Practice team blog
Last week’s announcement that an apprenticeship route into nursing is to be developed has caused quite a stir.
Despite vociferous opposition from the “too posh to wash” brigade – who maintain nurses do little that requires the ability to think, this year nursing finally becomes an all-graduate-entry profession. And the benefits of having a highly educated nursing workforce have been confirmed by the authors of a huge Europe-wide study, who conclude that all-graduate nurses could reduce preventable deaths. It seems unfortunate timing, therefore, to announce a scheme whereby “the brightest and best” healthcare assistants can skip the requirement to go to university yet still gain a nursing degree.
Although we don’t have all the details yet, it’s difficult to see how it will be anything other than a “degree-lite” if there is no requirement to attend university. It’s also difficult to see how a 50:50 split between theory and practice can be achieved, or how NMC-approved education providers can deliver the apprenticeship – unless non-university institutions are to be approved.
I can see the logic behind a scheme supporting the brightest HCAs to become qualified nurses, but if the current system of access courses doesn’t work, surely that should be improved? We need to enable those capable of gaining a degree to do so, but this must not involve anything that devalues – or even just appears to devalue – existing nursing degree courses. Universities won’t attract the brightest and best prospective students onto nursing degree courses that are perceived to be equal to apprenticeships.
However, while the academic integrity of the nursing degree must be protected, all-graduate entry has widened the gap between HCAs and nurses. It leaves a huge group of HCAs who are capable of providing high-quality, compassionate care but who don’t have the academic capabilities to gain a degree with little opportunity to develop their careers and improve their incomes.
Some employers are addressing this issue by improving career pathways for HCAs. These HCAs are being trained to take on more responsibilities specific to their individual roles and capabilities, and employed at band 4; their role could be compared to that of the old enrolled nurse.
Surely it makes more sense to improve career opportunities for HCAs than to risk devaluing the nursing degrees the profession has spent decades fighting for?
I spent a day last week experiencing the adult student nurse programme at City University in London. The student nurses on that programme will be spending time on placement on the same wards that I trained on 35 years ago. Without a doubt I know who is getting a better deal – the patients now.
There is a myth that some hold that it was good to have trained as a nurse before Project 2000 which actually took place in 1986 not at the turn of the century. That it was better to have trained when you were based at a hospital, when after only 12 weeks of preliminary training school you went straight to work on the wards, not supernumerary but on the rota. And before long you found yourself as a second year in charge on nights.
And the often-touted belief that in those good old days you really learnt to nurse not like now when it’s all theory and no practice.Well on my visit it was very clear to me how well supported student nurses are today. And how better prepared they are to look after a patient then we ever were.
“it was very clear to me how well supported student nurses are today”
Their course includes experiencing patient care in a simulation lab where there is time to practice, reflect and think about how best to care. The lectures were interactive and stimulating and include the use of patient stories told by real patients. They will be many months into their training as a nurse before they are expected to look after a patient and their supernumerary status allows them time to grow and develop their skills.
So if I was a patient now and had to choose between being nursed by me as a student as I was 35 years ago or by one of the students prepared by the programme I witnessed last week. Well as a patient it’s an easy choice. And as a student nurse it’s the same answer.
If I could have my time again I would love to follow one of the programmes offered now.
Last week ITV aired the first of its new series looking into the lives of student nurses. The producers say ‘Student Nurses: Bedpans and Bandages’ will offer “insight into what it takes to become a nurse in the 21st century”.
What a huge responsibility for the group of student nurses featured, not to mention their tutors and the teams they’re working with. They’ve been given a unique opportunity to challenge the negative stereotypes about nursing and nurse training that have emerged in recent years, and I hope the producers allow them to do this.
When we asked student nurses on Twitter back in August what they would like to see included in a documentary about their training, the overwhelming response was that they wanted people to realise and appreciate just how much work they do and the role they play as members of the multidisciplinary team. Many voiced that they feel the general public think nursing is an easy degree, requiring little academic input.
The title “Bedpans and Bandages” does little to challenge this stereotype. Although, arguably, calling it “Coursework and Exams” would do even less for the cause as no one would watch it.
My worry was that the programme would be edited for entertainment, and feature a set of larger-than-life characters whose lives appear to alternate between embarrassing moments and heartbreaking scenarios that cause them to question themselves and grow as a person in the 10 minutes they are being filmed.
The first programme, however, felt accurate. Yes, there was motivating music, tears and spilt urine samples. But it also showed the levels of responsibility students are exposed to, it showed their need to be personable and the high levels of intelligence and initiative that are essential to becoming a nurse.
It featured an incredibly likeable student nurse sat at a desk voicing her surprise about how much work the course entailed, accompanied by close-ups of her crowded timetable. Nurses were shown leading healthcare, making quick decisions and challenging anyone who dares suggest the profession lacks compassion.
Have you been watching? What do you think?
I was shocked last week by the RCN’s decision to remove indemnity insurance from most nurses.
The RCN described this as a “small” change.
While it may seem a small change to the college I am sure many nurses will be astounded to hear that they will no longer benefit from this cover.
I joined the RCN in 1981 as a student nurse. The three main unions at the time RCN, COHSE and NUPE were eager to attract our membership and our fees. But the main attraction of the RCN was the offer of indemnity insurance. After all what would you do if someone sued you?
Even when I became aware that vicarious liability meant my employer would cover me in most circumstances I held onto my membership. In the back of my mind was an insecurity that if it indemnity insurance was offered by the RCN as a membership benefit then it must be important. Perhaps that just demonstrated my naivety, but throughout my clinical career I maintained my membership because it offered me this reassurance.
From 1 July 2014, work undertaken by RCN members who are employed – for example by the health service or an independent healthcare provider – will be excluded from the indemnity scheme’s coverage. Self-employed members will remain covered, but aesthetic practice will also be excluded from because of the high claims risk associated with this area of practice.
I appreciate the RCN needs to tidy up its policies and finances and has concerns that some employers were passing on claims relating to its members to the college, but it has failed to explain why it offered a benefit that was actually of no benefit to most members in the first place.
It seems to me that buying into union membership is a bit like choosing an energy supplier. You have to look at carefully at all the benefits before typing in your bank details.
If you want to know more about vicarious liability click here.
A year on from publication of the Francis report, The Nuffield Trust has published a report on how NHS trusts have responded to Francis’ shocking findings and wide-ranging recommendations. So how much progress has been made?
Well, it’s something of a mixed bag, but Rome wasn’t built in a day. On the plus side, four in five of trusts responding to the Nuffield study said they were taking new action in response to the report, while hospital leaders said they gave greater priority to patient safety and care, and the organisational culture that drives quality.
The report also reveals that nursing is receiving a significant degree of attention, particularly over staffing levels, the role of ward managers, and ensuring fundamental standards of care. Trusts are also working to improve staff engagement and the way they handle complaints.
Less encouragingly, trusts reported that inspections by external regulatory bodies could be better coordinated to make data collection less onerous, and that there remains a profound tension between the competing priorities of care quality and financial performance.
But perhaps the report’s most worrying finding is that many staff still don’t feel confident about raising concerns, despite trusts working hard to create open and transparent cultures, and reviewing their whistleblowing policies.
Culture change takes time to embed, particularly in large organisations. So it’s hardly surprising if staff, having seen the appalling treatment meted out to many whistleblowers in recent years, aren’t immediately won over by these efforts. That’s one of the reasons we set up our Speak Out Safely campaign – it enables trusts to make a very public commitment to protecting staff who raise concerns, and gives staff a set of principles to hold their employers to.
Signing up to NT SOS is simple, and it sends a powerful message to staff, patients and families that the organisation wants to learn from mistakes rather than cover them up. However, to date, only 76 trusts in England have signed up. What kind of message does that send to staff in the rest of the NHS who may want to raise a concern?
- If your trust hasn’t signed up to NT SOS yet, you can download a letter inviting your CEO to consider it
During the hours when most of us are asleep, in hospitals and care homes across the country, night nurses are striving to ensure the care and recovery of patients.
Nursing at night carries significant responsibilities and challenges that often go unrecognised. Nurses are caring for the same number of patients as during the day but with far fewer staff and with much less infrastructure and back up.
They are responsible for their patients when the ward is not bustling with the multidisciplinary team. In the past when hospitals hung onto less acute patients, there were some wards where working as a night nurse meant looking after a ward of sleeping patients. Times have changed and night nursing is rarely such an easy option.
As well as the challenge of the work there is the challenge on the body. A wealth of research shows the physiological toll of working when your body thinks it should be sleeping. And of course there are the social difficulties – trying to maintain a normal social and home life when your hours are so out of kilter with many others in your life.
It’s great to see that George Eliot Hospital Trust is investing £400,000 to increase the number of night nurses. It is heartening that there is currently a focus on staffing levels but I hope this will also include considering whether there are enough nurses at night. It is all too easy to pull the curtains and turn out the light on what is happening on the wards at night as most managers are not there themselves.
Part of this is to recognise the both different and difficult job that nurses do at night. And of course primarily because for the patients the experience of being in hospital is 24 hours.
When reading about the background to the upcoming NICE guideline on medication use in residential homes (due March 2014), I was surprised to find that, despite the fact that the majority are not licensed for use in people with dementia, this is a widespread practice.
Risperidone, which is commonly used to control some distressing behavioural and psychological symptoms of dementia, is licensed only in specific circumstances and only for up to six weeks.
A review in 2009 found that around 180,000 people with dementia in the UK alone are prescribed antipsychotic medication, and it is suggested that two-thirds of these are prescribed them inappropriately.
Having nursed patients taking anti-psychotic medication, I am only too aware of the serious and life-changing impact extrapyramidal side-effects can have on those taking them. These risk of these side-effects increase with age. In addition, there is an associated risk of cardiac arrest and stroke.
At times, antipsychotics may be helpful to a person with dementia in the short-term. But it appears they are often used as a first-line response to some of the more difficult to manage symptoms of dementia. This raises the question as to whether they are prescribed to help the person with dementia, or to help those caring for them.
Changes clearly need to be made. Agitation and aggression may be caused by an underlying health problem that the person is unable to communicate, or this may be how the person is expressing their fear and confusion. One-on-one time with a person who is clearly distressed can help to alleviate these symptoms, but this is only possible if staff or family members are available.
None of this is new. The National Dementia and Antipsychotic Prescribing Audit has been gathering this information since 2009. It therefore stands to reason that the NICE guideline will reflect five years of careful consideration.
What do you hope to see included?
It is nearly a year on from the Francis report and the launch of our Speak Out Safely campaign to ensure staff will be supported when they raise concerns about care. It was disappointing, therefore, to read the recent CQC inspection of Barts Health Trust.
The inspectors found that “that staff morale was low. Too many members of staff of all levels and across all sites came to us to express their concerns about being bullied, and many only agreed to speak to us in confidence”.
One of the most telling findings was the disconnect between board and ward. While the leadership team was described as well-established and cohesive, the CQC found that it needed to be far more visible across all parts of the trust.
I suspect the temptation for any trust faced with a report like this is to look for quick fix that can be rolled out quickly, but as we all know, this usually results in nothing more than cosmetic change with no lasting impact.
Last week I went to the launch of a report “Staff Care. How to engage staff in the NHS and why it matters” by the Point of Care Foundation, which aims to improve patients’ experience of care and increase support of staff who work with them.
The report is a great read. At only 16 pages – and free of jargon – it has a clear message that caring for people who work in healthcare is the key to developing a caring and compassionate health service.
It is a rare report that really gets to the point of what staff engagement means. It acknowledges that engagement should not rely solely on annual staff surveys and meetings and is more than measures of job satisfaction and commitment.
The authors of the report suggest that:
- Staff should have well-structured appraisals, ongoing training and career development;
- Line managers should have people management skills;
- Teams should be well defined and regularly review how they are doing;
- Staff should have space to reflect on patient care challenges;
- There should be coherent goals for quality and safety from board to ward;
- Staff feedback should be acted on and staff empowered to make improvements;
- Values should be articulated and how these translate into behaviour be made clear.
I’d urge you to have a look at this report. It has some important messages for managers at all levels of the NHS and it is crucial that the momentum created by the Francis report is maintained in 2014.
One year on from the Francis report I wonder what difference it has made to nurses working with patients and what its legacy will be. We are still at a turn point but for real and lasting change to happen organisations have understand that while patients matter most, staff matter too.
As Jocelyn Cornwell, director of the Point of Care Foundation says “We’d like the NHS to be notable for being not just the largest employer in the country but also the best”.
We are inviting all NHS organisations, other healthcare providers and universities offering nursing programmes to publicly commit to supporting staff who raise genuine concerns about care by signing up to Speak Out Safely, and over 60 have already done so. If your trust hasn’t already signed up, you can download a letter to your chief executive asking that it does so.
Only a couple of decades ago you could, in theory, qualify as a nurse and spend 40 years in the profession without undertaking any form of study or updating. And while examples of nurses who did that may be few and far between I’m long enough in the tooth to remember the introduction of PREP in the 1990s, and I know a few did exist.
“I’ve been nursing for over 30 years and never needed to do any more studying, so I don’t see why I should start now,” one nurse told me furiously when I visited her hospital to canvass opinions on what kind of support nurses might need in fulfilling their forthcoming PREP requirements. She then proceeded to give full vent to her feelings about “reflective claptrap” and “clever-clever nurses” who “went on” about this article or that new technique. That nurse was an extreme example, but at the time mandatory CPD did seem pretty radical.
It’s no secret that PREP hasn’t been fit for purpose for some time. Early promises to audit individual professional portfolios fell by the wayside, and currently there is no system of checking NMC registrants have fulfilled their CPD or practice requirements. But that’s set to change, and you have a chance to influence what comes next.
The NMC has initiated a six-month consultation on revalidation, and is inviting all interested parties to give their views via an online survey. Anyone can give their views, and whether or not nurses and midwives take part in the consultation you can bet your bottom dollar that many of your most strident critics will.
It will be impossible to come up with a revalidation system that pleases all of the people all of the time. However, we can only hope the NMC do better than the General Medical Council appears to have done, according to a survey by Doctors.net.uk and come up an effective system that takes account of the realities of day-to-day nursing and midwifery practice.
I can’t promise you that completing the survey will result in the perfect revalidation system, but if you don’t, you can’t complain if you don’t like what’s imposed.
New Year is traditionally a time when we evaluate our lives and make resolutions to change or improve things. To reflect on the past year and make a fresh start for the one coming.
One of the most common New Year resolutions is to quit smoking. And it is one of the hardest to actually achieve, particularly without any support – pharmacological or psychological. Many people will be saying on New Year’s Eve that this is the last cigarette they will smoke but sadly for their health and that of their families for many that statement will not be true.
NICE has published new smoking cessation guidance for secondary care which we are featuring in our January 22 issue. The aim is to ensure that smokers are identified and offered support during their hospital visit or stay. And crucially that there is a join up with community services so that the support they need is available so they can follow through their resolution.
Take a look at the new guidance and see how well your hospital is doing to provide the right infrastructure. It is clear that staff need to be given training so that their one contact counts and that they know where to refer to for support.
I have a few friends and colleagues in mind who I am going to encourage to make this the year that they do really quit. And to that end I will suggest support they can access. With smoking being responsible for over 460,000 hospital admissions in England each year, interventions and support to stop smoking are crucial.
How many patients do you think you can get to quit this year?