Practice team blog
There is more to planning a hospital discharge than ordering medications and booking the transport. All the care and treatment that patients receive while in hospital can be compromised if their discharge home leaves them vulnerable.
Research out this month shows that this aspect of care is still being neglected in some areas, leaving patients at increased risk of being readmitted to hospital.
A survey by Healthwatch of 3,000 patients found that many were not involved in decisions about going home and that often they and their families were not aware of extra support they would need.
Communication between hospitals and community providers was found to continue to be an issue, with information not being passed on and services not being set up.
The declining number of district nurses is putting huge pressure on care being provided in the community so it is not surprising that some patients find themselves falling through a hole in the net of care once they are back home.
The authors of the Healthwatch report call for better communication between hospital and community providers. While this is needed, and will help to improve this issue, if the number of community nurses continues to be insufficient then all the hard work put into patients’ recovery is put at risk by their discharge home.
Three weeks ago, RCN chief executive and general secretary Peter Carter urged nurses to speak out about their achievements.
He was speaking at the annual RCN Congress for the last time before he steps down on 31 July and his parting words certainly struck a chord if the Twitter reaction is anything to go by. His point wasn’t that nurses need to start showing off but simply that the profession needs to stick up for itself and show the world just how much responsibility, initiative and intelligence the role requires.
But why do nurses need to be told to blow their own trumpets? Is the profession really so shy and retiring?
“But why do nurses need to be told to blow their own trumpets?”
The obvious answer is that no-one goes into nursing for the glory. You might be proud to call yourself a nurse, but while what you’re actually doing may be seen as heroic to others outside the profession, finding a nurse who describes themselves as a hero would be a challenge.
Although I agree with Mr Carter wholeheartedly, I think that we may need to accept that the type of people who choose a selfless career such as nursing, probably aren’t going to be the sort to brag about their achievements.
So how about bragging about someone else’s?
At first glance, the Nursing Times Inspirational Leaders list probably looks pretty insignificant to the majority of our readers. But if you’ve ever felt inspired by a fellow nurse then it couldn’t be more relevant.
There are 50 places on the list and my personal hope is that it will be packed full of frontline nurses leading by example. Everyone you put forward will be discussed by our judges and a decision made on whether they meet the entry criteria.
Being acknowledged as one of the UK’s 50 most inspiring nurse leaders will be a huge boost for your nominee’s career and show them the positive impact that they are having on nursing.
Please, get nominating – let’s make sure this list represents the leaders YOU want acknowledged.
In his book Do No Harm retired neurosurgeon Henry Marsh described the irritation of taking time away from his work to sit though mandatory training.
He wrote: “The seminar was scheduled to last three hours and I settled down to get some sleep”.
While I would be remiss to argue that mandatory training is not essential, I wondered how many of you dread the annual get together to go over fire procedures, resus and safeguarding? I did a quick straw poll of nurses to find out if their experiences matched those of Henry Marsh.
One nurse told me that during her update the fire officers apologised in advance as he had borrowed a power point he hadn’t looked at. Another described it as a tick box exercise where staff were lectured to but there was little time for discussion or questions.
A senior clinical nurse specialist recalled being told off because she was responding to an urgent email during a resus update and her colleague said several doctors appeared to be asleep at the back of the room.
The overwhelming impression is that mandatory training is delivered to people who do not have time to be there in a way that does not engage or encourage participation.
My straw poll of experiences of mandatory training may be selective and I apologise in advance to anyone who has devised a more imaginative and interactive ways of updating staff on the essentials. I know some organisations have now adopted e-learning to deliver updates and perhaps this needs to be the way forward. This could include some element of assessment so that staff would have to engage. There is no doubt that staff need to be updated but it has to be more than a tick box exercise. For one, surely we need to assess whether staff have understood the information delivered and assess learning needs?
Please tell us about your experiences. What works well? How can mandatory training be made more relevant and engaging?
It’s been talked about for so long that nurses could be forgiven for thinking nurse revalidation would never happen. But it is happening – and it’s happening soon.
From April 2016 all nurses will be required to undertake a range of revalidation activities including CPD, reflections and collating feedback.
In the current system, few nurses are asked to prove they have done 35 hours’ CPD when renewing their registration every three years. However, with revalidation, managers will have to confirm nurses have completed all their revalidation activities, so employers are now getting actively involved.
At last week’s Nursing Times Deputies’ Congress, half a day was spent helping deputy chief nurses get their organisations ready for revalidation.
Probably the most eagerly awaited session was a report from the organisations that have piloted the proposed new system. I suspect most people in the room were expecting to hear of some painful experiences.
But that’s not what happened.
The pilot sites acknowledged the challenges they had encountered - that’s to be expected in a pilot. But the sites not only survived the experience – they seemed positively energised by it. They spoke of revalidation as more than just a way of protecting patients by ensuring nurses are fit to practise. It is also a way for the profession to demonstrate its worth, and for individual nurses to embrace a culture of continual learning.
And the individual nurses in the pilot sites also seemed to have embraced revalidation.
While they may have had their doubts in the early stages, in practice they realised they were already doing most of the revalidation activities. As one said: “We’re already doing this – we just weren’t writing it down before”.
For the vast majority of nurses, revalidation won’t require many new activities – it will mainly involve keeping track of them and their impact on patient care. If you do that as you go along, you’ll find revalidation painless.
You may even start to value it as you realise the benefits it can bring to you and your practice.
Patients who suffer from delirium are more likely to have poor outcomes according to a systematic review and meta-analysis published last week.
A third of patients admitted to ICU were found to develop delirium. These patients were found to have an increased risk of dying during their hospital admission, have a longer stay in hospital, and cognitive impairment after discharge.
The researchers outline the long-term consequences of delirium, which is associated with increased mortality, functional disability and dementia.
As identified in this review the risk of delirium is particularly high in those admitted to ICU and it is also more of a risk to older people, those with terminal illness and those undergoing major surgery.
Delirium can be overlooked and misdiagnosed as dementia and as a result not be treated appropriately. Our new Nursing Times Learning unit on Dementia, delirium and depression clearly explains the differences between these three conditions and how they should be managed.
The systematic review clearly shows the impact of delirium on both recovery and long-term health. Update your knowledge of this condition by working through our online unit, which was developed in association with the Dementia Services Development Centre, University of Stirling. The case scenario format will help you to translate the theory into practice.
I wonder if anyone was surprised by the recent news that a group of GP practices have been placed into special measures.
The move came after Care Quality Commission inspectors raised concerns about a lack of staff learning following safety incidents, failure by nurses to understand mental capacity legislation, and outdated training on vaccinations.
The situation plays into the perception still held by many of practice nursing as a dead-end job with few career opportunities, and one that is still not widely regarded as an option for newly qualified nurses.
Over many years I have frequently heard concerns voiced about the lack of training and development available to practice nurses, who often work in isolation. There are complaints that some GPs do not allow time or money for training and many have learnt their skills “on the job”. Some of these nurses will face real challenges as they move towards revalidation.
However, things are changing. Increased demand and a shortage of GPs has highlighted the vital role practice nurses can play in providing care.
There are fantastic examples of practice nurses working in autonomous roles, as advanced nurse practitioners and developing new models of service. They play an invaluable role in managing long-term conditions and providing continuity of care.
There is great work underway to dispel the myth that practice nurses need secondary care experience before moving into primary care. Back in March we published an article about a scheme that aimed to recruit newly qualified nurses into general practice. The Health Education Yorkshire and Humber scheme creates high-quality undergraduate placements in GP practices. In over six years it created 350 student placements and the number of students considering general practice rose from 31%-73%.
Practice nurses are going to play a vital role in managing and delivering patient care in the future and the roles and opportunities that are emerging in general practice provide exciting opportunities. However, GPs need to understand that nurses need education and development along with supportive professional leadership networks. Only then can their potential be realised.
Last week we had the pleasure of hosting our fourth Student Nursing Times Awards.
It’s always a highlight in the calendars of everyone who works at Nursing Times and I can safely say that we were nearly as excited as our finalists were to attend.
I say “nearly” because the sheer joy of being recognised and rewarded for your hard work is hard to beat.
Having read some of the entries and spoken to the judges I have no doubt that every single one of our finalists deserved that recognition. To be fair, all nurses and student nurses deserve to be thanked for their work but we would need a significantly bigger venue and a lot more champagne if we were to award everyone.
But how do these awards look to outsiders, to those who haven’t read the painstakingly written entries, who aren’t aware of how the winners have gone above-and-beyond to improve patient care?
I was saddened to see a tweet suggesting that as nursing is a vocation, awards are not necessary:
— Andrew Jones (@GrrrrJones) May 13, 2015
In a way, I do agree. Our winners didn’t achieve because they wanted an award, they achieved because they want to be good nurses and improve patient care. Awarding student nurses won’t make them work any harder - if it is even possible for them to do so.
But that isn’t the aim of the Student NT Awards.
Rewarding excellence shows student nurses that they are entering a supportive profession and they should be proud of what they achieve. I don’t just mean awards finalists, the fact that we feel it’s necessary to have awards specifically for students is testament to how their work is valued.
In a time when nursing continues to be undervalued by those in charge, isn’t recognition of nursing achievement exactly what we need?
So after months of campaigning, and commentators pontificating about the implications of all the different coalition permutations, we have a majority government after all.
However you feel about that, you can at least look to the Conservative manifesto to see what is in store for the NHS. Or at least you should be able to. Last time of course, after promising no top-down reorganisations, within weeks the government embarked on the biggest reorganisation in the service’s history.
But let’s assume the new government will not want to cause such a major upheaval in successive parliamentary terms, and that it will stick broadly to its manifesto and the pledges made during the election campaign.
Some of these pledges will be a cause for optimism for many nurses. Few would disagree with the Conservatives’ promise to meet the additional £8bn funding called for in NHS England’s Five-Year Forward View - although the £22bn efficiency savings promised by NHS England in return will raise many eyebrows. The party has also promised to ensure mental health is given equal priority as physical health, to ensure everyone diagnosed with dementia receives a ‘meaningful care plan’ to support them, to improve public health and ensure the NHS has increased accountability when mistakes are made.
Other pledges may be more divisive - many wonder where the money and staff will be found to create a truly 24/7 NHS, while some say the Cancer Drugs Fund - which is to continue - diverts money away from other patients and into the pockets of pharmaceutical companies.
However, as Professor Donna Mead said when addressing the Student Nursing Times Awards last week, if you want to make the NHS a fit place for patients, you have to be interested in politics.
So take a look at the Conservative manifesto and see what you’ve been promised - this time there are no other party policies to consider. Only then can health professionals collectively hold the government to account for the pledges they support, and develop their arguments to caution against those they don’t support.
The nature of weekends have changed over the years. Fifty years ago pretty much everything stopped on a Sunday. If you went into the centre of a town it would be eerily quiet – unlike today.
The same was true in hospitals.
From Friday evening to Monday morning patients were basically suspended in a care bubble. Nurses, of course, continued to deliver nursing care but other allied healthcare services– physiotherapy, occupational therapy, investigations and the like – were adjourned for two days. Nothing was started over the weekend – things waited for the magic of Monday morning.
“Nothing was started over the weekend – things waited for the magic of Monday morning”
There have been some moves away from this clear-cut five days on, two days off system in recent years, but unlike town centres, there is still certainly the “weekend effect” in hospitals.
If we started designing health services from scratch would we think it sensible to call a halt to the care pathway a patient was following and take two days off? Would we leave expensive equipment idle for 48 hours? Is it a good plan for someone with a stroke to have speech therapy and mobilisation daily for five days and then have two days off? Or for a new treatment that needs to be started or changed to wait for more staff to arrive at the beginning of the week?
“Is it a good plan for someone with a stroke to have speech therapy and mobilisation daily for five days and then have two days off?”
Of course sometimes care has to be delivered at the weekend as a result of accidents and emergencies. However the “weekend effect” means that, for example, anyone who needs unscheduled surgery at the weekend can expect poorer outcomes and a longer hospital stay.
Researchers have identified five resources that would mitigate against the “weekend effect”. And not surprisingly top of the list is more nursing staff. The other four elements are full implementation of electronic medical records, inpatient physiotherapy, supported discharge programmes and pain management programmes.
Considering the cost of inpatient care it does make sense to adopt a seven-day approach. Patients will get better quicker and outcomes will be improved. But to achieve this, of course, we need more nurses – and those nurses to be compensated for working weekends when their friends and families are not.
Out-of-hours payments are the only fair way to run such a system.
Sometimes you see a headline and know an article is going to be worth the five minutes it will take to read. That’s how I felt when a member of our news team filed a story from the Unison conference: ‘Student nurses should be paid “living wage” while on placement, says union’.
If I didn’t work in an open-plan office, I would have cheered.
As an ex-student nurse I’m all too familiar with the exhaustion that comes from finishing your placement shift, grabbing some food and then heading off to work an evening shift in a bar. When you finish at midnight or 1am, getting up the next morning to head back to placement is tough to say the least.
”[…] there just weren’t enough hours in the day to earn enough money to live on”
As well as living with other student nurses, I took the possibly naïve decision to live with students from other courses. One housemate had a grand total of three hours a week in university and although I didn’t envy the outside reading she needed to do, I did envy the fact that she could easily juggle a part-time job around her studies.
The problem, for me at least, was that there just weren’t enough hours in the day to earn enough money to live on, revise, write essays, attend placement and lectures and sleep for eight hours.
Cutting the number of hours student nurses spend in placement or in lectures is simply not an option. The academic work is tough, but it needs to be; there’s a lot to learn in three short years. It just wouldn’t be possible for nursing courses to consist of three hours of placement/university-directed learning and a chunk of self-directed study, as my enviable housemate frequently bragged about.
So is it really necessary for student nurses to work part-time?
Many people would argue that student nurses have it much better than other students. They don’t pay tuition fees and receive a bursary. But even the top-level bursary equates to an hourly wage far below minimum wage and the amount student nurses can apply to loan reflects the fact they don’t pay tuition fees.
For many students, part-time work is essential despite the additional financial support.
So would paying students a minimum wage on placement negate the need to work part-time? Or would it change student nurses’ status and create a cheap workforce?
There are clearly pros and cons to the idea. Although I don’t believe it should be easy to become a nurse, the difficulty should come from needing to be good at nursing, not from having to survive three years of poverty.