Substituting for nurses

Nurses are named in the Trust discharge policy as the lead profession in discharge planning. The policy states ‘each discharge should be organised and coordinated by a named member of staff (i.e. the Named Nurse) who should be responsible for ensuring plans are effectively completed and communicated to all concerned’ (p.4). However, findings show that it was mostly the IPCCs undertaking the lead

discharge planning role on the general medical wards, particularly for patients with more complex discharge needs. While nurses continued to have a degree of

involvement in discharge planning, it appears from the observation data and participant accounts that the IPCCs had the primary responsibility for getting the work done in practice.

At least there is someone [i.e. the IPCCs] tracking that patient through the patient’s stay and you can quickly assess their home situation, what their home needs are from that one person and drawing on work that has been done before, rather than a nurse starting from a blank sheet of paper and planning their discharge. (Nurse: 13049C, FG)

We often get a [social work referral form from nursing staff] with no information at all, like ‘lives in a flat’, so rather than wasting the social worker’s time, we will come over to the ward, find out all the information about the patient, we actually find out as much information as we can on why that person needs a social work referral. Some of the time it’s not even a social worker that’s needed. (IPCC, 15020F, FG)

IPCC rang [admissions ward] to see if MF26 is going home today. He has X-ray at 2.15 p.m. Then rang placements officer about MA’s hostel but she wasn’t around. Asked for social worker and asked her about finding hostel at address patient had said. Discussed FK – social worker is collecting in reports for panel on Thursday - still awaiting reports from FK’s residential home and [elderly mentally ill] day care centre. [Another IPCC] offered to call day centre. Bleeped doctors to remind them about [weekly interprofessional meeting]. Rang day centre and left message for woman responsible for writing reports. (Field note extract, 10089:189-99) Nurses consistently cited a lack of their time as the reason why IPCC input was helpful.

The [IPCC] is someone who can spend more time with a patient investigating social issues, some of which are quite complex and this doesn’t get in the way of other clinical priorities interfering with that role. (Nurse, 13049C, FG)

I think patients get a better deal with [an IPCC] in place. I try to imagine our ward life without that input and it is quite difficult. [Patients] want to have time to talk over things - otherwise on other wards I have found myself doing a social assessment and it being a checklist really, just because you’re so pressed for time and that’s not the way to approach it. I think with that role of the [IPCC] they can sit down with the patient, the patient will talk about why the sister-in-law doesn’t help with the shopping and the family row they had that preceded that problem – it’s very sad that nurses don’t have that time because that’s something we’ve lost really on a realistic basis on the wards, but I think patients need to talk about that and need to talk about their social situations and that gives them that time, often to do that. (Nurse, 28049, Int)

The lack of time cited by nurses could be accounted for through nursing staff shortages. At the time of the study, the Trust was in the grip of a severe nursing recruitment and retention crisis. In 1999, the Trust’s vacancy rate for nursing and midwifery was 21%, its turnover rate 29% and its retention rate 76% (The Royal Hospitals NHS Trust 1999). These shortages were reflected nationally, the most acute shortages being in inner London (Buchan, Finlayson, & Gough 2003; Cameron & Masterson 2004). This, along with continuing efforts by managers to

reduce the hours worked by junior doctors (and therefore the substitution of parts of their work by nursing personnel) had meant that nursing staff were limited in the comprehensiveness of care they could provide. Often, the nurses providing care were bank or agency staff that were not part of the ward’s permanent nursing team.

It may be at the beginning of the week all runs smoothly, and there’s a named nurse there who makes sure it’s all done, but towards the end of the week when they’re not on anymore and you’ve got [an agency nurse] there who doesn’t know the patient you just get ‘I don’t know’, and a lot of the comments probably when nurses have said to patients, ‘I don’t know’ is from somebody who doesn’t know, doesn’t care, they’re not gonna be there tomorrow, and unfortunately we can’t resolve that because there is a national [recruitment] crisis which is why it’s fantastic we have people like the care co-ordinators that seem to fill that gap, that they are the fountain of knowledge, they’ve got their finger on the pulse. (Nurse, 08060K, FG) I’m becoming more worried about de-skilling nurses than I think I was previously. But because we haven’t got enough trained nurses, we can’t get enough trained nurses, we have to say “What is it that they should be doing, and what is it that other people should be doing?” and maybe we have to accept that. But I think we should be up front in saying, and that means the nurses of the future will have a big knowledge gap, or this big experience gap. (Manager, 27049, Int)

The flexibility of the IPCCs also enabled them to be in a better position than nurses to carry out the bulk of discharge planning work for some patients. The IPCCs could provide the continuity that nurses could not, because they could follow patients as they were transferred from ward to ward, and also were unaffected by the mismatch between medical teams and the ward bases (see p. 10). This was in contrast to nursing staff who were ‘ward-bound’ and therefore dealt with multiple teams of interprofessional colleagues who cared for patients on their ward. So the flexibility (and inherent mobility) in the IPCC role meant that patient-centred care in the face of the current organisational arrangements was easier for them than for nurses.

This aside, the lack of time cited by nurses necessitated decisions about the best use of nursing time. The following two sections examine the decisions that were made about what nurses retained and what IPCCs took on from nurses.