Practice team blog
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.
A few weeks ago I went to see Still Alice and cried. Despite close contact with people with dementia it was a shock to see a middle-aged woman with the condition, her rapid decline and the impact her illness had on those around her. As a woman in my fifties I was also frightened by what the future might hold.
After the film I found myself calculating now many useful years I have left. I even started to look up advice on how to help keep dementia at bay: learning a new language, exercising more, drinking less and eating well. Sadly none of these are a cast-iron guarantee of a dementia-free old age – and the latest research suggests, counter-intuitively, that being overweight in middle age and old age may reduce the risk of dementia.
While research into prevention and cure is ongoing we should be reassured by the progress that is being made in understanding how to care for people with dementia. However, much of this knowledge is not reaching those who provide day-to-day care. Many health and social care professionals lack training in dementia and sometimes our well-meaning actions cause unintended distress. Trying to convince a patient that his wife is dead when he believes he needs to catch a bus home to her is often counterproductive.
Our ritual and routine sometimes get in the way of providing imaginative dementia care. Yesterday I read about a structured programme of sensory activities that aims to ensure care home residents with advanced dementia enjoy the best possible quality of life. An important part of the programme is touch but the authors noted that staff had a problem relinquishing their gloves to provide the ‘loving touch’ that is integral to this approach. We will publish this article soon.
This week we have published a fascinating article that describes the concept of the “time machine” to help care staff understand the lived reality of people with dementia.
We all have a timeline of memories from early childhood to the present, with significant events such as the birth of a sibling, starting our first job and getting married. As dementia progress people move back along this timeline, losing recent memories first. Understanding where people with dementia are on their timeline can help you interpret their behaviour and respond to it appropriately. Ultimately the process is about holistic care and knowing your patient rather than assuming there is one way to ‘manage’ dementia; this requires education and a high level of skill.
Our newest learning unit is on differentiating dementia, delirium and depression in older people. These are vital skills to ensure older people are not misdiagnosed and fail to receive appropriate care.
In his recent report into whistleblowing Sir Robert Francis QC felt the need to call for legal protection for staff who raise concerns about care. This is a full two years on from his report into care failings at Mid Staffs, which lifted the lid on how the organisation treated staff who spoke up.
Numerous other high-profile whistleblowing cases have shown that Mid Staffs was not unusual in this. Bullying, excluding or vilifying whistleblowers seems the kneejerk response for many health and social care organisations.
It is profoundly depressing that many healthcare providers appear to think that any problems around whistleblowing and raising concerns simply don’t apply to them. Two years into our Speak Out Safely campaign, only just over 100 NHS organisations have signed up, making a public pledge to support staff who raise concerns, despite repeated invitations.
That leaves well over 200 in England yet to do so. Meanwhile, no NHS organisations from Scotland, Northern Ireland or Wales have signed up, and only three private providers have done so.
Why do these organisations not feel the need to reassure their staff that they will be listened to if they raise a concern? Do they think staff trust that they would be treated well, or do they simply not want to encourage people to point out things they don’t want to know? Or perhaps they need some evidence to galvanise them.
A report into its early use suggests the cultural barometer designed to identify poor workplace culture, developed by leading nurses, might just give these organisations the evidence they need, assuming of course they have the will to investigate whether their organisation’s culture could be allowing poor, or even abusive, care to go unreported.
It seems the tide may be turning on the way older people are treated in the NHS, with the need to develop and improve this important area of care at last being acknowledged and acted on. There were two announcements this week that gave me hope that change is coming.
One is that the first national programme for nurses to develop specialist expertise in the care of older people has begun. The Older Person’s Nursing Fellowship at King’s College, London is open to band 7 and 8 nurses, and the initial course has launched with 24 places.
The fellowship, funded by Health Education England, is being seen as the first initiative of its kind to develop highly skilled nurses with specialist expertise in the care of older people. It is an acknowledgement of the complexity of the care this group needs.
In the same week the NHS Confederation announced it is launching an independent commission on improving urgent care for older people. Leaders and experts from across the acute, primary, community and social care sectors, commissioners, patient groups and older people’s advocates will together put forward patient-centred, evidence-based solutions to be practically applied in local health and care settings.
The commission will look for examples of best practice to inform development of its report and recommendations. The final report will be published at the end of the year, with the confederation then rolling out a programme of practical activities to implement the recommendations at local level.
These are small but essential steps on the road to ensuring that care of this complex group is given the recognition it needs and is delivered by those who understand its complexities and have the knowledge and expertise required.
It was not a big surprise to me to read that mental health budgets have fallen by 8% in real terms during the term of this government.
But I was surprised to hear care secretary Norman Lamb’s reasoning around this decline in funding. According to the BBC, he explained that budgets were “not the full picture” and that “mental health care is given through a range of services including the voluntary sector.”
True, voluntary services such as mental health helplines offer invaluable support for people when they are at crisis point and do a fantastic job. But funding has been cut here too.
How can he possibly imply that volunteers are now providing mental health care so therefore it’s okay to cut budgets?
“The voluntary sector offers services that are vastly helpful to service users”
The voluntary sector offers services that are vastly helpful to service users but they cannot replace the work done by a community mental health team or by regular psychiatry appointments. Voluntary services should supplement care, not replace.
It is reassuring to hear that new standards for mental health services are being introduced and will be underwritten with some investment. But Norman Lamb’s comments give a worrying insight into a future where volunteers are relied on more and more to provide the type of care that should be given by healthcare professionals.
I don’t watch Top Gear, and perhaps my dented and increasingly rusty Ford KA explains why. But I am interested in the Jeremy Clarkson affair because until now he has been one of the “untouchables”.
It is interesting to note that it took several days for the incident to be brought to the attention of BBC managers – and it was Clarkson himself that raised the issue.
Why did it take so long? And why did no one else report it? Do employees of the BBC fear the repercussions of raising concerns against the rich and famous?
“Do employees of the BBC fear the repercussions of raising concerns against the rich and famous? “
Who can blame them when the prime minister is happy to make light of the incident on national TV while voicing concerns that his children will be denied their Sunday night entertainment, and over 600,000 people signing a petition to have Mr Clarkson reinstated.
Over the years I have met “untouchables” in the NHS who were never challenged about their behaviour.
Mr Clarkson’s suspension reminded me of a surgeon back in the early 1980s, who was brilliant at the technical aspects of his job but incapable of conducting a ward round without a temper tantrum. He was known to hit nurses on the head with clip boards if fluid balance charts were not up to date. His ward rounds were miserable and everyone was frightened of him, but his behaviour was excused as the actions of a perfectionist, and he went unchallenged.
What interests me about Jeremy Clarkson is not the future of Top Gear, or even his relationship with the prime minister. I am interested in why the incident was not reported earlier.
“It takes a lot of courage to blow the whistle”
It takes a lot of courage to blow the whistle, particularly when you are challenging people in power. There are numerous blogs on our website that are testament to the implications for staff.
Jennie Fecitt, lead nurse at Patients First, wrote “Seven years ago, as a senior nurse at Manchester Walk-in Centres, I blew the whistle on patient safety issues. I was bullied, victimised and received detrimental treatment from colleagues; my health and family suffered terribly. My NHS employer could and should have done more to protect me as a genuine whistleblower”.
Over two years ago we hoped the Francis report would bring about a change in culture in the NHS, but only yesterday I took a call from a nurse who was in despair about poor care in her workplace. She was too frightened to give her name or place of work, and was even concerned that I might track her call. How terrible that the only person she felt she could approach was a section editor of a magazine.
This is clearly not an isolated case. This year the results of the NHS staff survey revealed that nearly one third of NHS employees still do not feel secure raising concerns about unsafe clinical practice.
There is hope for the future. Sir Robert Francis QC’s new report “Freedom to Speak Out” offers 20 recommendations to support staff to raise concerns, and the Kirkup review presents clear challenges for maternity services.
“Perhaps it is time for a petition supporting those brave individuals who stand up and speak out when something feels wrong”
If the allegations against Jeremy Clarkson are proven he has to lose his job. This will send out an important message to people who think bullying from a position of power is acceptable and should have no consequences.
Perhaps it is time for a petition supporting those brave individuals who stand up and speak out when something feels wrong, whether that is the NHS, the BBC or any other organisation. Bullying cannot be an inevitable part of working life.
Find out about Nursing Times’ Speak Out Safely campaign
I like to think that one of the reasons we love the NHS is that the general population in the UK has a sense of fairness that is largely independent of where individuals stand on the political spectrum. We may argue about the finer details but the overwhelming majority of us agree that a healthcare system that is free at the point of need is fair.
Where there are arguments about fairness in the NHS they tend to focus around who ‘deserves’ care, and there are a number of easy targets. Common focuses of frustration and disagreement are ‘health tourism’ – non-UK citizens receiving free care; the ‘undeserving’ sick – people whose lifestyle choices may have caused their ill health; and the ‘frivolous’ patients – those who want treatment to enhance their life rather than cure ill health.
While there are many arguments about whether it is fair that one group or another should receive free healthcare, in another area there seems to be an overwhelming consensus that fairness means ever-greater funding. Many new drugs coming onto the market that advance treatments in life-threatening illness are eye-wateringly expensive. Yet when NICE says it can’t justify the expense for the benefits patients will receive, it is regularly vilified as denying hope to dying people.
As we read the undeniably sad stories of individuals being denied a drug that may give them an extra two months of life, of course we sympathise – and empathise. We want them to have the drug, and the chance of that extra couple of months. But the drug will be paid for from the finite resources of the NHS, so it will mean denying other people other treatments. The reason we don’t get as agitated about those people is that we don’t have their story, or a picture of them because they aren’t an identified individual. They are a group affected by a changed target or policy, and rather than dying earlier, they may just have to put up with pain and immobility for a while longer, a cheaper and less effective treatment, fewer community nurse visitis or fewer sessions of a much-needed therapy.
I wouldn’t like the job of deciding where the fairness line should be drawn, and I am certainly not suggesting that funding for expensive new drugs should be routinely refused. But a research report from the University of York recently suggested that, far from being miserly when it comes to approving expensive new drugs, NICE is actually too generous in the amount of money it recommends spending per quality-adjusted life year.
The report recommends that spending decisions look not only at the QALYs that may be gained by individual patients who receive expensive new drugs, but also at the QALYs likely to be lost elsewhere in the system in additional deaths, life years lost and poorer quality of life for the ‘unknown’ people. That sounds fair to me – what do you think?
The topic of when and for how long relatives and friends can visit on hospital wards has long been a much discussed topic. Open visiting versus fixed-hours visiting? Should it be the same for every ward and department? Can children visit? How many visitors should be allowed at one time?
The discussion continues around and around because at the root of it all is the problem that not one size fits all. No one blanket policy will suit every patient and every ward.
“No one blanket policy will suit every patient and every ward”
I was really heartened to see that one trust has developed an innovative approach to the question of hospital visiting. The new system focuses on the individual needs of patients and assesses whether they would benefit from having the freedom to be visited by family and carers 24 hours a day.
Imperial College Healthcare Trust has developed “passports”, which are issued to family and carers of vulnerable patients or people with dementia across the five hospitals within the trust. The card allows them to visit whenever they want.
The cards were developed by nurses, which is no surprise as they are the ones who spend their time debating the visiting issue with patients and their loved ones.
“Having a card means families can support their loved ones who are in hospital”
Having a card means families can support their loved ones who are in hospital, which can be a difficult and destabilising experience. Doubtless this measure will help the wellbeing and recovery of these vulnerable groups.
Where possible acknowledging that individual needs are met is the root to the best quality healthcare and the optimum patient experience.
When the idea of launching a Nursing Times app was floated a few months ago I was cautiously excited.
The need for an app was obvious. Since becoming online editor a year ago, I’ve watched as the number of you accessing nursingtimes.net on phones and tablets has dramatically increased.
But I’ve worked in the NHS and know that although a needed change might be obvious to the frontline, it doesn’t always filter up, in any organisation. So I held back on my optimism until the moment we actually pushed the button and made the app live.
I wouldn’t be surprised if many of the people reading this have felt the same at some point in their nursing career. It doesn’t take a genius to see that those on the frontline will be the first to spot potential patient care improvements, yet how often are they involved in the decision making?
That’s why we got involved with the Change Challenge.
The Change Challenge, or “Challenge Top-Down Change” to give it its formal title, aims to use crowdsourcing to give everyone working in the NHS, or using one of its services, a chance to put forward their ideas for implementing change within the health service.
Even those without a ground-breaking idea were able to vote on others, resulting in a set of ideas already peer-reviewed. The campaign has so far had a massive 7,500 contributions, giving us the first ever socially constructed roadmap for change in the NHS.
The next stage is to collect stories of change and experimental ideas on how to apply the changes put forward in stage one. You can get involved and make your voice heard on the Challenge Top-Down Change website.
Going back to our big change, the Nursing Times app hit both the App Store and Google Play last month and I’m delighted to say our wonderful readers have proved me right by downloading it in droves.
Subscribers can now download the app on Apple and Android absolutely free as part of their subscription, and access a whole range of content including rolling news and the latest practice. Just log in with the same details you use on the website. If you’re a subscriber but you’ve never used the website you will need to activate your subscription, a two-minute job that will give you access the thousands of practice articles, plus our range of online learning units on fundamental nursing topics.