Monday, 20 June 2011

View from an inpatient bed (3): The one about communication

‘The single biggest problem in communication is the illusion that it has taken place.’
George Bernard Shaw

One of the few things that Andrew Lansley has admitted he got wrong so far is that he failed to communicate properly how the NHS reforms outlined in the Health and Social Care Bill could actually work. The ‘listening exercise’ that led to the planned changes to the reforms has at least allowed for the drafting of this Bill to include two way communication.

Despite all the talk of NHS cuts and lack of resources, which is undoubtedly having a major impact nationally, I received excellent care as an inpatient for a few days a couple of weeks ago. But during my stay the most significant shortage that I experienced was that most precious of commodities – communication.  Communication is quite simply at the heart of everything we do and is probably the single most important tool in healthcare service improvement.

I witnessed shortcomings at every level. Failure of communication between peers, failure ‘up and down’ the medical hierarchy. Failure in communication with patients, relatives and visitors. Everyone working in their own bubble under the illusion that they were communicating effectively.

Nurse to patient: I arrived on the ward just before midnight and in hushed tones a very charming nurse explained to me in the dimly lit bay that there were ‘many forms’ to be completed before I could retire for the night. I completed one questionnaire and he left the ward, soon to return with another. After two fairly basic but faintly ridiculous questionnaires (was I living in wardened accommodation? Could I dress myself – I promise you, dear reader, I am not quite in my dotage yet), he disappeared into the night again and I waited, presuming another form was coming my way. I waited and I waited. Eventually – I got up and went to the nurses station where he was chatting with his colleagues. ‘Can I go to bed now?’ I asked plaintively and he nodded in surprise. Alas, I didn’t have my crystal ball with me that night and how nice it would have been for him to communicate with me that he had finished his questions.

Patient to nurse: Maybe it would be a good idea to explain to patients what to expect from the nursing and healthcare assistant team. The lady in the bed next to me had unfortunately broken both arms so needed help with the most basic of care, which on the whole she received to a high standard. But she didn’t know if she was supposed to press the call button when she wanted to get dressed or undressed or whether she was supposed to wait until someone offered to do it for her. This caused her some concern every morning and evening as she simply didn’t know how she was supposed to communicate with the nursing team.

Nurse to nurse: The handover rounds were appalling – a senior nurse mumbling to the amassed audience, imparting useless information. There clearly hadn’t been an ‘offline’ handover either. The little old lady – I’ll call her Molly-  in the bed opposite me (I was the only one in the bay born before the 2nd World War!) suffered from what I call happy dementia. She had no idea what was going on but was perfectly content in her own little world. She called me Dot for my entire stay and I was happy to comply. It was getting late one evening and Molly wanted to get back into her bed for the night. But she had no nightdress so put her dressing gown over her clothes and clambered in – at which point I toddled off to the nurses station (interfering? Moi?) to ask a nurse to bring a hospital gown and help Molly get ready for bed. The nurse happily complied, but had no idea that Molly was incapable of looking after herself. Surely this should be part of the handover process?

Doctor to nurse: The nurses changing beds one morning spent quite a bit of time complaining about how poorly the doctors communicated with them. They were, of course, breaking the golden rule of any service industry (and let’s face it – healthcare is the ultimate in service delivery). The golden rule? Don’t whinge about or undermine your colleagues, boss or organisation in front of your clients. Yes – the patients are clients. Often fragile, vulnerable clients. I was desperate to tell them that they were just as guilty of poor communication by not voicing their concerns to the doctors in question but as these nurses were in charge of needles and I was the recipient of many such needles during my stay, I felt it was wise to keep quiet.

Nurse to doctor: Still on the subject of doctor/nurse communication – every evening my 6 pm dose of IV medication was late – up to an hour and a half late. When I queried this, a very agitated sister pointed out to me that it was impossible to give a 6pm IV dose to everyone who needed one at 6pm and the doctors shouldn’t write patients up for a 6pm dose. Have you discussed this with the medical teams I asked? I was sure there was a simple solution. Surely this is something you discuss at the MDT meeting? (multidisciplinary team meeting). For months the ward had been struggling to meet a 6pm deadline which clashed with the normal drugs round, supper, dealing with visitors etc, and no-one had raised this issue with the doctors.

General communication skills: Oh how I would love to spend just an hour training the ward staff in communication. For the staff from overseas, I would make sure they knew how to phrase the most basic questions in colloquial English. One doctor caused great confusion by asking one of my fellow inmates where she was before she came into hospital. Of course the patient replied with details of exactly where she was when she had her accident – on the bowling green – (who would have thought that bowls was such a dangerous sport). This became a saga as the questioning continued – where was she staying? Did she live at the bowling green? Was she in a residential home? In the end, the patient finally understood – the question should have been ‘where do you live?’

I would teach the staff how to address patients – if you are doing the ward round – you acknowledge the patient. Whatever you do – do NOT talk about them as thought they are invisible. I would teach listening skills and how to get your point across in a non confrontational way. Communication with peers is even more important than communication with the patient in many cases.

The only way to achieved integrated care is through clear communication. If just one part of the pathway, i.e. the inpatient stay, is fraught with difficulties, you can multiply that manifold when you also consider primary care, community care, therapy teams, and social care.

Maybe the key is to ensure that the regular MDT meetings follow strict guidelines so that all key points are covered. Maybe the new clinical commissioning teams will include clear and measurable communication as part of the required standards. Whatever happens with the reform plans, communication at all levels is a vital part of the service improvement process.


Drmike said...

As an NHS patient who has spent nearly 13 out of the last 16 months as an in-patient in a London Teaching Hospital, I have been diverted by this and the preceding two views from an in-patient bed. I write this comment sitting up in bed in my isolation room inthe Haematology unit using 3G because yet again the free Wifi service in the hospital has failed. So communication failures at this hospital are electronic ones too!

I agree with the Finchers bloggist in the main. I particularly agree about twice daily nurses handover which is a spectacular wastevof time since nurses rarely read their colleagues' post-handover notes and where doctors never read these notes and conversely nurses never read the doctors' notes in the patient files.

Whilst I share the blog's remarks on boring process and meaningless questionnaires, I cannot think of a better way to get this important information about the social history and capabilities of the patient. I am mindful of my recent transfer to the surgical unit of another major hospital in the Group where I was asked all these questions for an hour at 1 am only to be clerked in by the surgical SHO at 2am!! My procedure was set for 8 am so I was only allowed 4 hours sleep pre-op. Not ideal!

Finally can I just put in a moan about NHS hospital food. My experience is that it is boring, tasteless, repetitively mended mush and as such undermines in morale terms all the hard work put in by the caters and clinicians. A revolution (patient led?) is required.

All in all my experiences of NHS care, speaking as a physician, are extremely positive from a clinical care perspective but I have reservations about funding and management. I will save these for another blog, another time.

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