse, Night Charge Nurse, two Charge Nurses and six Deputy Charge Nurses) are Registered Mental Nurses; one Charge Nurse is also a State Registered Nurse. Some half dozen of the other nurses are Registered Mental Nurses, while most of the remainder are State Enrolled by virtue of work done. With only one exception, all the qualified nurses were trained in the care of the mentally ill and not in the care of the mentally sub-normal. The Chief Male Nurse and Night Charge Nurse have both been at Ely for 21 years; the State Enrolled Charge Nurse has been at the hospital for 40 years, and the remainder of the Charge Nurses between 8 and 13 years. Many of the more junior nurses had served for many years at Ely.

Recruitment and training

254. In the nature of things, recruitment is primarily concerned with Nursing Assistants. Such posts were filled after notification of vacancies to the employment exchange and interview by the Chief Male Nurse. Little consideration was given to the taking up of references or to other enquiries as to suitability. Inevitably, most people appointed in this way had had little or no previous contact with nursing or hospitals and often came from previous employment in one or other of the heavy industries in the neighbourhood.

255.On appointment, new recruits to the nursing staff were given the barest outline of the nature of the work and immediately sent to one or other of the wards. There they received sufficient guidance to set about the tasks to which they were immediately applied. No training, formal or informal, appears to have been given to them at that, or any other stage. Certainly nothing in the nature of an induction course was in existence. And there was no arrangement whereby they should receive any further formal instruction, even in short periods set aside for that purpose on the ward. This pattern of recruitment was not calculated to raise the morale of existing staff, one of whom described the system to us in the following words : “They take people off the streets, put a white coat on them and call them nurses. It is very difficult sometimes to expect them to do jobs they are not trained to do”.

256. There was no kind of in-service training for existing members of the staff. Ely has no library of nursing text books, nor were there any such available on the wards to which nurses might refer. None of the nurses (senior or junior) who gave evidence before us had ever attended any kind of course or conference dealing with nursing matters (save that the Chief Male Nurse had attended one course on the medical aspects of atomic warfare!). We have already noted (in Paragraph 160 above) that the nurse recently put in charge of Villa 2, has never visited any children’s ward in any other hospital nor any kind of training centre. All the other members of the nursing staff on the male side were similarly without any kind of contact with any other institution concerned with the sub-normal, except that the Chief Male Nurse (on an occasion when he took a patient to Llanfrechfa) was then shown round that hospital.

257.No formal steps ever appear to have been taken to bring members of the nursing staff, cut off as they seem to have been from the main stream of advance, more closely into touch with the development of modern nursing methods. The Physician Superintendent was certainly aware of the need, as he put it, to produce a more liberal attitude towards patients and to get rid of “the old fashioned one of keeping them under the thumb of the staff, so that they would cause as little trouble as possible”. He no doubt did something to encourage such a change in attitude in informal discussion on the wards with the more senior nurses. He claims to have found the staff responsive, with the exception of older nurses “because it had become habit with them”.

258. The Chief Male Nurse seems to have been insufficiently aware of the problem. He agreed that the Assistant Chief Male Nurse and at least two of the Charge Nurses were “of the old school”, But so far as the style of patient management is concerned, the Chief Male Nurse said simply that: “We have had discussions but we did nothing to change the present way of doing anything “. On the more general subject of in-service training for nursing assist­ants, the Chief Male Nurse only became aware during the course of our inquiry of the relevant Circular (HM(55)49) and acknowledged that this topic had not been discussed within the hospital, even in general terms, until the latter half of 1967. “We are hoping”, he told us, “to get something operative on this eventually”.

259. The HMC itself appears to have considered the question of training on two occasions:

(a) Following the report of visiting members, dated 15th October, 1965, when the members suggested not only a review of the establishment but also: “Encouragement of visits by staff, to other hospitals, conferences, meetings etc., the establishment of a training school”.

(b) On 9th June, 1966, when it was reported that talks had taken place between officers of the HMC and of the RHB on the possibility of initiating nurse training facilities at the hospital.

260. This discussion ,appears, however, to have been concerned more with the development of a nurse training school at Ely than with the humbler topic of in-service training. And when, not surprisingly, it became clear that a training school was not a very realistic possibility at Ely, the topic appears to have been dropped. This is apparent from the terms of the letter (referred to in Paragraph 244 above) from the Group Secretary to the RHB, commenting on Mrs. “Z’s ” report.

261. The more modest suggestion referred to in paragraph (a) above was not apparently followed up at all. Thus the situation persisted whereby, for example, the nurse in charge of Villa 2 would have welcomed the opportunity of visiting other training centres and hospitals, had this occurred to him as a means of broadening his knowledge and experience. At the same time the HMC, as well as the Physician Superintendent, were said to have been anxious that such visits should be encouraged. Yet neither the nurse referred to nor any other, ever made any such visits or attended any such conferences.

Supervision

262. For the purposes of nursing administration, the hospital, as already explained, is divided into a male side and a female side. The former is in charge of the Chief Male Nurse, Deputy Chief Male Nurse, Assistant Chief Male Nurse and Night Superintendent; but both the Deputy and the Assistant Chief Male Nurse also act as ward charge nurses. The female side is in charge of Matron, assisted by a Deputy as well as an Assistant Matron — neither of whom undertake duties in charge of a ward.

263. In November, 1958, the Ely Hospital Branch of the Confederation of Health Service Employees suggested:

(a)The creation of a post for Night Deputy Charge Nurse;

(b)The “promotion” of the Deputy Chief Male Nurse, so as to relieve him of ward charge nurse duties.

This latter suggestion was again put forward in November, 1966, and, yet again during the latter part of 1967 (on this occasion because the new Hospital Secretary had expressed himself surprised that the Deputy Chief Male Nurse was in fact in charge of a ward). On each occasion, the suggestion appears to have been rejected “for economic reasons”.

264. On the female side, the Matron applied for an increase in her establishment by the appointment of an Assistant Matron; this application was considered in November, 1966, and again in March, 1967—when it was closely studied by the Chairman and Vice-Chairman of the HMC; at this time, in view of Matron’s assurance that “in spite of the difficulties she could carry on”, the suggestion was rejected on financial grounds.

265. No formal consideration appears to have been given to the possibility of administering both sides of the hospital as one unit. Nor has any express consideration been given to any re-organisation of the senior nursing staff structure or of the relationship of the staff at Ely with that in the hospital group as a whole.

Status of nurses

266. To some extent, we suspect, because of the continuance of a “Poor Law Tradition “, and because of the traditional dominance of the Physician Superintendent in a hospital of this kind, the nursing staff (and particularly the senior nursing officers) have probably not been accorded the status and responsibility that is appropriate. Yet “status” can be an important aspect of pride in one’s profession, that can help in itself to promote higher standards.

267. The lack of attention to induction and in-service training, and absence of sufficient auxiliary staff to undertake cleaning duties (noted in Paragraph 234 above) have led to under appreciation of their nursing role. The establishment of a Joint Consultative Committee has not been considered. And such representations as have been made for improvements in the nursing structure appear to have been rather casually considered; they were never the subject of any written reply on behalf of the HMC. No meetings of senior nursing staff have been held, of the kind at which the Matron and the Chief Male Nurse (in collaboration with the Hospital Secretary) could discuss informally with Charge Nurses and Sisters the nursing, general care and welfare of patients. Only since the appointment of a new Hospital Secretary, in January 1967, have any regular meetings been held between Ely’s four senior officers: Physician Superintendent, Hospital Secretary, Matron and Chief Male Nurse.

268. None of the senior nursing officers have been provided with standing orders, defining their share of responsibility, and in the last 12 months the Chief Male Nurse and Matron have ceased to attend regularly at meetings of the house committee or HMC (no doubt largely because both these bodies had ceased to hold any of their meetings at Ely). There has been no practice of submitting written reports, from the Matron and Chief Male Nurse, to the HMC; and they have seldom, if ever, submitted any requests in writing to the HMC.

269. The Chief Male Nurse certainly does not appear to have been regarded as effectively in charge of all nursing disciplinary matters. At the time of the “T” affair (see Paragraphs 166 to 175 above), the Chief Male Nurse did not attend at all upon the meeting of the HMC which considered “T’s” complaint. And, more recently, at the time of the “B” affair (see Paragraphs 176 to 224 above), although the Chief Male Nurse did attend the relevant meetings, the investigation and presentation of the case appears to have been primarily the responsibility of the Physician Superintendent. Both Matron and Chief Male Nurse have plainly regarded themselves as subordinate to him. This position appears to have been accepted by the administrative officers and the Physician Superintendent, who still regarded himself as having an overall responsibility for all the nursing staff and a duty to act as a coordinator.

270. Nothing more precise than tradition, modified within the last 12 months by the new Hospital Secretary (who has been trying to involve the two senior nursing officers in a more formal pattern of consultation), has been responsible for the rather imprecise state of affairs described. In the result, however, the Chief Male Nurse must, understandably, have felt less than sure of himself and of his precise authority and share of responsibility.

Conclusions

271. Lax and old fashioned standards of nursing, reminiscent in too many ways of the old era of “custodial care “, have been accepted. The nursing establishment, not excluding the establishment and organisation of senior nursing officers, has not been kept in line with the changing requirements which result from the change in quality of patients and their diminishing availability for work on the wards. Virtually no attention has been given to the training and instruction of nurses, both on recruitment and in service, and to the need for keeping the nursing staff abreast of modern developments in mental nursing; pursuit of the “Will o’ the Wisp ” of a nurse training school at Ely has distracted attention from more modest, but more urgent needs. The status and responsibility of the nursing staff, particularly the senior nursing officers, have not been redefined to bring them up to date.

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