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The case of the disappearing staff nurses

As plans to develop the ward bonus and a training programme move forward, I am becoming increasingly fascinated by this aspect of my work.

Published research seems to suggest that financial incentives are not enough to motivate health workers: good management, supervision and training is also seen as important. We are trying to use this evidence and link the ward bonus with training so that they are complementary and supportive of appraisal and appropriate training, rather than simply about rewarding performance. Of course we hope this will improve the standard of nursing care, but ideally it might also improve motivation.

It all seems possible, neat and tidy. A good idea.

Until you meet the devil who is sitting there, happily ensconced in the details. Then you realise that your good idea is not, in fact, a solution.

Here is an example.

In the hospital where I work, there are some fundamental difficulties that make nursing - difficult at the best of times - even more challenging. An obvious factor is that nurses of all cadres, and senior nurses in particular, are short on the ground. The few nurses in management positions simply do not have the time to provide full supervision to frontline staff, and this can affect patients.

Every week there is a staff nurses’ meeting in the matron’s office attended by the 8-10 staff nurses or ‘in-charges’. I went to the office last week to find the deputy matron sitting behind her desk alone.

“No meeting today”, she said. “There aren’t enough staff nurses to meet”.

Staff nurses who were in post last week can no longer be found in the hospital and their wards are now left without replacements.

Another challenge is a lack of clarity around roles. The health service here has adapted to enormous changes during years of civil war and also to the multiple and diverse initiatives and influences that exist in post-crisis development. The nurses have also adapted, and been subject to those influences, meaning there is a huge mix of skills and experience. Many work outside of their traditional job description, often through necessity, and often without the support thorough training or ongoing supervision provides. Nursing aides, for example, often work in a role similar to a UK staff nurse, while newly qualified staff nurses act in a capacity that we would recognise as ward sister. So the question is, do you accept that the work of many nurses over-extends their training and try to give them the skills to work safely, or do you try to limit their role?

Pragmatism, I believe, suggests that with human resources already stretched - my hospital is actually relatively well resourced compared with other health facilities -reducing the role of whole cadres of nurses could prove disastrous. So, increased access to training to make sure nurses can safely undertake their work would appear to be a good way to improve patient care.

But this leads me back to the case of the disappearing staff nurses. Where have they gone?

They have left their posts to undertake further training.

You can’t deny that it’s a good idea.

Becky Cridford is one of the eight 2010 Vodafone Foundation World of Difference International winners. To find out more about this opportunity visit the World of Difference website.

Readers' comments (57)

  • I feel It is not just the money that retains the nursing staff but the way we are treated and managed. We are treated like a bunch of naughty school children that have to be kept under a non-clinical control, constantly told we are not doing enough, well enough and could do everything better and much more efficiently. We don`t work on our own and are actually just one small part of a much larger team but this seems to be forgotten in the bigger scheme of things. The attitude seems to be: lets just keep nurse bashing and then wonder why morale is low and nurses don`t want to stay!!!!!!!!!!

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  • Anonymous | 4-Jan-2011 10:27 am, I agree.

    I think that money is an essential component of staff retention however. At the end of the day we are paid far too little for what we do, it is a simple fact. But ward 'bonuses' are the wrong way to go to rectifying this. A rise in the basic wage of a Staff Nurse to reflect the level of skill, education, qualification and responsibility we have would be a much better and more sustainable solution.

    But you are right in the fact that there is much much more to the fact that morale and retention is so low.

    We are a highly skilled, autonomous profession in our own right. It is about time we are recognised as such.

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  • Oh, and as for the case of the disappearing Staff Nurse? I disagree with the article. They havent have left their posts to undertake further training, those who are able have already gone abroad to Australia, Canada and the US for superior pay and working conditions; and I plan to join them as soon as possible too.

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  • If Mikes boss is listening, please give him a pay rise so that he can afford to go to Oz ASAP, I am sick of hearing how amazingly well qualified he is and how badly paid and hard done to he is. Good luck Australia!

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  • Anonymous Mike is 100% correct on everything he says.

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  • "We are a highly skilled, autonomous profession in our own right"

    If that were really true for all nurses then we would be paid more and taken seriously.
    Unfortunately there are still huge numbers of nurses that do not do their jobs properly and we need to recognise this and do something about it. If there are still large numbers of patients that are dying because "nurses" do not take proper care of them then we do not deserve better pay. Stop blaming low staffing levels and poor pay for nurses not doing their jobs. Nurses need to prioritise patient care and make sure the important jobs are done before the jobs they like to do. The recent case in Staffs was not all down to low staff numbers, some of it was down to bad practice and to nurses turning a blind eye to what they knew was wrong, a definite breach of their Code.
    At the moment nurses that do a consistently excellent job are in the minority, they need to become the majority before we can demand more money.

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  • i have bee told that to get a pension work to 74 i am tired worn out and physically and mentally exhusted the low pay poor working conditions just add to stress if i was younger i would be of to another country where they look after there nurses

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  • "Stop blaming low staffing levels and poor pay for nurses not doing their jobs. Nurses need to prioritise patient care and make sure the important jobs are done before the jobs they like to do"

    Nurses are prioritising in the way you describe. That is why people are starving, bed sores are present and hygeine is poor. The Nurses have to prioritise doctors treatment orders and drugs before they can even think about moving on to basic care. Dealing with the drugs alone takes 2/3 of a shift and that doesn't include all the time spent running around looking for things, or preparing multiple multiple IV meds that need to be given.

    You are wrong about staffordshire. It was short staffing, I know two Nurses who worked there. The hospital was putting ITU-vented patients on things like pressors onto a 30 bed medical wards where there were only 2 RN's.

    A situation like that means that the other 28 patients get 100% neglected. No choice for the Nurse but to do that. No choice at all.

    Those Nurses filled in enough paper incident forms to kill off an entire forest. Many many calls were made to the DoH, the NMC, the Unions. Nothing was done.

    A nurse in that situation (2 ITU patients plus 28 others) would be left with absolutely no choice but to push you out of the way and run past you as you were shouting for help or a commode or a pain killer.

    I am a very caring Nurse and every time I go into work I skip my breaks and give 100% to ensure my patients are okay. And I am not even close to being able to do the job properly because of the staffing numbers. I work with Nurses who have been qualified for over 40 years and Nurses who graduated a year ago. And we are all in the same boat.

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  • Anonymous | 5-Jan-2011 8:58 am if you don't like my comments you are more than welcome to go away and not listen to them.

    The fact is Staff Nurses now ARE highly trained, qualified and professional. Are you even a Nurse? Because with attitudes like yours quite frankly the profession would be better off without. It is attitudes like yours which stop us from becoming a cohesive profession, that stop us from demanding the status and pay we deserve. At the end of the day it is not the individual Staff Nurse who is responsible for poor care, but the working conditions that is forced upon them such as low staffing levels.

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  • Mike, People like anonymous cannot tell the difference between a Nurse and a care assistant. He/she will also be unable to comprehend how complicated patients are these days compared to yesteryear and how much education a Nurse needs to have to implement Doctors orders without killing someone.

    This stuff is way over the head of sweet little anonymous.

    In the United States RNs make much more money than teachers and police offiicers. When I lived over there I met many people who went into Nursing after years of working as a cop or teacher.

    They all agreed on one thing: Working as an RN in acute care requires more intelligence, education,and critical thinking skills than their previous careers. This isn't because Nurses today are all trying to be doctors. It is because health care is complicated, patients are sicker and the treatments that the doctors prescribe require the person who is delivering the treatment to be extremely on the ball.

    Nursing is also a damn site harder. Many left Nursing and took a pay cut to go back to the police and school teaching. They simply could not handle the workload and all the life and death responsibility.

    I also knew accountants, journalists, loan officers, etc etc who switched careers into Nursing school, (Nurses can make over £40 an hour in the NY area) Same story. They took a pay cut to get out of Nursing and go back to their old jobs. They just couldn't think fast enough on their feet to handle it. Some of these people had previous degrees yet barely scraped through Nursing school as it is so much math and science over there.

    When I tell them that Nurses make less than teachers and cops in the UK they do not believe that it is possible. I just explain to them that things are a bit backward in the UK and that the public has no real understanding of what Nurse is or why hospitals need them.

    Anonymous thinks that Nurses can just go to work and spend their days making beds, handing out pills, and washing/feeding patients without getting anyone killed through neglect.

    Point is just ignore anonymous as he/she is a loon.

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  • I am often involved in investigating untoward clinical incidents. The majority of times they arise from a chain of small mistakes which when put together cause a very serious situation, much like the well know “Swiss cheese” model.
    Many of these small mistakes are made by “experienced nurses” many that have good academic qualifications. Examples of these mistakes include:
    • Omitting to administer prescribed medication
    • Administering the wrong dose
    • Failing to administer medication at the appropriate time
    • Failing to report that medication has not been administered
    • Administering medications to the wrong patient
    • Leaving drugs potted up on bedside tables
    • Failing to recognise a deteriorating patient
    • Failure to record observations
    • Failure to report a deterioration in patients condition
    • Failure to rescue deteriorating patients
    • Poor documentation

    None of the above “require the person who is delivering the treatment to be extremely on the ball” and being “short staffed” or “underpaid” is not an excuse for failing to carry out basic duties which are what the above are.
    Lets get the basics right before we demand to be treated like highly educated, skilled professionals.

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  • No those things occur absolutely and 100% because of overwhelming patient loads and constant interruptions. We know this as a result of the research done into Nurse patient ratios and failure to rescue stats. There is a good term to research.

    The things you mention above are not the reasons that Nurses need to be intelligent. There is a whole lot more going on during the course of the shift than what you mention above.

    I have said it before anonymous and I will say it again. You are an idiot.

    I know of intelligent well educated nurss who have won awards for bedside clinical excellence. They refuse to work in places where they are expected to take on more than 4 patients because they KNOW that they would make drug errors etc,

    These errors don't occur because of bad nurses who do not care. They occur because Nurses are not able to accomplish 80% of their workload during the course of their shifts. This will never improve until the wards are run properly and we have safe nurse to patient ratios. Throwing more health care assistants at the problem isn't going to help.

    You obviously have NO CLUE about what is going on at the front lines. That is obvious.

    If you want to get a clue I suggest you read a blog called Militant Medical Nurse. She has been documenting for years the things that go on at her trust that cause good hardworking RNs to fail.

    Google it. Or google Nurse Anne blog.

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  • Also google the term Linda Aiken and nurse patient ratios.

    Ms. Aiken did an in depth study of hospital staffing. She learned that when an RN has more than 6 patient it becomes physically impossible to administer drugs on time and properly and catch deterioration in conditions fast enough. It is also 100% impossible to document correctly or at all. The only time any documentation gets done on my ward is if we stay over 2-4 hours unpaid at the end of the shift to do it. So it doesn't get done, and it scares the living hell out of us. So do all the other mistakes that are occuring.

    In the UK ward Nurses have 10,15,20 patients per RN. That is a far cry from the recommended ratio of 1-6.

    There is a point where you can give an RN more patients and more workloads than she can deal with no matter how smart, or compassionate or well trained she is. And in the UK we have reached that point a long time ago.

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  • I can't believe that anyone that thinks like you works in healthcare. I cannot believe that you think that nurses with ridiculous patient loads are "incompentent" when mistakes are made.

    You write to Linda Aiken at the university of pennsylvania and tell her that you think that Nurse with 15 patients is crap if she doesn't document, get drugs out on time or notice changes in condition. I am sure she will have a good laugh at your stupidity.

    As long as there are people like you working in the health service Nurses will continue to fail.

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  • Just try standing in the coroners court and saying that you didn't do the observations on the deteriorating patient because you were too busy, or that you left the patients drugs on his table because you were too busy and so it wasn't your fault when his visitors two year old helped himself to the nice coloured sweeties and died.
    Prioritising means doing the important life saving jobs first. If you don't have time to do the other things, then don't do them. If the patients are safe that is all that matters. If you still feel that your patients are being neglected then initiate a Safeguarding Vulnerable Adults investigation which will involve specialists from Social Services and will highlight problems that will have to be acted on.

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  • "Just try standing in the coroners court and saying that you didn't do the observations on the deteriorating patient because you were too busy, or that you left the patients drugs on his table because you were too busy and so it wasn't your fault when his visitors two year old helped himself to the nice coloured sweeties and died."

    The coroners won't have it. They will blame the nurse. Yet hospital management puts nurses in position where they have actually no choice. What about when you have 8 deteriorating patients on obs and one goes downhill. You then miss obs on the others and then they go downhill. The nurse is entitled to no help in this situation and it is wrong.

    What about when the patient in bed 10 starts choking and you miss the patient in bed 1 falling because you were with bed ten? It is not possible to stay on top of everything and yes indeed the nurse will get the blame. That is why nurses are leaving the profession in droves. What about the patient who pulls their central line out right when you are smack in the middle of giving a confused man his pills. There is no place to put the pills back or lock them up without taking too much time away from the collapsed man on the floor who pulled out his line.

    I am interrupted on average every 30 seconds during my drug round with this kind of thing.

    Coroners are getting smarter. They are aware of the evidence regarding nurse patient ratios and they are demanding that hospitals staff their wards properly.

    Anyway anonymous I did a post about your comment on militant medical nurse if you want to check it out.

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  • "that you left the patients drugs on his table because you were too busy and so it wasn't your fault when his visitors two year old helped himself to the nice coloured sweeties and died."

    Parents fault.

    It is impossible to get these people to take their drugs fast enough to allow you to get on to the next thing without delaying other patients care dangerously. Sometimes the only option is to leave those pills on the table even though it scares the living shit out of you and you know that the coroner will be on your ass if the patient or visitors do anything stupid with the left pills.

    I am getting out of the UK for these very reasons. I am sick of being in situations where I am forced to do these kinds of dangerous things even though I know that I could go to jail and lose my registration for doing it.

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  • Nice one Anna, you have just admitted that you do something that you could be struck off for. You have admitted that it is dangerous but you still do it?
    Maybe its nurses like you that have got the NHS into its present state, the sooner you go abroad the better.
    If your rantings on Militant Medical Nurse are anything like they are on here, I think I'll give them a miss.

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  • All bedside nurses are put in these situations thanks to the likes of you.

    If management controlled the number of patients per nurse, the constant interruptions that Nurses get whilst trying to deliver patient care, and ensured that everything that the Nurses require was there and in place then drug errors would be a thing of the past.

    I would do some further research into this if I were you.

    I work with nurses who have been qualified for over 40 years and newer nurses as well. We are all in the same boat. I have no doubt that if you worked on my ward caring for 15 medical patients by yourself that you would make many, many errors.

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  • My ward sister and matron are begging me not to go. I make less mistakes than most of them. I take my job pretty damn seriously.

    So what do you want to? Strike all of us off and take over yourself and try and do it? Go for it.

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