Editorial
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Journal of Clinical Nursing 1992: 1: 55-56 Editorial The new Patient's Charter issued by the British Department of Health in the Autumn of 1991 amends and outlines Patients' Rights for the first time since 1948, when the National Health Service was instigated. The most significant issue for nursing is the Charter Standard which states that any individual: 'should have a named, qualified nurse, midwife or health visitor who will be responsible for their nursing or midwifery care.' This standard is heartening for qualified nurses who have recently expressed concern about the developing role of health-care assistants throughout the hospital and community nursing services. Such assistants are heavily involved with patient care delivery, partieularly in areas where patients/clients require assistance with activities of living over prolonged periods. The new charter clearly identifies that it is the 'qualified nurse/midwife' who is responsible for patients' nursing or midwifery care, whether or not it is he/she who delivers it. Therefore, it seems reasonable to assume that the qualified nurse is responsible for delegation of care to health-care assistants, thus retaining the right not only to prescribe care but also which forms of care should be delegated. To what extent does such delegation fit with primary nursing.' Are health-care assistants to act as associate nurses, or merely as helpers to associate and primary nurses.? The situation seems very unclear, and it is easy to visualize the reappearance, or in some instances, a continued adherence to the concept of task allocation. Certainly a qualified nurse can be 'responsible' for care which he/she delegates in a task-orientated manner just as effectively in 'management terms', as that which is delivered using the primary nursing mode. The optimistic outlook must be that many qualified nurses are increasingly convinced that patients prefer primary nursing, and will therefore choose to manage care delivery in this way. The alternative pessimistic picture is that qualified nurses are expensive commodities and that in certain long-term patient care areas, tbe ratio of trained to untrained nursing staff/health-care assistants, may require the use of task allocation. For example, where the ratio of qualified nurses to assistants is 1:3 and there are certain tasks which can legally only be undertaken by the qualified team member, task allocation does appear to be the most effective way of managing the work to ensure patients/clients physical needs are met. The social and psychological requirements of individuals are acknow- ledged in the Patient's Charter, for example, each individual is assured in one standard that all health services should make provision so that proper considera- tion is shown to them, by ensuring that privacy, dignity, and religious and cultural beliefs are respected. Similarly, it states that practical arrangements should include meals to suit all dietary requirements, and says private rooms should be available for confidential discussions with relatives. However, the major thrust of the Charter emphasizes the need to: 'provide services that produce clear measurable benefits to people's health' (Department of Health, 1991). As we know, it is much simpler to measure throughput within a Health Service in terms of physical improvements, the number of operations performed, the cross- infection rates, than the psychological advantages of pre-operative counselling or 55
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Transcript of Editorial
Journal of Clinical Nursing 1992: 1: 55-56
Editorial The new Patient's Charter issued by the British Department of Health in theAutumn of 1991 amends and outlines Patients' Rights for the first time since1948, when the National Health Service was instigated. The most significantissue for nursing is the Charter Standard which states that any individual:
'should have a named, qualified nurse, midwife or health visitor who will beresponsible for their nursing or midwifery care.'
This standard is heartening for qualified nurses who have recently expressedconcern about the developing role of health-care assistants throughout thehospital and community nursing services. Such assistants are heavily involvedwith patient care delivery, partieularly in areas where patients/clients requireassistance with activities of living over prolonged periods. The new charterclearly identifies that it is the 'qualified nurse/midwife' who is responsible forpatients' nursing or midwifery care, whether or not it is he/she who delivers it.Therefore, it seems reasonable to assume that the qualified nurse is responsiblefor delegation of care to health-care assistants, thus retaining the right not only toprescribe care but also which forms of care should be delegated.
To what extent does such delegation fit with primary nursing.' Are health-careassistants to act as associate nurses, or merely as helpers to associate and primarynurses.? The situation seems very unclear, and it is easy to visualize thereappearance, or in some instances, a continued adherence to the concept of taskallocation. Certainly a qualified nurse can be 'responsible' for care which he/shedelegates in a task-orientated manner just as effectively in 'management terms', asthat which is delivered using the primary nursing mode.
The optimistic outlook must be that many qualified nurses are increasinglyconvinced that patients prefer primary nursing, and will therefore choose tomanage care delivery in this way. The alternative pessimistic picture is thatqualified nurses are expensive commodities and that in certain long-term patientcare areas, tbe ratio of trained to untrained nursing staff/health-care assistants,may require the use of task allocation. For example, where the ratio of qualifiednurses to assistants is 1:3 and there are certain tasks which can legally only beundertaken by the qualified team member, task allocation does appear to be themost effective way of managing the work to ensure patients/clients physical needsare met. The social and psychological requirements of individuals are acknow-ledged in the Patient's Charter, for example, each individual is assured in onestandard that all health services should make provision so that proper considera-tion is shown to them, by ensuring that privacy, dignity, and religious andcultural beliefs are respected. Similarly, it states that practical arrangementsshould include meals to suit all dietary requirements, and says private roomsshould be available for confidential discussions with relatives. However, themajor thrust of the Charter emphasizes the need to:
'provide services that produce clear measurable benefits to people's health'(Department of Health, 1991).
As we know, it is much simpler to measure throughput within a Health Servicein terms of physical improvements, the number of operations performed, the cross-infection rates, than the psychological advantages of pre-operative counselling or
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56 Editorial
supporting an informal carer of a child with learning difficulties in their ownhome.
Clinical nurses in senior positions are increasingly being held to account for themanagement and allocation of nursing resources. This is correct as long as thereare sufficient resources for them to ensure quality nursing of their patients/clients. The situation becomes more difficult where economic constraints result,for example, in district nurses having to decide whether or not providingassistance with bathing for an elderly person suffering from dementia, is actuallya social or health-care problem. Within hospital settings, the senior clinicalpsychiatric nurse may be faced with deciding how best to allocate duties to theonly other qualified nurse available. For example, she may wish to send adetained client on an accompanied shopping trip which in her professionalopinion would reduce the clients tension, and possibly even the need formedication, and to provide a group dynamic session for six clients on the ward.Her choice must surely be influenced by what is 'the greatest good for the greatestnumber.' These issues are increasingly becoming clear as demand for health careseems inexhaustible, while resources have to be contained. Perhaps primarynursing in terms of highly qualified experienced nurses delivering care topatients, is too expensive in all but the high technology and psychiatric intensivecare areas.
The Journal of Clinical Nursing aims to stimulate debate about issues such asthese, and the real problems that faee clinical nurses today. While it isacknowledged that research demonstrates primary nursing is a cost-effectiveoption in some areas, there is still insufficient evidence to prove that this is so inall areas of nursing/midwifery care. The objective of the Patient's Charter is toraise the standard of care throughout the British National Health Service; thiscannot be achieved without the assistance of nurses, mid wives and health visitors.
I would like to invite correspondence on how we might best allocate manpowerresources in order to attain the most cost-effective nursing systems. Such systemswill inevitably involve the measurement of patient outcomes relating to theorganization of nursing/midwifery. Many nurses have conducted small pieces ofresearch, or through their own observation have decided the best ratios of trainedto untrained staff in certain care areas, and have overcome some of the problemsof allocating care within cost-contained situations. These are early days for thePatient's Charter and our response to it. Please take the opportunity through thepages of this new Journal to stimulate debate and the cross-fertilization ofexpertise on this controversial subject. I look forward to hearing from you!
Editor,Beeches, Crapstone,Yelverton, ' - -Devon PL20 7PW, UK
MARY WATKINSJanuary 1992
Reference
Department of Health (1991) The Patient's Charter UK. HMSO, London.
