It’s time to start looking after nurses to boost carePractice blog
Are nurses too quick to use rapid tranquillisation?
Rapid tranquillisation on mental health wards is much-debated.
On the one hand, rapid tranquillisation is sometimes needed to maintain the safety of the ward, on the other hand it carries with it extreme risks to the patient, can be addictive and arguably should be the last resort when all other methods of de-escalation have failed.
Patients are often subscribed tranquillising and antipsychotic drugs PRN so they can approach staff if they feel they need additional medication. In my experience, this can work well with patients being afforded the opportunity to take responsibility of controlling their symptoms before escalating.
However, as a staff nurse what do you do if a patient asks for medication they do not appear to need?
As you can’t tell what’s happening in someone’s mind, should you take their word for it that they know what they need?
What if they have been sitting watching TV, appearing calm for the past hour, and strolled to the nursing station to request highly-addictive benzodiazepines?
Giving medication without clinical need is not in the patient’s best interest and may in fact be feeding an addiction.
But, what if saying “no” leads to aggressive behaviour, putting patients, staff, visitors and the hospital environment at risk?
I have witnessed patients requesting lorazepam without clinical need only to be, rightly, refused this by nursing staff. In order to ensure they got the medication they wanted, I’ve seen patients then damage hospital property, threaten staff and other patients and escalate to the point that staff have no choice but to medicate in order to maintain the safety of the ward.
This positive reinforcement of disruptive behaviour only leads to the same happening again.
Benzodiazepines are all too often given without consideration to the long-term consequences. The MDT must look at ways to balance the short-term benefits of using these drugs with the long-term affect they may have on the patient and the nature of their care.
What do you think? Do we give out too many benzodiazepines without considering the consequences of long-term addiction? Are we too quick to use rapid tranquillisation to de-escalate?
'How do we close the research-practice gap?'
There is an old man who occasionally catches the same bus as me to the station. When he arrives at the bus stop there is an odour which in the confined space of the bus gets worse.
It took me a while to work out that the smell was from compression bandages on his legs which are usually heavily stained with exudate. Month after month the smell hasn’t improved and I would assume neither have his ulcers.
How does he feel when people instinctively move away from him, look the other way or fan themselves with a copy of the Metro?
I can’t make a judgement on his care or whether he is compliant but I do wonder whether his wound management is based on the best available evidence.
Management of leg ulcers, unlike other nursing activities, has a fairly robust evidence base. A well-managed venous ulcer can heal and we have a host of products for management of odour and exudate.
Sadly, the evidence has also highlighted the profound psychological effect ulceration has on people’s lives leading to social isolation, depression and anxiety.
So when I look at my fellow bus companions bandages I am left wondering about the research-practice gap.
Who is removing this gentleman bandages and assessing his symptoms?
Is anyone talking to him about how he is managing is hygiene and washing is clothes?
Has anyone talked to him about his shoes that don’t fit comfortably over the bandages?
Has anyone asked him how he feels?
The application of compression bandaging is a specialist skill and the Leg Ulcer Forum is clear that it should be undertaken by nurses with specialist training.
However not all patients have access to specialist services and the net results is on-going, expensive and ineffective care that has a negative impact on patients.
We all have a responsibility to use evidence based practice but practitioners need to have access to it. While practitioners should ensure they are up to date, researchers must ensure that their work is disseminated as widely as possible.
The problem is academic institutions usually measure the value of its researcher by their publications in academic journals with impact factors. This measure is not based on the impact on patient care but on the number of citations to the journal - those with higher impact factors are deemed to be more important than those with lower ones.
Perhaps it is time for researchers’ success to also be measured by their impact on patient care.
Futher reading:
Resources for community clinics must match those of the hospital
A friend recently tried to have a Doppler scan and tissue viability assessment in the community rather than in the hospital.
Sounded sensible – just around the corner.
But the saying is there is no such thing as a free lunch. And in this case it seemed there was no such thing as accessible care.
A trip to the hospital is only another 30 minutes on the bus and as it turns out this would have been time well spent.
Appointment number one failed as the staff member who could work the Doppler machine was not in until later. Appointment number two failed as the nurse using the Doppler machine could not get it to work properly – no back-up support available to assist. Appointment three failed because the wrong type of gel was available to get a reading.
Three weeks have now passed as the clinic only runs once a week. And the venous ulcer in question continues to exist but fortunately not to expand.
Running outpatient clinics and other services out in the community is good for the patient as it makes services more accessible and can be cost-effective.
The plan is that services for long-term conditions such as venous ulcers will be looked after by outreach and community services. But for this to work they must be properly resourced in terms of staff and equipment.
Community care is not supposed to be care on the cheap.
My friend did not feel the failure of each appointment was down to the willingness of the staff as each time the staff did their best to rectify the problems that occurred at each consultation. But that there was not the human and equipment resources to offer the service that deserved the commitment of the staff.
Challenging behaviour is often a symptom, not a personal attack
Throughout university we’d been taught that patients with this diagnosis can exhibit “challenging” behaviour, that they can divide teams and we should reflect on how we feel to avoid burnout.
Although we spent a great deal of time analysing how best to nurse patients with a personality disorder (PD), this was approached in a clinical manner. We barely covered the reasons why someone might choose to behave in these ways and want to spend their time in hospital.
So, what is it about this diagnosis that worries nurses before they’ve even met the patient?
Although those with PD can often put a strain on nurse time, I don’t believe reluctance to engage is the result of laziness.
Nurses join the profession wanting to help people. But trying to care for someone who appears to be thwarting attempts to be helped can leave health professionals feeling hopeless. It can be difficult to empathise with someone whose behaviour doesn’t always appear to fit with what they are saying. And even harder to put yourself in someone’s shoes when they are doing everything they can to avoid discharge, a situation that can often come up when nursing this patient group.
Let’s face it, mental health wards are a far cry from the Hilton so why do they want to stay?
It can be easy to forget thatBPD is an illness in itself and the challenging behaviour that can come with it is a symptom, not a personal attack. Understanding this behaviour makes it easier to get a grip on what is actually happening.
In my experience, this is where compassion can often fall down.
And, in these situations, maintaining unconditional positive regard can be difficult.
I agree with the Willis Commission that nurse education is of a high standard, but I feel that training is focused solely on helping and supporting people who want to get better. Little time is spent exploring the reasons why someone might rely heavily on services, often without any apparent reason.
Learning why someone may want to stay in hospital and go to extremes to resist discharge may help nurses, particularly those newly qualified, to remain compassionate when faced with challenging behaviour.
For this reason, it is essential that education on personality disorders centres on the reasons behind the presentation, rather than simply how to manage challenging behaviour.
After all, not everyone can learn compassion, but everyone can learn understanding.
Would you accept payment from the drugs industry?
Last week the ABPI released figures suggesting that doctors, nurses and other health professionals in the UK received £40m last year from pharmaceutical companies. The money pays for medical education events, training and development, and fees for services such as speaking engagements and participation in advisory boards.
I know many nurses, particularly those with specialist roles, benefit from the educational events and sponsorship offer by drug and appliance companies. But should professionals, who make objective decisions about purchasing products and drugs, rely on this financial support. Is it naïve to think there is no undue influence?
We all like to assume we would not be open to influence of the drugs industry but we have to question why spends such large amounts of money on us – after all their job is to ultimately to generate sales.
I have attended sponsored educational events and seen the benefits that could be gained from amassing potential customers in one place at the same time. If you have a new product to sell this is the ideal way to market it. Yet it is clear these events also provide valuable information and a chance from nurses to network and share experiences.
Many nurses are struggling to find funding for education and training and there is a growing dependence on industry financial support. Nurses who receive such support need to be clear about their relationship with industry, and this must be open and transparent. This is vital to ensure that we continue to serve the needs of the patient not the company who funds training.
But an additional concern is how we meet the training needs of nurses whose jobs do not fall into the target groups for drug industry investment. Post Francis there is clear evidence that all nurses need time out to reflect on care; to have supervision and regular updating. Who is looking out for all their training and networking needs?
'No other profession has faced the implication that it has been accepting the wrong people'
Over the years I have seen the nursing profession deal with some enormous challenges, including seismic changes in nurse education, the eradication of an entire level of the profession and countless media storms – both justified and not.
For the most part, when the chips are down, nurses roll up their sleeves and get to work. Their morale may suffer, stress levels may rise and they may have a moan among themselves, but they generally handle whatever is thrown at them without kicking up too much of a fuss – at least not publicly.
However, the mood of the profession seems different as it absorbs the implications of Patients First and Foremost, the government response to the Francis report. I’ve seen far more openly expressed anger – from nurses at every level of the profession. And little wonder.
No other profession has faced the implication that it has been accepting the wrong people, with aspiring nurses facing a year’s work on the lowest salary rung as HCAs before three years of study. And exactly who did the government consult about this proposal? The entire nursing community appeared to be in the dark until the response was published.
Nursing competes to attract the brightest and the best – it wants people who have other options rather than those with nowhere else to go. While income is unlikely to be the primary motivator for most, the prospect of an additional year of financial hardship is likely to deter many excellent candidates from a nursing career. For people contemplating a career change or a return to work after having a family, that extra year could be simply unaffordable. And don’t get me started on how this flood of one-year-only HCAs will affect the wider nursing and HCA workforce – it’s too horrific.
I believe the profession has been insulted and shouldn’t simply accept its lot with weary resignation. Can you imagine doctors taking this on the chin? I can’t. So go on - get angry. Let the government know what you think of this insulting proposal.
'Does the government response support frontline nursing?'
The Francis report was clear that nursing was not working and made a series of recommendations broadly welcomed by the profession. Although it was damming about some nurses and the care they did not give it gave hope for the future. But this response to the detail and consideration in the Francis report feels a bit too much of a sideways swerve, a dodge even.
The Mid staff inquiry was permeated with stories of patients and relatives who felt invisible to the nurses who were supposed to be caring for them. Unfortunately it feels that the government response may have stripped out some of the elements that would have made the difference to day to day work on the wards. It does not mean that they will not happen but being left out today does not strengthen their cause.
For example the proposal of the key nurse that meant that an individual nurse would feel responsible for a patient’s care, the emphasis on how important it is for nurses to be present and active in ward rounds. Getting the ward sister out of the office and supervising staff and speaking to patients and relatives is mentioned but not supported in resource terms.
All these sensible and practical measures have instead been overshadowed by a scheme, not even proposed by Mr Francis, to have student nurses do a full year of pre-training training. A scheme so full of problems – how it is supervised, supported and resourced. What is the point/cost of continually training HCAs who will then disappear off?
The impact of the pre-training year will not be felt by the patients for many years, if at all. There are however some measures in the Francis report that will make a difference now. Let’s be sure that we don’t lose some of the good stuff and don’t let it be overshadowed by the crowd pleasing candy.
'Can you manage nurses if you don't actually nurse?'
Years ago I worked with a nurse manager who was happy to tell her staff that their standards were too high. She rarely ventured onto the wards where standards of care were a problem. Wearing a suit and managing with extremely long arms from an office several floors away from her wards meant she rarely saw a patient let alone what was happening behind the curtains.
Can you manage nurses if you don’t actually nurse?
The recommendations of the Francis report suggest nurse managers need to be more clinically involved. But we have created a system that undermines the value of clinical care. Career progression with higher status and salaries takes our most able nurses away from the bedside. This creates barriers between clinical nurses and nurses who don’t nurse. Nurses commenting on this website appear to have little regard for their managers because in their eyes they lack clinical credibility.
Perhaps, on this issue, we can learn something from medicine. Doctors place great value on clinical skill and expertise. Doctors in management positions practise medicine and also go to meetings. Medical directors look after patients. So when they talk about medical issues they are informed by first-hand experience, who can argue with that?
Sadly, walking wards and spending time with staff once a month or even once a week does not equate with being a clinical expert.
It would be great if nurse managers carried a clinical caseload but how would it work in practice? I am interested to hear your views.
'We want to make it safe for health professionals to speak up about patient care and safety issues'
We often receive calls from people with random queries or requests that we simply can’t help with.
I’ve had students asking me to send everything we’ve ever published on the subject of an assignment, authors asking for copies of articles they wrote over 20 years ago but can’t remember exactly when, and patients asking me for a second opinion on advice from their GP.
However, something told me this call was different – the caller was obviously struggling to control severe distress and I knew I had to at least listen, whether or not I could offer any practical help.
She was a nurse who had raised concerns about patient care and been rewarded with a horrific experience of bullying that had left her traumatised and unable to work.
The only practical help I could offer was to refer her to Patients First, the organisation set up to support NHS whistleblowers.
However, the call brought home to me the reality of just how badly some health professionals are treated when they try to take issue with colleagues’ poor practice, in a way that simply reading about similar stories couldn’t.
That call planted the seed that resulted in our Speak Out Safely campaign, organised in association with Patients First and Public Concern at Work.
We decided to wait until the Francis report was published as we knew this would bring the issue into the spotlight. It was a long wait, but we hope it was worth it.
We have since had people question elements of the campaign, and in particular, whether we are aiming only to improve protection for people who take their concerns outside their employing organisation.
So, to be clear, we want to make it safe for health professionals to speak up about patient care and safety issues within their organisations, and to have their concerns taken seriously so that they don’t need to take them outside.
We realise that after serious harm or injury is too late, so we want to achieve a situation where people will feel able to speak up when their concerns are at a level that can be easily addressed and nipped in the bud.
After all, the dreadful examples we’ve all read about at Mid Staffs, Winterbourne View and elsewhere didn’t appear out of nowhere.
At some point, people got away with minor incidents that made them feel they had a licence to get away with worse.
So our petition calls for implementation of Mr Francis’ legal duty of candour for healthcare providers and professionals, obliging them to speak out when patients are harmed.
His other recommendation that it become a criminal offence to prevent someone speaking out was added to ensure health professionals have legal protection against the sort of bullying my caller and many others have experienced.
And we’re also adding to his recommendations that disciplinary action should not be taken when people speak out, unless a criminal offence has taken place or it would be unsafe for someone to remain in practice.
We believe this will enable organisations and individuals to learn from incidents, and for those responsible for poor practice to realise they can’t get away with it (and hopefully to receive training or support to improve before it becomes a disciplinary issue).
The other two elements of the campaign focus respectively on concerns raised internally and externally. Persuading trusts to make explicit that staff will be supported when raising genuine patient concerns should help to ensure their concerns can be addressed internally.
However, if they do need to take their concerns outside, we believe a full review of the Public Interest Disclosure Act is needed to ensure they are protected and that any as yet unidentified loopholes are closed to ensure others don’t have the experience of Jenny Feccit and her colleagues, who did not receive the protection from bullying they had hoped for.
We’re in it for the long haul on the campaign – asking governments to enact new laws or amend existing ones rarely results in a quick response.
But if you all sign our petition – and persuade colleagues, friends and family to do so too, we’ll get there.
And that’s vital – for both patients and professionals.
‘Babies have fluid levels?’
Six months ago I received my second favourite text to date. A picture of an eight week ultrasound and the words “You’re going to be an aunty!”
My sister-in-law’s pregnancy was ridiculously smooth. No morning sickness, no drama, in fact the most exciting things got was when she posted on Facebook about eating pork pies – was she finally experiencing a pregnancy craving? No, she’d just found a really good pork-pie shop.
Things went so smoothly in fact that when, four weeks before her due date, the baby hadn’t turned we all assumed she was just taking her time and all would be fine. But she didn’t turn and remained breech.
As the realisation that she would most likely be having a caesarean hit home it occurred to me that despite my three years of nurse training, I had no idea what was going on.
“They’re going to try and turn the baby” They can turn the baby from the outside? “The fluid levels are the low-end of normal” Babies have fluid levels? “She’s going to be conscious throughout the c-section” She’s going to see the operation?
Whenever I voiced my lack of understanding or grilled any mothers I know about their interpretation of what was going on, I was met with the same quizzical look and the comment “But you’re a nurse – surely you know about all this!” But the truth is that I didn’t know. My training is in mental health and even my general placements didn’t go anywhere near perinatal care. I may be able to recite section-rights in my sleep but advice on anything remotely physical? No chance.
Although the feeling of helplessness is so much more acute when it’s your own family, it occurred to me that I often felt like this working on mental health wards whenever someone came in who had a physical problem.
The word ‘nurse’ covers so many different areas that at times I’m almost hesitant to use it to describe myself. The roles of mental health nurses and general nurses are so different I sometimes wonder if they should even carry the same title. Particularly as public perception of what a nurse is tends to be limited to general nurses, despite nurses being present in all areas of healthcare.
Is this something only mental health nurses experience or do nurses from all specialties have those moments when they feel their knowledge doesn’t quite live up to their Staff Nurse title?
Incidentally, I now have a new favourite text: “Isobel Eve Entwistle born at 11.59 today, all is well with everyone”.
