Practice blog

'Hiving off important responsibilities devalues nurses' skills'

22 May, 2012 Posted by: Ann Shuttleworth -

News that a West Midlands trust is to extend a scheme whereby unemployed people deliver patient care makes me deeply uncomfortable.

First there is the issue of whether it is right to be asking jobseekers to spend eight weeks doing unpaid work in an NHS that is shedding staff. I appreciate that many unemployed people need support in their search for work, and being able to show relevant work experience can make all the difference to job applications.

While Sandwell and West Birmingham Hospitals Trust may not be using unpaid workers to undertake work previously done by paid staff, there is certainly the possibility for trusts to consider this as a way of filling gaps left when staff numbers are cut.

I also have misgivings about the type of work the jobseekers are being allocated. While many of the tasks are uncontroversial - general tidying, welcoming visitors, running errands, and reading to patients – they are also being asked to serve drinks to patients and assist with feeding.

Ensuring patients receive adequate nutrition and fluid is a fundamental nursing role, and in the reports highlighting poor standards of care over the past couple of years, nurses have been repeatedly accused of failing their patients in this respect.

The profession has been accused of being more interested in academic qualifications than in core nursing responsibilities, yet fluid and nutrition are suddenly the domain of those undertaking unpaid work experience.

Hiving off these important responsibilities devalues nurses’ skills and puts patients at risk, yet nurses will still be held accountable if anything goes wrong, because they will be delegating the tasks to the unpaid workers.

Nursing has come in for a huge amount of flak recently, and the poor practice of the few has been used as a stick to beat the many. How is the profession ever to put its house in order if it is bombarded with mixed messages about its key responsibilities?

'We need more health visitors AND more district nurses' 

14 May, 2012 Posted by: Kathryn Godfrey -

The recent report on community nursing released at RCN Congress highlights the pressure that community nursing is currently under.

Falling district nurse numbers, social care cuts, and an ever growing number of increasingly complex patients. It’s a frightening mix and with a significant number of district nurses set to retire in the coming decade, it’s hard to see that others will be rushing to step into their shoes.

It’s already a tough job without all the increasing pressure currently being loaded on. Working in a ‘hospital without walls’ is a challenging role. Making decisions about frail and elderly patients with multiple co-morbidities in their own home takes skill and training. There is no second opinion readily at hand – you are on your own with limited resources. While nursing support workers do a great job in working alongside registered nurses in the community, the complexity of the work means that the ratio of registered nurses and support workers must not swing too far in the wrong direction.

The push to increase the numbers of health visitors is welcome. However this campaign is more likely to recruit from the community nurse workforce as those already working in the community are more likely to apply. For those working in hospitals, it can be a leap of faith to take that step to work outside the hospital environment that they are used to.

Also the increase in health visitor numbers must not be used as a panacea for the fall in district nursing numbers. I was struck  by how Andrew Lansley answered a question about declining nos of district nurses at RCN Congress by talking about the increasing number of HVs. A good initiative but it’s not the same thing.

The RCN report makes clear for the urgent need  for more district nurse numbers and support for this crucial arm of the profession. Lack of support and care of patients in the community will inevitably lead to more hospital admissions. It feels like we are just going around in circles. Policy makers need to wake up to the fact that all the money comes out of the same pot so cuts in the community will lead to increased costs in hospitals.

'How can you revise if you don't have a plan?'

7 May, 2012 Posted by: eileen shepherd -

Along with “What biology coursework is now on You Tube?” and “How can you revise when your physics book is downstairs?” Sadly my daily lecture on the benefits of a plan, to-do lists, colour pens and PostIt notes is greeted with, at best, rolling eyes and a “whatever”.

The ongoing debate about revision plans reminded me of the debate in nursing about the value of documentation.

Is it possible to start work without a plan of what you are going to do? Yet a news story last week highlighted the enormous amount of work nurses have to leave undone because of staffing levels.

One of the tasks frequently omitted was the planning and documentation of care: 47% said they failed to develop or update care plans; 33% failed to adequately document care; and 28% failed to complete care plans.

The test of a good care plan is that staff, at a glance, can identify what has been done before, if it was successful and what is planned for the future. I remember working with a ward sister who advised staff to read the care plan first and then ask questions. She believed a good care plan should save time rather than make work.

Yet many of us have a dysfunctional relationship with documentation. It is viewed as an add-on, often completed after the work is finished in the office over a cup of coffee. The quality and quantity of paperwork is a barrier to completing it and incomplete documents have little practical value for day-to-day work, so no one looks at them or trusts the content. Sadly the value of good documentation is often only realised when records are used as evidence in court.

I would argue that a patient’s written care plan is pivotal to providing personalised care and there needs to be a radical rethink of how this happens in practice.

Clinical staff must be involved in the design and content of documents so they are clinically useful. The temptation to add in another assessment or tick list to meet a new directive or target needs to be carefully considered.

Nursing documents should be owned by individual patients and the nurses caring for them. They should be dynamic description of patients’ wants and needs, how these can best be addressed and the progress patients are making. If this is the focus, nursing documentation will become a valuable and essential part of care. But if this is to happen, the most important requirement is that time is made available and staff are supported to ensure this essential part of care is completed.

'We must recognise when medical intervention is inappropriate'

30 April, 2012 Posted by: Ann Shuttleworth -

One parent has cancer, and has been on the Liverpool Care Pathway for weeks. She and her family have received excellent care and support, which has focused on keeping her comfortable and offering emotional and practical support to her and her loved ones.

Of course they are all finding this period difficult, but my friend told me that the team caring for his Mum has enabled the family to find pleasure in their remaining time together. She is comfortable and able to satisfy herself that she is attending to things that are important to her, while her family are reassured that any distressing symptoms will be addressed promptly by professionals who understand end-of-life care.

My other friend’s Dad has advanced dementia and is now frail and declining before our eyes. He is in a nursing care home yet he has been taken to A&E twice in the past couple of months, and then admitted to hospital where he has had arterial blood gas analysis and aggressive antibiotic treatment which was distressing for him and therefore his family. After the first trip to A&E my friend asked the home not to take him in again. She understands that he is dying, and that heroic interventions simply prolong a life that is devoid of any pleasure, yet he was taken in a second time and the process was repeated causing the same levels of distress to all concerned.

These two situations reminded me of a paper at last week’s RCN Research conference, in which Karen Waters reported on a study of the end-of-life care received by patients with dementia. Like my friend’s Dad, 78% of her retrospective sample received burdensome interventions.

Like my first friend’s Mum, many people with cancer or other diseases that are recognised as being potentially terminal receive excellent end-of-life care that gives them both physical and emotional comfort and supports their family. No one tries to “save” them because it is accepted that this is both inappropriate and impossible. Shouldn’t those who are simply reaching the end of their life be able to expect the same?

Some details have been changed to protect confidentiality.

Trolleys as beds: how have we come to this?

23 April, 2012 Posted by: Kathryn Godfrey -

You realise what trouble we are in when policy advice is being given on whether it is best to look after patients on a trolley in A&E or on a trolley in a ward corridor. We seem to have got past the point where either of these situations are unacceptable and are now being seen as inevitable.

The advice last week from the College of Emergency Medicine is that this is the safest way of dealing with current capacity problems in some hospitals.

Maybe so but we have to careful that we are not setting up a system that will become the norm ie that every 20-bedded ward will now become 20 patients plus the one unfortunate on the trolley.

Apparently there is substantial evidence patients are harmed waiting in overcrowded emergency departments or ambulances but there is no evidence of harm to patients through waiting on wards. It may be of course that once a significant number of patients do end up on trolleys in ward corridors that we will establish that that causes harm too.

Ward corridors can be frantic and frightening places. Any patient parked in a corridor will get a ringside view of what is happening throughout the ward, much of which will appear alarming. Ringing phones, harassed staff, ringing buzzers,  distressed relatives. It will all be on view and I can’t imagine it will be good for their health and recovery.

The college does specify that the patient stuck on the trolley must be “stable, orientated and not receiving active treatment or require monitoring”. However it won’t be long before that detail is lost and the trolley be treated like the 21^st bed. The college may be giving useful advice  — the worry is how it will be used.

'Nurses have to knowingly carry out detrimental bed manoeuvres every day'

16 April, 2012 Posted by: eileen shepherd -

Listening to recent news reports on discharge from hospital at night I wondered where were the nurses representing the needs of a 94-year-old man sent home at 1am in the morning.

The Times news story and the data it was based on was flawed, but it did make me think again about what it really means to be an advocate. Is it possible to represent your patients if you have no power to influence or change their circumstances?

I was reminded of a time - when I was working as a bank nurse at a large teaching hospital - I was asked to transfer Mr Jones, who had dementia and visual impairment, from an acute medical ward to a surgical ward at around 12.30am.

He was one of the great number of “unwanted patients” in a busy hospital pushed for beds. His medical treatment was complete and but his long-standing health problems meant he needed a bit more time to get his social situation sorted before he was discharged home. As I pushed him through the empty corridors he asked time and time again where we were going and as we got to the surgical ward his distress was tangible to the staff who greeted him.

As I told the surgical nurse about his problems I could feel her anger growing. She shared my distress about moving this frail and vulnerable person from a ward where he had become familiar with his environment and routine. Yet we were both powerless to prevent it happening.

When we were told to move Mr Jones I asked the bed manager what would happen if we refused to. She replied: “We will just get someone else to do it”. Down in A&E someone needed an acute medical bed and Mr Jones lost out.

Bed manoeuvres happen every day in hospitals and I suspect many nurses have had to push patients to other wards knowing that it will ultimately be detrimental to their wellbeing.

So where does this leave nurses as advocates? Should they think about the needs of the person waiting for the bed or focus exclusively on their patient? The NMC advises “Advocacy is concerned with promoting and protecting the interest of people in the care of nurses and midwives, many of whom may be vulnerable and incapable of protecting their own interests”.

But how do you do this in a system that is so pushed and underfunded that it demands nurses compromise the needs of patients in their care for the greater good of those elsewhere?

'The battle for nurse representation on CCG boards isn't over'

9 April, 2012 Posted by: Ann Shuttleworth -

After all, who would ever assume the bulk of NHS care commissioning could be done effectively without the involvement of the largest group of health professionals.

Except it wasn’t a no-brainer was it? What are now CCGs were originally to be GP commissioning consortia, and there was no requirement for GPs to involve nurses - or any other health professionals for that matter. As a result of pressure from many quarters, including our own A Seat on the Board campaign, the government came up with a less contentious name for the consortia and made it mandatory to involve other professionals.

So now the NHS and Social Care Act has passed into law, and like it or not, health professionals have to make it work for the good of their patients. But it seems the battle for nurse representation on CCG boards isn’t over. As we revealed last week, CCGs will not be allowed to take on their duties unless they have a nurse on their board - but they are free to design the nurse’s role, and there are wide variations in the status of nurses on CCG boards.

Most health professionals agree that making the new NHS work is going to be difficult at best. But if nurse involvement on CCG boards is just a token gesture, it will be nigh on impossible. It took years for hospitals and trusts to accept the value of appointing directors of nursing in the first place, and even longer for them to see the value of making them board members. Surely the profession isn’t going to have to fight the same battle all over again with CCGs. If commissioning is to be led by health professionals then the ones who spend most time with patients and look at them from a holistic perspective must be fully involved in the process.

'Our nurses are burnt out but still offering good care'

2 April, 2012 Posted by: Kathryn Godfrey -

It was probably not much of a surprise to nurses out there on the frontline that their experiences are nearer to those of nurses in Greece, a country facing economic meltdown, than nurses in countries we would feel more usually feel comparable with such as Holland.

This fascinating survey published in the BMJ shows that 42% of nurses in England felt burnt out compared with 78% of nurses in Greece, 41% in Ireland and 40% in Poland. However only 10% of nurses in Holland and 15% in Switzerland felt burnt out.

Burnt out but still offering good care. A closer look at the statistics reveals that despite reporting high levels of burnout, nurses in England report lower levels than some other countries of wards that have ‘poor or fair quality of care’. For example 19% of nurses in England reported the ward they are working on to have ‘poor or fair quality of care’ compared with 35% in Holland, 27% in Sweden, 35% in Germany and 28% in Belgium.

Nurses were also asked if they would give their ward a poor or failing safety grade. The results from the nurses in England were comparable with the majority of other European countries at 7% compared with Greece at 17% and Poland at 18%.

So burnt out but still soldiering on. But for how long? The survey shows 39% of nurses in England are dissatisfied with their job and 44% intending to leave their job in the next year. Let’s hope that a good proportion of the 44% are planning to find another job in the NHS otherwise there is a phenomenal crisis brewing.     

This survey of 2,900 nurses at 46 hospitals took place in 2009-10 before the details and extent of the government health reforms became clear. So it seems likely that the level of stress and pressure of English nurses will move even closer to that of Greece as they face the uncertainty of life in today’s NHS.

'Is three years long enough to prepare our nurses for practice?'

26 March, 2012 Posted by: eileen shepherd -

When I was a student there were very few options for dressing a wound; eusol and paraffin, paraffin gauze, hydrogen peroxide or a dry dressing.

And guess what? Wounds rarely healed. The field of tissue viability has developed significantly over the last 20 years and now wound management requires considerable skills including detailed assessment and product selection.

This growth in nursing knowledge is not confined to tissue viability and the challenge is to squeeze more and more into the nurse curriculum so that newly registered staff will be able to hit the ground running.

I remember being petrified on my first day as a staff nurse; a different uniform brings an expectation that you know what you are doing, have all the answers and are able to make decisions. You have passed your exams so you must be a competent practitioner.

But registration is just the beginning of the journey to becoming a nurse.

New staff nurses must be nurtured so they not only consolidate their practical skills but are able to live up to the guiding principles and ideals that brought them into the profession in the first place. Failure to give this support leads to frustration, disillusionment and ultimately loss of good nurses from the profession.

Perhaps nurse training just isn’t long enough. Extending it to four years to include a 12-month postgraduate preregistration experience would enable nurses to consolidate their theoretical and practical skills and begin the transition from novice to expert in a protected environment.

This would follow the pattern set by other professional groups. Pharmacy is now a five-year course with a one-year postgrad prereg course where pharmacy graduates gain essential practical experience.

Why can’t nursing replicate this model?

'Many nurses would not wish to administer the drugs to end an intolerable life'

19 March, 2012 Posted by: Ann Shuttleworth -

The subject of assisted suicide, it seems, just won’t go away.

Legal cases come up with increasing frequency, in which individuals wanting the right to die at a time of their choosing challenge one aspect or another. In the meantime healthcare professionals appear to be polarised, making it impossible for the associations representing them to develop policies that gain support from a majority of their members.

The latest case to come to prominence is that of Tony Nicklinson, who earlier this month won the right to ask the courts to declare that a doctor can end the “indignity and misery” of his life.

Mr Nicklinson has had locked-in syndrome since, at the age of only 51, a stroke in 2005 left him paralysed and only able to communicate through an Eye Blink Computer. While his body may be helpless, Mr Nicklinson’s mind was undamaged. He now says he is Anyone wanting to gain some understanding of what this means for his quality of life should read the Patient Voice article Mr Nicklinson wrote for Nursing Times in 2011. After seven years Mr Nicklinson wants the right to ask a doctor to end his life without fear of legal redress.

Unless he wins his case and succeeds where others have failed, the law on assisted suicide will almost certainly continue to be challenged by other individuals who are unable to end their own lives but either already find them intolerable or know that a time will come when they do. At present their only option is to refuse food and die a lingering death of starvation.

Of course, if the law were to change, the onus would then move onto the people asked to facilitate assisted suicide. Many health professionals, even if they support the principle of assisted suicide, would not wish to actually administer the drugs that would end these intolerable lives.

I suspect that sooner or later those who argue for assisted suicide will prevail, simply because there will always be another determined individual ready to fight all the way to the highest court. Each time the subject hits the headlines in a way that demonstrates just what such people endure every day, public opinion is likely to shift in their favour.

If and when the law does change, there must, of course, be rigorous safeguards to ensure no one is pressurised to request assisted suicide. However, there must also be support and training for any health professionals willing to accede to such requests – and no professionals must be pressurised to do so.

'There are not many days when you don’t meet a patient with diabetes'

12 March, 2012 Posted by: Kathryn Godfrey -

I was up in Glasgow for the Diabetes UK annual conference last week.

Diabetes is an important topic for nurses - and for us at Nursing Times, one which we marked with our diabetes special that included a range of useful practice articles - after all, there is not many days go by when you don’t meet a patient who has diabetes.

Some shocking statistics about lower limb amputations were revealed. Shocking in numbers and shocking because, for the most part, this is a preventable complication of diabetes. 80% of people who have a lower limb amputation die within five years.

Proper foot care is at the heart of prevention which is why another statistic, that 2% of foot ulcers occur while patients with diabetes are under care in hospital, is important. If foot ulcers can develop under the noses of health professionals then something is wrong.

Diabetes UK launched their Putting Feet First campaign in Glasgow to try to get the message out about the need for better foot care. Nurse education is crucial and our free-to-access online learning unit produced with NICE is part of the solution. If you have not yet done it and want to be part of a better statistic (the number of nurses who are up-to-date on diabetic foot care) then get to it.

'Patients must retain the right to decide how they are referred to by health professionals'

5 March, 2012 Posted by: eileen shepherd -

As a student nurse I was taught to address patients formally - Mr, Mrs, Miss, Ms - unless they requested otherwise. It was drummed into us that patients must never be labelled as bed numbers or by their diagnosis - “the stroke in bed 4” was deemed unacceptable as were terms of endearment such as “sweetheart”.

I found these rules relatively easy to follow. I had been brought up to address adults formally and it still makes me laugh that my mother never granted permission to use her first name, not even to her children’s partners.

But such rigid social conventions are no longer the norm and walking the line between formality and informality is a difficult one. So, a cautionary tale…

I once nursed a lady, let’s call her Mrs Devlin. Her first name was Elizabeth. She lived alone and had no family in England. She had long-term mental health problems and was very suspicious of nursing staff. Every time I looked after her I addressed her as Mrs Devlin and we got on brilliantly, but some nurses found her uncooperative and difficult.

No one noticed a connection between her name and how she related to staff until her sister visited from Ireland. She noticed that some of the staff referred to Mrs Devlin as Elizabeth. Apparently, from childhood, Mrs Devlin hated her first name and had always refused to answer to it, preferring to call herself Lily. No one asked Mrs Devlin if they could call her Elizabeth and she responded by withdrawing from them. Clearly, an attempt to break down barriers through informality had only created yet a bigger one.

Many nurses ask their patients whether they would prefer to be addressed by their first name or as Mr, Mrs, Miss or Ms. This is a loaded question which perhaps implies that nurses want to be on first names terms, and I am sure many patients feel pressurised to comply with this expectation.

We can never make assumptions about patients and basic social conventions are vital in establishing relationships, particularly when patients feel vulnerable, dependent and emotionally fragile. Patients must retain the right to decide how they are referred to by health professionals and to assume otherwise is disrespectful.

'Tackling drug use costs the UK eye-watering sums'

27 February, 2012 Posted by: Ann Shuttleworth -

Our Practice section contains two articles about the use of illegal drugs – one about the legal and ethical issues nurses face when their patients use cannabis for therapeutic reasons, and one discussing nurses’ attitudes to substance users, and whether drugs should be decriminalised.

Unsurprisingly, opinions on the general issue of drugs varied, but that didn’t really matter – our opinions aren’t going to affect anyone’s health and safety. Nurses’ opinions, on the other hand, do affect others. Whether you’ve been aware of it or not, it’s almost certain that some of your patients have used illegal drugs. And in some cases that fact may have been relevant to their presenting condition.

If you haven’t been aware of their drug use it may be because those patients have not disclosed the fact because they feared your disapproval. They may even have worried that you would refuse to treat them or might alert the authorities. And you might even be surprised at which patients they were; drug use isn’t the exclusive preserve of the young – 69-year-old Sir Paul McCartney may have decided to give up cannabis but some of his contemporaries are doubtless still indulging in that and other substances.

The impact of UK drug laws on healthcare and health professionals is rarely discussed and difficult to quantify, but they certainly present health professionals with dilemmas and difficulties. They may also cost the NHS far more than we realise. While some patients’ treatment is directly related to their drug use, how many others with unrelated problems suffer complications because the professionals caring for them did not have important information that would affect treatment decisions? And how many harm themselves because they find it difficult to access information that might make their drug-taking less dangerous? 

Political debates about whether drug laws should be abolished, relaxed or tightened up tend to look at issues around criminality. Perhaps next time politicians take a leaf out of the nursing book, and look at the issue holistically. Tackling drug use costs the UK eye-watering sums – perhaps we need to find better ways of spending that money. 

'It's good news for practice nurses'

20 February, 2012 Posted by: Kathryn Godfrey -

News that a training course for practice nurse training is to be accredited by the Royal College of General Practitioners (RCGP) is significant.

Practice nurse training across the country is patchy, poorly provided and follows no set standards.

As practice nurses are employed by general practice, GPs need to be involved and taking responsibility for their training. This step to accredit the Foundations of General Practice Nursing course at Plymouth University is a sign that GPs are finally recognising the deficit in practice nurse training.

GPs are more likely to pay to send their staff on courses accredited by the RCGP so hopefully this will help improve access to training for practice nurses. The coming Care Quality Commission  standards will also help.

By April next year under CQC standards, GP practices must prove they employ “sufficient numbers of suitably qualified, skilled and experienced persons” who receive “appropriate training [and] professional development” and are “enabled…to obtain further qualifications”.

Some GP practices will find it difficult to adhere to this standard and it will push them to look more closely at their staff training needs.  

The lack of access and availability of practice nurse training has been accepted for so long but it is of course unacceptable – let’s hope this is a move forward.

'Being a student nurse makes you grow up fast'

14 February, 2012 Posted by: Kathryn Godfrey -

I was watching some student nurses deliver some sensitive and effective care on a ward last week.

Their attitude to the patients was both respectful and compassionate. It made me think about this group and wonder how they must be experiencing the current media onslaught on nursing.

And the negative stories about nursing students which have been out in the last year or so  – reporting  a lack of compassion and a lack of numeracy skills. It’s hard work training to be a nurse – combining the dual demands of studying and practical placements.

It requires dedication and energy. And it is a challenge to be on the wards dealing with very sick patients, seeing things that your friends who are studying other subjects will very likely never see.

The majority of student nurses take on this challenge as young adults and as we know training as a nurse makes you grow up fast. At least when you get to your third year you begin to feel as if you know what you doing and you can take the variety of challenges in your stride more easily.

I am hoping the Student Nursing Times Awards which we have launched this year will go some way to supporting and celebrating the efforts of student nurses and all those involved in training the nurses of the future. 

If you are a student nurse in your third year, a mentor, lecturer or run the best nursing course then please take this opportunity to enter online by March 2^nd.

'Ward sisters are the lynchpins that hold wards together'

6 February, 2012 Posted by: eileen shepherd -

“It’s so bizarre how differently one is treated in a Sisters uniform…” @lopo485

Our news editor Steve Ford sent me this lovely tweet last week.

The comment from @lopo485 got me thinking about the value we place on uniform and how important it is to patients and other staff.

Many years ago, when I was a ward sister, I decided to stop wearing my sister’s uniform and dress in white like the other registered nurses.

During this time I gained a real insight into the power of uniform - and particularly that of the sister. I suddenly had to spend more time explaining who I was. I realised how much harder it was for my team to get things done. Staff, ranging from porters to consultants, frequently apologised - “sorry I didn’t realise you were the sister”.

But my experiment stopped late one Friday afternoon. I was sitting with an elderly patient who used to be a nurse and she asked me why I didn’t wear my sister’s cape. I explained that I felt uniform created artificial barriers and hierarchy between the team and described my experiences.

She sat there for a while and said: “But isn’t that the point? People look for you - and up to you, and your uniform is something to be proud of. You’ve earned it and the respect that goes with it. It gives you the authority to get things done and people need to know who you are.”

She was of course right. Ward sisters are the lynchpins who hold their wards together, and they need to be visible and accessible. Last week Sir John Tooke, head of University College London’s medical school, suggested nurses lack adequate role models, and championed the ward sister “as a very strong representative of the caring profession”.

My experiment taught me that all staff should be respected and their views listened to regardless of the colour of their uniform. However, health professionals have to work as a team - and all teams need a leader. On busy wards, a distinctive uniform enables patients, visitors and staff alike to recognise that leader immediately.

As lopo485 says: “people seem to notice me more, everyone wants to speak to me! Random [people] shout good morning sister! It’s lovely really!”

I couldn’t agree more - it is lovely, but it’s also an important statement: “I’m leading this team and you can come to me for support.”

Oppose the heath bill and be ignored

30 January, 2012 Posted by: Ann Shuttleworth -

The royal colleges - representing health professionals (whether these are medics, nurses or midwives) - are not natural rebels.

Possibly mindful of their charitable status, if they disagree with government plans they prefer to do so behind closed doors, and to use the carrot of co-operation rather than the stick of confrontation.

Despite this, last week the Academy of Medical Royal Colleges were preparing to announce that, with the exception of the Royal College of Surgeons, all were opposed to the Health and Social Care Bill. The academy later pulled back from releasing the statement - apparently after college presidents received ministerial phone calls - and agreed to continue discussions with the government. Many will be disappointed at this apparent loss of nerve, but at least Mr Lansley cannot claim to have the academy’s support (can he?) That cat is out of the bag.

Until last week the government could dismiss opposition as coming primarily from the “usual suspects” - unions, hostile media and pressure groups. It could claim the avalanche of opposition from individual health professionals was rooted purely in self-interest or aversion to change. And it could tell us that the clamour from alarmed members of the public had occurred because the poor dears simply didn’t understand such a complex piece of legislation.

So now, only the surgeons are truly on-side. A profession that cynics might say stands to benefit most if the Bill becomes law without significant changes. Why? Because it’s difficult to see the aftermath not leading to longer waiting lists - and when people wait longer for surgery, if they have the money, they are more likely to go private.

Despite the plethora of clearly argued cases against the Bill that have been presented over the past 18 months - many of which have come from highly respected organisations not given to overtly political pronouncements, the government has pressed on. With virtually no credible support, how will it now justify forcing through this radical, unmandated and unpopular legislation?

Ignore the politics and take a good look at intentional rounding

16 January, 2012 Posted by: eileen shepherd -

The principles underlying the approach are sound. Any system that guides the organisation of care to build a therapeutic relationship between nurses and patients has to be welcomed. An article by Gregory Dix published in this week’s Nursing Times outlines how IR has had a positive effect on care on a medical admission unit in his trust. It enabled nurses to be proactive rather than reactive, anticipate patients’ needs and find out what works for them. I don’t think there is much to disagree with.

The problem comes when intentional rounding is championed by policymakers who believe blanket adoption is a catch-all answer to the challenges facing nurses.

We only have to look back to the “named nurse” policy to see the pitfalls of this approach. In the 1990s, policymakers hijacked some of the organisational elements of primary nursing - that each patient would have their own nurses - and set a time frame for implementation. The philosophical principles of primary nursing were ignored and “Not my patient” became the slogan that epitomised the failure of this initiative in many hospitals. And we live with the legacy of this failed policy today.

The transcripts of the Mid Staffordshire inquiry has demonstrated that nurses need to reassess the principles that guide how care is delivered to patients. Intentional rounding is only part of the solution. The problems facing nursing are complex and sound bites suggesting there is one answer are foolish and - more worryingly - misleading to the public.

So, ignore the politics and take a good look at intentional rounding; it is a really useful tool. If it is not for your team - fine, but you need to be prepared to explain why.

Politicians are not qualified to tell you how to nurse but they do it anyway. We need to find a way to ensure the nursing forum is about nurses and their patients rather than politicians, otherwise I fear a repeat of the “named nurse”. Cosmetic change with no substance is time wasted.

Don't rush to judgement on Stepping Hill

9 January, 2012 Posted by: Ann Shuttleworth -

Now that a second nurse from Stepping Hill Hospital, Victorino Chua, l has been arrested for allegedly tampering with medication, I wonder whether those who attacked Rebecca Leighton so viciously will reflect on their actions.

Ms Leighton was arrested last year shortly after the police inquiry began into a number of suspicious deaths at the hospital. Her arrest led to a media feeding frenzy as newspapers scrambled to unearth ‘dirt’ on her and portray her as a rather sleazy party girl. Meanwhile, Facebook pages sprang up containing shocking threats and incitements to violence against her and calling for punishments last seen in medieval Britain.

While Facebook eventually took down the offending pages I am yet to hear of any individuals being arrested for posting such malicious content. It seems that, while teenage boys indulging in riot fantasies from their bedrooms must be given long prison sentences, it’s OK to threaten to kill a nurse - so long as she’s suspected of wrongdoing.

Even when Ms Leighton was released without any charges related to tampering with medication, social media saw plenty of comments about her having ‘got away with it’. If she had the means to do so, I suspect she could have successfully sued hundreds if not thousands of people who libelled her in their rush to judgement.

Nurses are entrusted with caring for people at their most vulnerable, so it is not surprising that there is an outcry when they abuse this position - regardless of whether this abuse is serious enough to be deemed criminal. However, they are entitled to the same treatment as anyone else when suspected of abusing their position - they are innocent until proven guilty. I hope Mr Chua receives better treatment than Ms Leighton.

Deciding to quit may not be enough

3 January, 2012 Posted by: Kathryn Godfrey -

A friend told me on New Year’s Eve that she was going to quit smoking.

After 30 years of smoking it was time to flush the fags down the loo and breathe easy.

The decision was inspired by the dentist telling her that her planned tooth implant would stand a better chance of success if she gave up smoking 6 weeks beforehand .

Her partner was less than supportive saying she spent more time talking more about giving up smoking than actually doing it and was sceptical about her chances.   

Great news,  I said – how are you planning to do it? Well, she said, she was just going to stop.  That was the extent of the plan.

As we know, giving up smoking is hard but sustaining the change is even harder. 

I was surprised to discover that my friend had no knowledge of any of the support available – for example,  smoking cessation groups or the Quit Kit that she could get from the chemist.

I gave her as much information as I could but it was not the ideal setting. Anyway, the subject was making her sufficiently twitchy that she was heading outside to have one of her last cigarettes of 2012 and ever, or so she hoped.

So what I am thinking is that health professionals have an important role to play in prompting people to give up smoking in 2012 but they also need to make sure that they know of the support that is available.

All the research shows that supported cessation is much more likely to be successful in the long term than the ‘I am just going to give up’ approach.  

Where do you stand?

'Many nurses have no part in decision-making processes that directly impact on patient care'

26 December, 2011 Posted by: eileen shepherd -

Mary is a sister on a surgical ward. She was told a few months ago that theatres no longer have staff to escort patients back to the ward after 5pm, so ward nurses now have to collect them. Mary only has four staff on a late shift and queried how they will manage, but the business manager said there is no alternative. On the first evening of the new system two nurses went off on escort, buzzers started ringing and a patient complained about having to wait 15 minutes for a bedpan. A problem solved in theatre created a new one on the ward.

Does this sound familiar? We work in silos, one directorate competing with another for resources. Solving a problem in one area often means it is just pushed onto another service - and all too often nurses are expected to absorb change and get on with it.  These artificial boundaries create systems that may work well for the organisation but are not always best for patients.

Like Mary, many nurses have no part in decision-making processes that directly impact on patient care and I wonder if anyone ever measures the ripple effect of change on other wards, departments and services.

We talk a lot about patient stories informing care. I would argue that nurses’ experiences are powerful too. You are at the front line and witnessing day to day the positive and negative effects of changes in services. 

So my New Year wish it is that nurses’ stories become part of the quality agenda. I am not talking about staff satisfaction surveys but the actual words you use to describe what happens to you and your patients. Your voices must be listened to because ultimately you see and know what matters to and works for patients. Your voices coupled with patient voices are a powerful force and should be used to shape services for the better.

Happy 2012.

'In their late sixties, how will nurses keep up with the demands of the job?'

8 December, 2011 Posted by: Ann Shuttleworth -

The debate about whether the country can afford to pay public sector pensions will, I’m sure, continue to rage long after the current dispute is resolved. And I doubt some sections of the media will ever stop referring to them as ‘gold-plated’.

But I’d like to take a step back from the politics, and look at the practicalities. So let’s try to disregard the fact that people are being asked to work longer and pay more in order to receive less (go on - I know it’s hard, but do try).

There are some basic issues that make the ever-rising retirement age simply unworkable for a huge proportion of public sector workers – and nurses in particular.

As they work on into their mid and late sixties, how are nurses expected to keep up with the demands of the job? They can have access to hoists, sliding boards and other equipment to move patients, but even so, many other aspects of the job make it hard physical work.

Will there be a division of labour so younger nurses take on the heavy work and older ones are given light duties? I can see that playing out well on the wards.

And while ageing doesn’t have to equate with ill health, I’m only too aware myself that it is associated with a certain amount of unavoidable physical decline. A lot of it is manageable if irritating if you’re deskbound – the aching knee means you don’t bother going out at lunchtime, and I sometimes think a reduction in my hearing ability wouldn’t be all bad when a colleague bellows across the office while I’m trying to proofread.

But I’m lucky, my job doesn’t require me to walk miles a day, and hearing loss would mean I’d only miss out on an unwanted opinion rather than a plea for help from a frail patient. Working until 68 is unlikely to cause me much physical damage – although I’d probably benefit from having someone responsible for finding my glasses every time I leave them on a printer or someone else’s desk.

I suspect the working conditions of those who make decisions about how long people can be expected to continue nursing are more like mine than they are like yours.

Maybe Mr Osborne should spend a week working as a healthcare assistant. After all, you’re expected to ensure patients can make informed decisions, so surely politicians should be enabled to do so too?

'Nothing happens at the weekend'

29 November, 2011 Posted by: Kathryn Godfrey -

Patients should be as safe in hospital at the weekend as they are during the week. And from a nursing point of view we need to avoid that ‘nothing happens at the weekend’ feeling that patients can get.

It is important to maintain quality of care every day of the week. For example, patients who are being helped to get dressed should not be left in their pyjamas at the weekend or left in bed rather than being sat out in the chair.

It can be tempting for a mood of ‘it’s only the weekend’ to become part of the culture of care. Patients may not be having surgical procedures or going for X-rays during the weekend but they can still progress and develop from the nursing care that they receive.

It can be hard to keep up energy levels at the weekend as well as during the week. I remember it sometimes being hard to maintain the momentum during the weekend. It does require that wards and units be sufficiently well-staffed to avoid patients experiencing the equivalent of being held in a holding bay for 48 hours, waiting for care to ignite again first thing on Monday morning.

Weekends can be difficult for patients - particularly if they do not have visitors. The care that nurses offer can help patients to make progress in their recovery, whatever the day of the week it is.

'Washing my patients' feet'

21 November, 2011 Posted by: eileen shepherd -

Without even thinking I replied “washing patients’ feet!” Perhaps an odd answer but for me, somehow, it sums up what nursing is all about.

I remember busy shifts when decisions were made to only wash faces, backs and bottoms - getting the essential parts clean because the ward was so busy. It is easy to miss the feet off the list yet so many patients, particularly older people, cannot reach their own to wash them - even when they are well.

I often hear the word ‘basic’ used to describe core elements of nursing work and I worry about what this implies. To me, it suggests something simple and easy. Yet washing and dressing people, changing sheets when someone is critically ill in bed, giving a patient a drink or something to eat - these are all fundamental to comfort and recovery.

As we know, if you get these tasks wrong, everything else will invariably also be wrong. Patients have to be viewed as people and nursing cannot be broken down into small tasks where no one person has a complete overview of what is going on.

So, back to feet.

One of the greatest pleasures for me was to fill a bowl with warm water, put it on the floor and put my patients’ feet into it. Sometimes you could physically see the stress and anxiety drain from a patient’s face as they wriggled their feet in the water. Stopping for a few minutes before drying and moisturising the skin just gave us a little bit of valuable time to talk, for me to find out how they were feeling and what they were worried about.

Unlike other interventions - doing an IV or filling in an assessment - washing feet really is an act of kindness. It takes a little bit of time, but it shows that it matters to you that your patient feels clean, comfortable and ultimately, cared about. It is a lovely thing to do.

'The students’ situation could be a sign of worse things to come'

14 November, 2011 Posted by: Ann Shuttleworth -

How ironic that one in four student nurses who responded to our survey had difficulty in getting a flu jab.

The NHS is running a huge Flu Fighter campaign, calling for all staff to get vaccinated to protect themselves and their patients this winter, yet students on placement - and their patients - are being denied the same protection.

But it’s not just the short-term implications we should be concerned about here. The students’ situation could be a sign of worse things to come if the NHS fragments more - which looks like an odds-on certainty unless the Health Bill changes radically before it becomes law.

Students who experienced difficulty in getting the flu jab were caught in a Catch 22-style situation, in which their clinical placement trusts told them to go to their GP for the jab, whilst their GPs sent them back to the trusts. Some finally opted to pay for themselves.

Like so much in life, it all came down to money. The trust occupational health departments would not vaccinate the students because they weren’t employees, while the GP practices said the students did not fit the criteria that would gain them payment from the PCT.

If the health service can’t organise free flu jabs for people coming into close contact with its patients and in its facilities, what will happen when a range of private providers come into the mix and budgetary responsibility for particular patients is unclear? Will they be shuttled back and forth between providers who deny responsibility for their care? I only hope that someone will actually provide the care they need while the accounts departments argue over who pays the bill.

Let's nap on nights: but not in the bath

7 November, 2011 Posted by: Kathryn Godfrey -

When one of my nursing friends was on nights she used to have a sleep in one of the ward baths during her break.

We still laugh about it today as a piece of typically mad behaviour. But maybe it was not so mad after all.

In this week’s practice articles there is a discussion about research on the benefits of napping at night during night shift work.

The results suggest that restorative napping may be helpful in improving energy, mood and decision-making.

All nurses will be familiar with the struggle of staying alert and energised during a long and sometimes interminable night shift. Whenever the clocks go forward I always give a thought to the poor night staff who are having to work an extra hour.

As a newly qualified staff nurse I remember doing a pattern of nights that was seven nights on and six days off.

As the nights went on I would feel more and more exhausted and cut off from the world - living in a special night shift bubble where nothing happened other than me desperately trying to stay asleep when all my flatmates were awake and daring to talk.

In those days I had a duvet cover with a paisley pattern and sometimes during my night shift, when a wave of tiredness would hit, I could see the pattern before my eyes. I imagine that a restorative nap during the night would have helped to clear that pattern from my eyes and enabled me to function at a more optimal level.

Restorative napping could be the way forward - but let’s find a better place to have a kip than the ward bath.

'The changed demands of healthcare require organisational commitment'

31 October, 2011 Posted by: Ann Shuttleworth -

The media storm following publication of the latest CQC report on hospital care of older people has abated has left health professionals – and particularly nurses – feeling bruised and battered.

Of course some extreme examples described in the report were simply unacceptable. No one should have to lie in excrement for two hours, and it is hardly something staff could have been unaware of.

However, the commentary once again got hijacked by the people who think nurse education shouldn’t extend far beyond wiping bottoms, making perfect hospital corners and mopping fevered brows. What these people fail to realise is that healthcare is a totally different landscape from the time when nurses’ responsibilities were primarily what we now variously call basic, fundamental or essential care.

Nurses have moved into territory once occupied by medics, not in a power-hungry land grab, but because their education has equipped them for this - and because there simply aren’t enough doctors to take on the increasingly complex tasks and responsibilities modern healthcare demands. Would those who want nurses to return to what they see as a golden age that probably looks like 1950 also be prepared to accept the technology and medical interventions available at that time?

But however much the nursing role has changed, the fact remains increasingly vulnerable patients, with increasingly complex healthcare needs, don’t always get the care and compassion they need. So how can healthcare providers address this?

Of course there’s no single answer, but giving clinical staff the right support and leadership would go a long way. And this needs organisational commitment rather than expecting hard-pressed ward managers and team leaders to carry the entire burden. So here’s one option: originating in the US and brought to the UK by TheKings Fund, Schwartz Centre Rounds give staff from across a hospital a forum to discuss non-clinical aspects of patient care - the emotional and social aspects of their jobs. Typically taking place once a month, with lunch provided, the one-hour meetings take a single patient story, presented by the team who provided care, and discuss emerging issues.

A Kings Fund evaluation revealed that staff value the Rounds enormously for providing space to reflect on their work and support in dealing with the emotional challenges associated with caring for increasingly frail patients. It’s probably too much to ask that the mass media acknowledge the changed demands of healthcare, but the organisations employing nurses and other professionals in their increasingly demanding roles must do so - and offer them real leadership and support in fulfilling their responsibilities.

'Every interaction with a patient is a therapeutic one'

17 October, 2011 Posted by: eileen shepherd -

She described this as her survival technique on a ward where she knew she couldn’t be in three places at once. “When I realised I no longer felt their pain, I knew it was time to leave” she said.

That same day I had the pleasure of visiting a unit in Nottingham who care for people with personality disorders. I was really heartened by their approach to patient care - and how they care for their staff.

In the Ansel Clinic they aim to ensure that every interaction with a patient is a therapeutic one.

It rolls off the tongue easily - but how do they actually do it?

The clinic uses an operational framework based on social therapy so that staff at all levels - consultants to cleaners - are supported to work within such challenging an environment as this. Systems are in place for regular debriefing, reflective practice and supervision.

It was interesting to hear how staff from all disciplines, including managers, work alongside each other - and even those working in cleaning and hotel services have training to help them to understand personality disorder, enabling them to function as part of the team.

I was struck by how these ideas could be adapted and used by nurses - particularly those in acute care and care of older people settings.

All nurses need to have time to stop and think about what they are doing, how they are doing it and why. Sadly, many are not given this chance.

No nurse should ever feel as my friend felt. Staff have to be supported to give effective care and to work out solutions when things start to go wrong. Those who need extra support can then be identified. This requires staff at all levels to share the same objectives for their service.

So who looks after your team to ensure every interaction with patients is a therapeutic one?

Where do you find your patience?

10 October, 2011 Posted by: Kathryn Godfrey -

There are countless pressures and incidents that require your patience throughout the nursing shift.

Not being able to find the right equipment that you need to carry out tasks. Interactions with members of your team including members of other professions who may not always understand your role. The reality of being a nurse – dirty uniforms, not being able to go to a party because of your shifts, paying to park your car at work and of course the inevitable NHS reorganisation.

And most importantly you need patience with those that you care for, even those for whatever reason you find difficult. Patience with the man who is continually calling out for a nurse. Patience with the elderly woman who keeps sliding down the bed and needs repositioning.  And with relatives who don’t seem to appreciate that there are other patients on the ward and expect instant action from nursing staff.

Yes that’s your job but it does require patience.

Where do you find it?

I would be interested to know. Is it from support from your manager? Is it from chat and jokes with your colleagues? Or is it coming from some invisible internal source? Are you born with it or do you have to train yourself in this quality?

'My top 10 suggestions for improving nursing'

3 October, 2011 Posted by: eileen shepherd -

We have many problems and they all need to be addressed if we want to get nursing back on track. I don’t claim to be an expert but I have pulled together my top 10 suggestions. Please change, adapt, disagree as you see fit - I can take it. But let’s have a clinically focused conversation about what really matters to nurses and their patients. So, with a deep breath and in no particular order:

Too often the direction of the profession has been dictated not by patient need but by the demands of health services, and these are not always compatible. We need the building blocks that allow nurses to feel confident and able to deliver safe and effective care to every patient, every day, on every ward, on every shift in every hospital.

It’s not rocket science, but I think we are going to need a 21st-century Florence Nightingale to take on the establishment. Any volunteers?

We have a NEW website just for student nurses, with everything from the usual site at a discounted price plus more. Take a look now at www.studentnursingtimes.net and subscribe for just 70p a week.

'We've all had to insist our parents receive a fundamental aspect of care, quickly'

26 September, 2011 Posted by: Ann Shuttleworth -

Depending on how you want to look at it, our collective parents are either draining the NHS of vast proportions of its resources or keeping an awful lot of health professionals in gainful employment.

A get-together with friends will rarely get beyond the first drink before someone kicks in with “My Dad’s not too good again”. And then we’re off, comparing symptoms, care packages and treatment plans.

For the most part, our parents receive fantastic care from the NHS. But of course, things do sometimes go wrong, and if you’re making heavy use of the health service the chances that something will go wrong for you are obviously greater - particularly if you have complex needs requiring the input of numerous specialties.

So the other thing my friends and I have in common is that we have all, at some point, had to step in and insist that our parents receive a fundamental aspect of care, and that they receive it quickly. I’m not talking about anything out of the ordinary here, but a pressure-redistributing mattress, a diagnostic test or a side room in which to die peacefully.

We have all found it uncomfortable to assert ourselves, despite being generally confident and articulate - and having more knowledge of health and the healthcare system than the average citizen.

So while my friends and I quote stroke strategies and NICE guidelines to get the best for our parents, what happens to the patients whose families don’t know what they should be insisting on, or who don’t have any relatives?

The only thing that ensures frail, undemanding and rarely visited patients getwhat they need is the presence of a skilful and compassionate nursing team that is willing and able to take on the role that we pushy offspring fulfil for our parents.

'Staff need to be clear about what constitutes theft'

19 September, 2011 Posted by: eileen shepherd -

Most parents will have experienced that terrible moment when their first born child comes home from nursery school with a piece of logo or a Playmobile man tucked into a pocket. Did they put it there by accident or did they steal it? What do you do?

Life doesn’t get less complicated.

Last week I was talking to an NHS manager about fraud in the NHS and we got onto the topic of taking 2 paracetamol out of the drug trolley if you had a headache. Is it theft? Is it only theft if you do it without permission? Is it theft if sister says it’s OK? Or is it just stealing whatever way you look at it?

Some trusts advise wards can keep their own supply of paracetamol for use by staff but this has to be purchased independently at the discretion of the ward sister.

So, even though there is a cupboard full of analgesia, if you have a headache you need to ask someone if they have got a couple pain killers in their hand bag. Wards should also have their own first aid kits for staff to use.

Is this silly? I don’t think it is.

In the past there was a culture that assumed NHS property could be used by NHS staff; the odd paracetamol or bandage wouldn’t be missed. This has been extremely unhelpful. What if it’s not a paracetamol,  but ibuprofen or codeine or a replacement for an empty inhaler. Staff need to be clear about what constitutes theft - otherwise they put their job and professional life on the line.

So here are three more dilemmas:

1. While you are locking up your bike outside the hospital you cut your finger. Can you nip into the clean utility room and grab a plaster out of the ward supply?
2. You miss your tea break at 2am because someone had a cardiac arrest. Can you make a slice of toast using the ward’s supply of bread before you get on with the drug round?
3. You discharge 10 patients before lunch and there is loads of food left over on the trolley. Can you put some on one side for your break?

What do you think?

'It's a bit of a shame there are no men in the ward, she said'

14 September, 2011 Posted by: Kathryn Godfrey -

It all seemed pretty straightforward, the drive to have single sex wards and bays.

No question in my mind that it is the best way forward. It is what patients want, it promotes dignity and privacy. But things are not always as they seem. Sometimes they are more complicated.

I visited an elderly relative this weekend, an 83-year old who was being cared for in a six-bedded bay with five other women. She was positive about the ward and about where she was being cared for.

I found myself saying it was a good thing that she was being cared for in an all female environment, how it is much better that it was all women. I felt quite smug as if by writing about the single sex initiative at Nursing Times I had had some part in implementing national policy.

Well, she said, it is a bit of a shame there are no men here as we would be having more of a laugh. Men have a better sense of humour, don’t they?

I was quite surprised by her response and questioned her more closely – what about if you were on the bed pan or having a wash wouldn’t you feel uncomfortable if there was a man in the bed opposite? No apparently not if the curtains were pulled properly.

So perhaps we do need to find ways for the sexes to meet when in hospital as there are social  benefits that must not be forgotten in the drive to separate men and women.

'It's a disservice to most nurses if we use poor care to define the profession'

2 September, 2011 Posted by: Kathryn Godfrey -

A Mail online article which criticised the use of tabards also talked about a crisis in nursing. Detailing a story of poor care the author said: ‘Talk to anyone who’s spent time in an NHS hospital recently and, nine times out of ten, you’ll get a similarly unhappy story.’

I am not saying that the care she received was good. It does indeed sound unsatisfactory. However I do not think that experience can be extrapolated to stating that ‘nine time out of ten’ or indeed 90% of the nursing profession are providing below standard care. 

Nurses too long held the position of angel in the public mind. Nurses could do no wrong. When I was a student nurse we would sometimes get free taxi rides home to the nursing home as the driver would wax lyrical about the care a relative had received. However now the media has swung to the opposite position where nurses are ‘begrudging’, ‘uncaring’ and ‘slovenly’ as described here.

Of course the truth lies somewhere in the middle.

As much as the view of the angels was inaccurate – there were nurses giving bad care then as unfortunately there are now – so is the view today that 90% of nurses are giving poor care.

The majority of nurses are struggling to maintain standards of care with fewer numbers of qualified nurses per patients. Having to deliver more complex care for patients and deal with significant budget cuts is putting pressure on already stretched resources.

It is important that episodes of poor care are highlighted but it is a disservice and demoralising to the majority of nurses if we start to see those as defining the profession.

'Do nurse badges have any relevance to nurses today?'

22 August, 2011 Posted by: eileen shepherd -

Having a clear out at home a few weeks ago I came across an old jewellery box, a Christmas present from my parents some 35 years ago.

The ballet dancer no longer goes round as the key to turn it was lost years ago. Inside was a load of rubbish; earrings without a matching pair, a couple of old bangles, some fake pearls… but at the bottom was my hospital badge.

Finding it brought back fantastic, happy, memories of learning to be a nurse. I trained at Charing Cross Hospital in Hammersmith in the 1980s, and the hospital badge complete with military style ribbon was one of the most distinctive in London. I am happy to argue this point!

I was so proud as a newly qualified staff nurse to get my medal, bringing with it a sense of belonging, achievement and also history.

And the story behind the hospital badge tradition is fascinating – each is unique and personally special to the nurses who wore it.

I recently came across a wonderful article by Sue Sullivan, who explains the history of the Charing Cross medal. She says, “It is rumoured that the bronze metal was from a cannon captured in the Crimean war. The ribbon attached is supposedly from the Colonel in Chief of the Household Brigade, who was thrown from his horse and taken to the hospital. In order to show his gratitude for his nursing treatment, he asked Queen Victoria for the right of nurses at the hospital to wear the ribbon of the regiment.”

Good story, but do badges have any relevance to nurses today?

If I am honest I’m not sure.

I stopped wearing mine in practice as it used to hit patients, often in the face. Some trusts now advise staff not to wear badges for a variety of infection prevention and health and safety reasons. Perhaps moving nurse training away from hospitals to academic institutions, with their own system of honours and awards has made them obsolete. Are they are just part of a bygone age, in which hats, cuffs and aprons kept us in our place? Should they be consigned to the history book as an interesting novelty? Perhaps it doesn’t matter.

Mine is back in the box with fond memories. Secretly I am very proud to own it.

Evidence or instinct?

15 August, 2011 Posted by: eileen shepherd -

Should you wake patients at 2am to measure vital signs? We posed this question last week in Behind the Rituals and the debate is still going on in Twitterland.

Why did we ask? A few of you thought this was a stupid question. @firstilast gave me the biggest laugh of the week “No, let’s not carry out clinically indicated observations. That way patients get to sleep… for a very long time”.

Good point, but for others the issue is less clear cut.

If a decision has been made to carry out 4-hourly obs then surely nurses are obliged to do them?

As a student nurse I remember making a list of patients who should have their obs done in the middle of the night. Clinical judgement was used and usually involved patients who had just had surgery or were critically ill. Everyone else was left to sleep – which begs the question why 4-hourly obs were needed in the first place.

@AshDuffyHayes suggested the positives of waking patients outweigh the negatives, but others voiced concerns about loss of sleep. @JuliePacker highlighted the effect of disturbed sleep in ITU and this was reinforced by @AgencyNurse who said “it’s all about clinical judgement and should be individual to the patient. Routine obs [can] wait until the pt wakes”.

Many nurses commented on the expertise of the nurse making the decision, using terms such as instinct, clinical judgement, intuition and knowing your patient. Perhaps this is where the answer to the question lies.

Rigorous adherence to 4-hourly observations is probably a good idea for the novice nurse who is still learning and developing skills. In the hands of the expert nurse informed decisions can be taken to prioritise sleep over recording observations. As David Jones noted in his expert comment, nurses should be able to carry out an “end-of-bed” observation without waking a sleeping patient… but they should also trust their instinct and if they feel the patient is deteriorating the question they should ask themselves should be whether four-hourly observation is enough”.

Nurses have to balance competing priorities when caring for patients and the patient’s best interest has to be at the heart of this process. As @ShannonsideTrng says “It depends on the competence of the nurse to judge, therein lies the art and science of nursing!”

'A lot of research is barely seen by the nurses who could use it'

9 August, 2011 Posted by: Ann Shuttleworth -

One of the reasons I love my job is that it feels worthwhile. I and the rest of the practice team may not be actually delivering patient care, but we are helping you to do so. We do this by publishing double-blind peer reviewed articles, written in plain English by experts in their fields and focusing on the implications for nursing practice.

We often come up against a barrier when inviting these people to write for us - their universities insist that they only write for journals with an impact factor

While many of our authors are nurses working in clinical practice, a substantial proportion work in higher education. However, we often come up against a barrier when inviting these people to write for us - their universities insist that they only write for journals with an impact factor. This is a method of assessing the value of research through the number of times articles are cited by other authors.

The IF has a huge influence on universities’ ability to attract funding for future research, so I can entirely understand their wish to focus on journals with an impact factor. However, nursing journals with a high impact factor tend to be the highly academic or specialist titles. These have small circulations, and few of their readers are likely to be providing hands-on patient care. So a lot of excellent research, with real implications for nursing care and patient outcomes is barely seen by the nurses who could really use it. And the people undertaking the research are frustrated that their valuable work is not being circulated widely.

The method of evaluating the quality of universities’ research is due to change in 2013. From then, universities will have to demonstrate that it has an impact outside academic circles. Quite how has yet to be finally determined, but they are likely to be required to provide case studies. This will involve huge amounts of work on the part of universities, to set up relationships with clinicians who can put their research into practice or track down instances of it being used, then additional form-filling.

It seems to me that a useful addition to the new evaluation structure would be to encourage universities to ensure their research is disseminated to a wider range of publications. Of course I’m biased, I think nurse researchers should be required to submit all research that adds to the nursing evidence base straight to us at Nursing Times. However, I’d settle for them being encouraged to ensure their research is published somewhere that gives it a good chance of being seen by the people who can use it to make a difference.

A large proportion of universities’ research is publicly funded. That means you and I pay for it.

Doesn’t that mean we should benefit from its findings when they could improve the healthcare we receive?

Nurses make the most awful patients

2 August, 2011 Posted by: Kathryn Godfrey -

Nurses are not always good at being patients.

I realised that I need to practise being a better patient after a recent visit to the doctor with a foot problem.

I had done my usual thing when I have an ailment that needs medical attention. First, I gather together information, some of it up to date and some not, and then supplement it with background info from the internet.

Using that combination, I will then decide whether it is worth going to the doctor and, a significant percentage of the time, will decide nothing can be done and so will stay at home. If I do decide that a visit to the surgery is worthwhile, I will go with a preconceived idea of what action will be taken.

I discovered last week that my approach is not doing me any favours.

Having had my sore foot for some time, deciding that it would be a waste of time to go as the evidence base was not in favour of steroid injections, etc, I did finally go to see the doctor. And he came up with a solution, and a good one, that I had not anticipated. A simple soft heel pad that could be bought from the chemist and time will do the rest.

Thank you for asking – yes it is gradually getting better.

I am not really sure why I have decided that my ‘knowledge’ will be better than that of the expert who is paid to keep up to date with treatments for common problems in primary care.

So that’s it, I am letting go.

I am going to pretend I’m going to the hairdresser, not the doctor. Instead of triaging myself I am just going to look in the mirror and think – someone needs to do something about that -  just show up and let the expert do the rest.

What’s the matter with nursing?

25 July, 2011 Posted by: eileen shepherd -

“What’s the matter with nursing?” cried a BMJ editorial a few weeks ago. Just about everyone seems to have a view, with many commentators looking for a scapegoat or a quick fix. Many of my friends know exactly what’s wrong. They don’t make nurses like they used to. In our day…

Well, it’s easy to hark back to a golden age, but I would challenge anyone who does to think carefully about the workload, staffing and challenges of modern healthcare. Most wards have significant numbers of chronically sick, frail and vulnerable patients. Many nurses work on wards that are not fit for purpose, with staffing levels that have not changed in years. Many of you describe your working life as a war zone. And this week we learnt that ward sisters in some hospitals spent 40% of their time on bureaucracy.

Most of the criticism levelled at nurses relates the essential care given to dependent older people.

So let’s be honest about how we care for older people. Although there are many individual examples of excellent care, there has never been a golden age. I remember the warehouse-like Nightingale geriatric wards during my training in the early 1980s. In the 1990s, I took over management of a rehabilitation hospital where communal toileting, communal clothing and milk and sugar in the tea pot were standard practices. When I asked staff why they did this they were happy to explain. The toilets were difficult to access with a wheelchair; patients’ clothes got lost so it was better to use the hospital ones; and it was quicker to put everything in one pot than ask patients’ preferences since most had dementia.

Scary stuff for a newly appointed senior nurse.

I learnt how easily staff lose sight of what they were doing and why. If we put nurses in silos, give them little education, no feedback, and an inappropriate skill mix they will cut corners. Deidre Wild, a nurse researcher with a passion for care of older people describes it as caring for, rather than about, patients. Getting the job done, rather than thinking about how best to do it, becomes the priority.

My staff worked in a vacuum. What was missing was a crucial element - strong clinical leadership provided by empowered, skilled and enthusiastic ward sisters.

The ward sisters who inspired me to be the best nurse I could be weren’t in the office doing the paperwork but equally they weren’t mucking in. They worked as role models alongside staff, facilitating, challenging, managing and developing every member of the team. This role is for nurses at the top of their game, who can teach, inspire and develop our next generation.

Everyone knows ward sisters hold the key, but is there a will to make the organisational change and investment to ensure we keep our best nurses close to the bedside? If we don’t do this what is the alternative?

'Training to be a health visitor takes a leap of faith'

18 July, 2011 Posted by: Kathryn Godfrey -

Being a health visitor has characteristics that makes it different from many other nursing roles. You don’t wear a uniform, you manage your own caseload, you visit clients in their own homes and rarely carry out a nursing procedure.

It can be difficult for nurses to contemplate so much change to the way they work.

So the lack of certainty about health visitor jobs highlighted last week in Nursing Times’ exclusive report  will not help nurses to make that move into health visitor training. Few nurses will be interested in training for a year if they think there will not be a job at the end of it.

What a lost opportunity, because health visiting is an interesting and fulfilling role that offers nurses a different way of working.

When I cycle through my old patch in North London I vividly remember families in my caseload, including the large family I visited who were told their baby with a physical disability would not walk. The day she took her first steps at the age of two years her father rang me to come immediately to see and celebrate this momentous moment in their family life.

These relationships are what makes health visiting so rewarding.

If the government wants to carry out its strategy to increase the number of health visitors by 4,200 over the next four years it will need to find a way to ensure that the jobs are there for the new health visitor trainees.

You don’t have to be a prima ballerina to deserve a little dignity

11 July, 2011 Posted by: Ann Shuttleworth -

Like Eileen Shepherd, I was appalled at the story of Elaine McDonald, who lost a supreme court appeal against the London Borough of Kensington and Chelsea’s decision to withdraw the night-time care that enabled her to use the toilet.

Instead Ms McDonald has been told to use incontinence pads – even though she has mobility problems rather than incontinence.

Of course it is dreadful that a woman who is not incontinent should be condemned to lying in her own waste throughout the night. Where is the dignity in that? But something else also angered me about the story.

Ms McDonald is a celebrated former ballerina with the Scottish Ballet, and received an OBE in 1983.

I know this, and a whole lot more, about her because her case was covered extensively across the media. From the BBC and the Guardian to the Daily Mirror and Daily Mail, the story was given huge prominence, particularly online. But the stories focused on Ms McDonald alone, and made much of her distinguished career and honour.

What about the many other people who may be affected by this decision? Councils are desperately looking for ways to save money and have just been given a clear message. It’s OK to stop funding night-time visits to people who need help to use the toilet.

Charities commenting on the case pointed out that the court decision had wider implications for some of society’s most vulnerable people. Michelle Mitchell from Age UK called the decision shameful and said it “opens the door to warehousing older people in their own homes without regard to their quality of life”. However, her comments and those from other charities came towards the end of the BBC’s and Guardian’s stories and were ignored by the Mirror and the Mail.

As far as the media are concerned the story is interesting primarily because Ms McDonald is, to quote the Mail “a once beautiful and gifted former ballerina”. Surely the real story is that tens, if not hundred, of thousands of older and disabled people may now be expected to lie in urine and faeces until their daytime carers arrive?

You don’t have to be a prima ballerina to deserve a little dignity.

'I went from mild discomfort, to anxiety then panic as I held onto a full bladder'

8 July, 2011 Posted by: eileen shepherd -

I was driving on the motorway a couple of days ago counting the miles to the next services and regretting the second cup of tea I had before I set off.

Predictably the traffic ground to a halt. As minutes passed I went from mild discomfort, to anxiety, then panic as I held onto a full bladder.

So why share this with you?

This week, the supreme court was asked to rule on a case in which 68-year-old Elaine McDonald, who had had a stroke, wanted the council to provide a night-time carer to help her use a commode rather than supply her with incontinence pads.

She lost her case.

Sadly this is not an isolated situation. Everyday, people in their own homes, care homes and hospital are required to use incontinence pads when they could be continent. They do this because of lack of time, lack of care or lack of knowledge on the part of those caring for them. This ruling is not the start of something new, but more worrying, it legitimises a system of care already in place.  

Being allowed to defecate and urinate in a dignified way is a basic human right. It is difficult to imagine what it is like to sit in bed and have to make a decision to pass urine into a pad, when you know you are continent.

Rationing of continence products is already common in England.

Many nurses involved in assessing continence are concerned that their ability to provide care is hampered by restrictions on resources. In parts of the country cuts to pad budgets mean patients may not get the number or type of product they need. They either do without or top up themselves. Many do not have the financial resources to do this.

Functional incontinence should be carefully managed to maintain patient dignity and promote independence. But in so many cases it is easy to ignore the problem because patients have no voice and no one to speak out for them. This is truly shameful.

If you have problems accessing appropriate continence care for your patients I would be interested to hear about your experiences.

Two hourly, three hourly turns, what we do just doesn’t work

6 July, 2011 Posted by: eileen shepherd -

I have been really interested in your debate about the effectiveness of 30 degree tilts to reduce pressure ulcers.

I have two thoughts, one professional and the other personal.

My first thought is if we know how to prevent skin breakdown, why is pressure ulceration still a major problem?

Several weeks ago, Judy Harker, a tissue viability nurse consultant, talked about the challenges of pressure ulcer prevention and the work underway to improve care. The problem is that although we have guidelines, the supporting evidence is surprisingly poor.

I agree research into essential care can sometimes feel like “teaching your grandmother to suck eggs”. But looking forward we are facing very different challenges of caring for older, sicker and more dependent patients, and this must demand systemic investigation. We need to know more about individual risk factors and how interventions can be used efficiently and effectively.

On a personal note, both my parents died in recent years.

My father died with a grade 4 pressure ulcer and my mother with ulcers on both heels.

I wish the staff had known about 30 degree tilts, turning and mattresses. They both died with infected,  painful wounds which could have been prevented if every nurse involved in their care had thought about their complex health problems and understood their risk factors, hypoxia, neuropathy etc etc..

This shouldn’t happen and any research that improves nurses’ knowledge has to be a step in the right direction.

Judy Harker noted a possible link between the value a nurse places on pressure ulcer prevention and the patient care that they deliver.  Discussing ways to improve care is essential and we have to work together as a nursing community to find solutions.

Looking at your debate about 30 degree tilts, I note one brave contributor who put his hand up and said “I didn’t know that”. 

I am absolutely sure he is not the only one.

Being a nurse changes everything

28 June, 2011 Posted by: Kathryn Godfrey -

We take our jobs home with us like our uniforms.

When I change a bed at home, I tuck in the clean bottom sheet with a  hospital corner. And of course I pull the sheet tight to make sure there is no crease in the sheet - pressure ulcer prevention at all times. 

Even though I no longer practise as a nurse I still notice how much of my nursing experience has seeped into my life. In fact being a nurse colours and changes a lot of the  things that you do – the small things.

Even when you are washing your hands at home, because they are a bit grubby, it’s hard not to wash them in the same way that you would if you were about to carry out an aseptic technique or had been touching a patient. 

I find it hard not to rearrange my partner’s pillows when they look ridiculously uncomfortable even though I know that is the way he likes to sleep.

It’s hard not to apply a plaster to a child’s cut finger in a very specific way. If I visit someone in hospital, even if others are sitting on the bed I find it hard to do so. And I am no keener to sit in the chair that is besides the bed. It just feels wrong.

I still walk faster than all my family and friends, a habit learnt from walking up and down a ward and trailing along long corridors at speed to pick up blood, linen or drugs.

And I still enjoy cheese and onion pasties, a habit picked up  from night shifts. That and lots of tomato ketchup.   

I bet there are lots of bits of nursing that have crept into your everyday life and habits.  Are there any that you want to share?