Editorial

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Anyone who has ever looked at or listened to a patient complaint will understand just how important the most basic elements of care are to our patients. Never mind the highly technical equipment, or the latest diagnostic test, it is often the time taken to explain a procedure or a hand on an arm in time of distress that the patient remembers. McBrien’s paper (119–126) describes these very issues in his exploratory examination of spiritual care in the emergency department. Dealing with the patient’s (or family’s) psychological distress, and their spiritual needs is an essential component of high quality patient care, is as important as their physical care, and may have greater long-term impact.

Lack of basic care is central to poor patient experience and is routinely found as the essence of healthcare failures, whether individual or system-wide. There is concern that it is the basic elements of care that get forgotten in a drive towards efficiency and effectiveness, creating cultures where throughput and targets are more important than the individual episode. And it is nursing that has taken the burden of this criticism, as the professionals who are ultimately responsible for care provision. And rightly so, when we hear stories of patients being left in dirty linen, little or no pain management, or complaints about rudeness and poor communication. In the UK the most recent Prime Minister’s Commission on Nursing (2010) has addressed this (as have previous strategic documents), with an emphasis on nurses’ accountability for planning and delivering high quality care. Likewise, Lord Darzi’s report on the future of the NHS (2008) talks openly about getting the ‘basics right, first time, every time’ (P11), and, more recently, when interviewing for nursing posts in the last month we repeatedly heard a desire to get back to basics in order to affect the quality in our service.

So what do we mean by quality, what are the basics of care, and how do we achieve them for every patient? Lord Darzi (2008) sets out a relatively straightforward vision of quality that incorporates three distinct (but overlapping) elements – clinical effectiveness, safety and personal.

In recent years, we have made huge strides to improve the effectiveness of healthcare. Creation of bodies such as National Institute for Health and Clinical Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) in the UK, has led to a reduction in variation in clinical care and service commissioning, improving patient outcomes. Internationally, we only have to look at resuscitation, and through International Liaison Committee On Resusctiation (ILCOR) we have international consensus on key elements of resuscitation. At the same time, standards, including waiting times, staffing, and infection rates etc. have been established in many countries to drive up clinical effectiveness and patient safety. Many healthcare systems also examine patient satisfaction or monitor patient complaints and thank you letters to establish feedback. Although all these major developments have made significant changes to care provision, there is little discussion of where the basics come within this vision of quality. It may be argued that ‘basic care’ means different things to different people, or to different teams, but there is little variation in basic human need, regardless of where, or how, care is delivered.

Every patient should be able to expect to be treated with dignity and respect, to have some privacy in their care, and to have their most basic human needs met, e.g. support with toileting, eating, and hygiene. The activities of daily living are a good start, and 20 years after training these still feel relevant to an holistic approach to assessment of patient care needs. Patients must be safe in our care, whether in provision of their treatment, or in preventing harm, through infection, falls, etc. Patients should also expect their carers to be knowledgeable in their specialty, to get treatment right and to discuss care with them honestly.

It is not only what we do, but importantly, how we do it that is ‘basic’ to care and it is this that is difficult to define, to capture, and to measure; but it certainly can be ‘felt’, as a patient. There is undoubtedly a difference between the clinician, whether nurse, doctor, or physiotherapist, who can deliver all of the elements of care whilst assuring the patient they are actually involved, and the one who simply delivers. The patient feels listened to, understood, and important to that clinician; all the essential components of an effective interpersonal relationship. And by building effective relationships with patients we can truly understand and meet our patient needs. McBrien’s study describes these relationships in terms of ‘connectedness’ including basic elements such as touch, intuition, and being present.

So what has happened that we have lost this essence of the basic? Some will argue that we are simply over-worked – the demand for healthcare, and especially emergency care, is increasing across the world. We are probably a victim of our own success, as diagnostics, treatments and facilities advance. There is no doubt that the pace seems to be ever increasing, with constant pressure for cost reduction. There is evidence that increased numbers of qualified nursing staff reduce risk, and improve patient outcomes, but being too busy, in itself, is no argument for poor basic care, if many areas can deliver on similar resources.

Others are concerned that nursing has taken on too many ‘non-nursing’ roles, and so have had to delegate, or give away the most basic elements of care. Extending roles, and certainly the advanced nursing role, has always been controversial. There is a dilemma (mainly for those looking on) that these staff forego nursing to undertake doctors tasks. However, nurses have always challenged their boundaries to improve patient care, and also delegated work that others could do. In emergency care alone, we have handed off work to physiotherapy, plaster technicians, and social services that used to be done by the individual nurse. Equally, the care provided by nurses in advanced roles is generally exceptional, as they bring together all the elements of their knowledge and expertise. Also, when it is horrifically busy, undertaking one of these extended tasks, e.g. intravenous drugs, though time-consuming, can provide the opportunity to build up a relationship with a patient that might otherwise have been missed. Undertaking the most basic episode of care can equally provide this opportunity and if we are guilty of losing our basics it may be that we have decided that these elements of care are no longer ours to deliver, or control, and so have absolved our responsibility for them. It is not simply which tasks we undertake that is important, but also our approach and how we communicate, both of which cannot be delegated.

Still others will criticise training, blaming too much academia and not enough reality, or time spent on placement. The Prime Minister Commission (2010) is very clear in it’s support of graduate training, which will bring the UK in line with many other nations, but which may further underpin these concerns. However, there is a sense that this has always been a challenge; right back to my training I clearly remember staff worrying about new training programmes, and their impact on nursing, and yet we continue to train many excellent nurses. It is essential that we attract the right people into the profession, and to build the confidence and the capacity of those trainees to deliver the quality services of the future. To do this we need to recruit the right students, those who understand what nursing is and what it stands for, and we need professionals who provide a positive image of what nursing in the 21st century looks like.

Despite all these challenges, I see excellent care given every day across many clinical areas. It may be that we simply need to remind ourselves of the importance of these basic elements, and to share these with our colleagues and other professional groups. Being explicit about the standards you expect in your clinical area may be enough for staff, and patients, to be reassured that the most basic elements of care are important to all. Getting the balance in care will continue to be a challenge, especially in environments such as emergency care where the number of patients presenting for care increases, where the patient journey is fast, and where we are challenged daily by individual patient needs. However, what is clear is that basic nursing care underpins every element of a high quality patient experience. Using Lord Darzi’s conceptual framework of quality, nurses who understand this balancing act can make safe, clinically effective patient assessments, and deliver care that is personal to each individual patient.

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References 

1. Department of Health, 2008. High Quality Care for All: NHS Next Stage Review. DH, London. <http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf>.
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2. Department of Health, 2010. Prime Minister’s Commission on the Future of Nursing and Midwifery; Front Line Care. DH, London.
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