Practice team blog
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.
The revelations of the Francis Inquiry into care at Mid Staffordshire hospital two years ago made shocking reading. How could something like this happen in our NHS?
Today Sir Robert Francis sought to answer this in the Freedom to Speak Up Review, which explores the problems staff experience when they want to raise and escalate concerns. While reading through the summary of the report I was reminded of a quote from Marie Manthey, a pioneer of the primary nursing movement, which captures simply what our priorities should be:
“Patients matter most but staff matter too”
What Sir Robert has demonstrated is the difference between a culture that nurtures staff and one that sees both staff and patients as commodities who can be pushed through systems based on industrial processes rather than the principles of humanistic care.
It is difficult to read Sir Robert’s account of talking to people who tried and failed to raise concerns in organisations designed to care. He says:
“It is difficult to read Sir Robert’s account of talking to people who tried and failed to raise concerns”
“The genuine pain and distress felt by contributors in having to relive their experiences was every bit as serious as the suffering I witnessed by patients and families who gave evidence to the Mid Staffordshire inquiries. The public owe them a debt of gratitude in the first place for speaking up about their concerns, and secondly for having the courage to contribute to this Review”.
There are 20 recommendations, which have all been accepted “in principle” by Jeremy Hunt, but my concern is how these will be implemented. I can already see chief execs reaching for a pad trying to work out a to-do list, but as Sir Robert makes clear:
“We need to establish everywhere a culture in which all staff feel safe to raise their concerns.”
My concern is that while we talk a lot about culture and openness and honesty, this winter we have seen meltdown in many parts of the NHS. There has been a mantra in the NHS over recent years that you don’t need more money – you just need to do things differently. But the winter crisis in A&E has indicated that many NHS organisations have been pushed as far as they can go.
“Francis has laid out a framework for ALL staff to raise concerns”
Nurses struggle day in and day out to provide the bare essentials of care to patients. They are forced to cut corners and compromise because they have neither the time nor the resources to do otherwise.
Yes, NHS managers need to facilitate a cultural change that allows staff to raise concerns. But in return these managers need adequate resources so they can support their staff to do the best job they can.
Francis has laid out a framework for ALL staff to raise concerns. Politicians now need to be ready to deal with the reality of providing care in a service that is underfunded and run on the goodwill of staff.
Storytelling has been a cornerstone of education and culture across the world for centuries.
In preliterate times stories were used to pass on the important knowledge and cultural norms and values that sustain communities.
While storytelling has retained its significance in many cultures in the developing world, in the West it became seen as largely for entertaining or educating children. But the value of storytelling in education and training has been increasingly recognised in the UK over the past few years, and this is a welcome development.
We all love good stories - I remember far more of the stories I read as a child than the academic texts I read as an undergraduate. That’s because stories engage us, take us on a journey, and show us the world from a different perspective. So I’m delighted that storytelling is increasingly used in healthcare education and practice, as our articles on the use of stories in NHS organisations and nurse education demonstrate.
There can be few areas with such a wealth of powerful stories as healthcare. These may be from patients, families or staff, and can range from the tragic to the triumphant. Appropriately used they can offer staff - and patients and their families - the opportunity to look at life through someone else’s eyes. These stories should be used to help health professionals to improve their abilities to offer patient-focused care.
In healthcare nothing stands still or stays the same.
And if you look in the opposite direction for too long something will happen behind you. An example of this is tuberculosis. Once nearly eradicated, it has crept back into our lives, slowly and insidiously over the last 15 years.
The UK currently has the second highest rate of TB among Western European countries and, if the current trend goes unhalted, England will have more TB cases than the whole of the United States within two years.
Last week the government announced a new strategy to tackle the rise in the number of TB cases. The £11.5m investment announced by Public Health England and NHS England will deliver a 10-point action plan, the Collaborative Tuberculosis Strategy for England 2015-20.
This will include improving access, treatment, diagnostic and care services. And it will focus on tackling the disease in difficult-to-reach groups and improving screening and treatment for new migrants.
This is welcome news indeed, but in many ways overdue. The increasing incidence in hot-spots like London, Leicester, Birmingham, Luton, Manchester and Coventry has been clear for some years. Let’s hope that this new funding and strategy will now tackle this as a national issue, rather than the job being left to localities, and we will work towards eradicating this disease.
Last week, I received an email from a student nurse wanting to ask the Student Nursing Times community for some advice.
We host a regular feature on Student NT for our readers to discuss problems and offer advice, so this email was nothing new. But its content struck a chord with me.
Victoria started her email by saying that the nurses on her placement “weren’t very nice”. She was told to “get on with it” and “find your own learning opportunities”, she felt ignored and it sounded like your classic too-busy-for-students ward.
But her main concern wasn’t for herself, but for the patients the ward was meant to be looking after. As an outsider looking at the ward culture from a fresh perspective, Victoria saw how patients were ignored and she noted “there seems to be a massive lack of compassion and respect for patients”.
We know that there are wards out there run by individuals who are burnt out or so overwhelmed with paperwork and stress that they can’t see the wood for the trees. But every person who responded to Victoria seemed to have experienced the same:
“Sorry to hear that you are experiencing this. I too had a similar problem at one of my placements”
“I can really empathise with your situation as I have been there too”
“Had a similar experience myself in my mental health placement”
“I too had this, so I can completely understand where you’re coming from”
“What you describe is not unique to where you are. Indeed, I have experienced the same scenario both as a student and as a qualified nurse”
“Victoria, this sounds very much like my first MH placement in first year…and looking back on it I recognise it was something of a baptism of fire.”
Thankfully, many of the commenters suggested Victoria raise her concerns and I hope those who could empathise with her had already raised theirs. But with so many student nurses reporting similar experiences, I had to wonder, do student nurses feel able to take their concerns further? And when they do, is something done about them?
Raising concerns doesn’t need to mean getting staff into trouble. But it does mean management are made aware that the culture on that ward, for whatever reason, isn’t working.
Are you surprised to hear student nurses reporting these experiences?
The rhetoric of providing health care in the community, away from hospital, has been with us for years but the recent media coverage of problems in EDs illustrates how little progress has been made in shifting care from hospitals to primary care services.
It is evident that community and social services are failing to meet demand and with a shortage of GPs and community nurses there is a growing acknowledgement that practice nurses have a critical role patient care and preventing hospital admission.
The problem is that practice nursing is considered by many as a dead end job with few career opportunities and still not regarded as an option for newly qualified nurses. However there are practice nurses across the country working in autonomous roles, as advanced nurse practitioner and developing new models of service. They have an invaluable role in managing long terms conditions and providing continuity of care.
This week I visited Health Education Yorkshire and the Humber who have recognised the potential of practice nurses and are working to change perceptions and engage student nurses in general practice as a career pathway. However many students do not have the opportunity to work in general practice during their training and the myth that you must have acute experience before working in the community still prevails in many areas.
Practices 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.
If you sit in my GP’s surgery and watch the way the practice nurses greet their patients it is clear that continuity of care brings with it great satisfaction and reassurance for patients. Ensuring we have enough practice nurses to sustain these relationships with patients is clearly part of the solution to the ED crisis.
We’re coming up to two years since Sir Robert Francis QC published his report into care failings at Mid Staffs. Unlike many “seminal” and “watershed” reports on the NHS and healthcare more widely, which lie gathering dust having been ignored by those targeted with recommendations, the Francis report has already led to changes in government policy and health service practice.
While Sir Robert was at pains to avoid blaming any individual or group for what he saw as systemic failings, many news organisations laid much of the blame on nurses. It is heartening, therefore, to see that both the government and employers are recognising that the quality of patient care is affected not only by the numbers of nursing staff on duty but also the ratio of qualified nurses to healthcare assistants.
One of the areas the Francis report paid particular attention to was the treatment of staff who raise concerns about care. It recommended better protection and treatment for these people, who have been bullied and discredited in many organisations over the years, often losing their careers and suffering mental ill-health as a result. Unfortunately, the situation has not improved significantly.
Our award-winning Speak Out Safely campaign was inspired by the report; by persuading employers to publicly commit to supporting staff who raise concerns we hoped to contribute to the culture change needed across healthcare. To date, just over 100 NHS organisations in England have signed up to the campaign, along with 35 other organisations. That’s great, but it leaves an awful lot more yet to do so – including the whole of the NHS in Scotland, Wales and Northern Ireland.
Sir Robert was asked in 2014 to chair an independent review of the treatment of whistleblowers. His report is due to be published early this year, when we will be redoubling our efforts to persuade NHS and independent healthcare organisations to support SOS. Let’s hope that 2015 is the year when the whole healthcare system finally recognises that people who raise concerns should be celebrated and cherished instead of bullied and bankrupted.
When I visited my mother in hospital on Christmas Day I felt very grateful to the staff, who were working as hard as always. My mother’s needs were as acute on that day as on any other.
Working over Christmas is tough for nurses as they balance the demands and needs of their own lives and their work in a job that is 24/7. As nurses well know, illness takes no account of bank holidays. And winter pressures are particularly acute this year. Waiting times in A&E are already showing that trusts across the country are struggling to hit the four-hour wait target.
It is difficult to go to work when others are not. Getting up early when it feels like the rest of the world is in bed, or leaving behind family and friends settling down on the sofa to watch a film as you go in for a night shift isn’t easy. But it is without doubt that patients really appreciate nurses’ efforts at this time of year.
One in four older people are dreading Christmas with fears of being lonely and missing loved ones who have died, a survey by Age UK reveals. For many patients in the community, a visit from a nurse may be their only human contact over the “festive” season.
An older person who is struggling through a lonely Christmas will feel greatly lifted by your ring on the doorbell and the care and support you offer. Patients waking up in bed in hospital will know that your arrival for a shift on Christmas day is not without some sacrifice.
Nurses are the backbone of the health service and at Christmas they offer care to patients as always and a lifeline to the old and frail in the community. I hope that appreciation makes it easier to get out of bed and go to work over the holidays.
Since we launched Student Nursing Times four years ago, we’ve hosted hundreds of blogs from student nurses who want to share their experiences and advice. Most of these blogs tell stories of overcoming fears but the most heart-felt blogs almost always contain the words “role model”.
But why do student nurses find it so important to have a role model? Is this really a critical part of becoming a “good” nurse?
Like most student nurses, I learnt first-hand what a poor role model looks like. On a community placement, I was assigned a mentor who would frequently tell her colleagues she was in meetings but instead meet her friends for long lunches, visit her daughter or go shopping. Patient care seemed a long-way down her list of priorities.
Did this experience hinder my learning? Absolutely. But at the time I believed this was only because I missed out on patient visits, not because I learnt this was the right way to do things.
Conversely, my next placement was on a psychiatric ICU where my mentor would make me explain to her the purpose of every drug I administered, its side effects and why this drug was likely to have been prescribed.
I learnt a lot about mental health medication, but I learnt even more from watching her communicating with patients that they might have to wait a little longer today as I needed to learn. She did everything thoroughly and her approach gained patients’ respect.
Having a bad role model wasn’t damaging in itself - I knew which of these two nurses I wanted to be like. One who saw nursing as something she did when she had to in order to pay the bills, or one who had patience, excellent communication skills and an awareness of just how much knowledge nurses need to have in order to keep patients safe. I didn’t realise it at the time, but of course the second became my role model from day one of the placement, and I gained so much more.
So our SNT Christmas competition this year isn’t aimed at rewarding student nurses. This year, we’re rewarding the role models who do more than they probably realise to enhance students’ learning.
Student nurses can nominate anyone who has gone the extra mile to make them a better nurse. Find out more and read some of the entries so far here.
And if you’re a student nurse, make sure you put forward that nurse, OT, physiotherapist, doctor or healthcare assistant who at some point in your training has been your role model.
When I was a student nurse we were taught that gloves created a barrier between the nurse and patient. So for much of my early nursing career I thought nothing of changing soiled beds, emptying commodes and gathering up sputum pots with bare hands. Although I also remember being obsessed with washing my hands at every available opportunity.
I was reminded of this when I visited a friend in hospital a few weeks ago. I was surprised to see healthcare assistants put on gloves to help my friend sit up at lunch time, serve her food, make her bed and carry out routine observations. My friend was not infectious and their reasons for choosing to wear gloves was unclear.
This week we published the results of a small study exploring student nurses’ reasons for wearing gloves, which raised some interesting questions. The students who took part appeared to lack a clear rationale for their decisions; one student commented that she wore gloves for all patient interventions “as I wouldn’t feel comfortable not wearing them”.
The authors note that in clinical placements, students conformed to whatever practices they observed their mentors and other staff doing in relation to glove use. They seemed to lack the underpinning knowledge needed to make decisions for themselves. It also appeared that gloves were often used as barrier based on an assumption that all patients pose an infection risk.
We all have a responsibility to ensure patients receive safe care, and to protect ourselves from risks of infection, but use of gloves must be based on a sound evidence base and protect the unique relationship we have with our patients. The World Health Organization has clear guidance on when gloves should be worn, and all healthcare providers should have policies to guide nurses. However, it is impossible to change practice without addressing staffs concerns and fears, no matter how irrational these appear to be.
Next week we are publishing a guide to personal protective clothing that provides a useful update on when and how to use this essential equipment.
I am interested in your views of glove use and when you decide to wear them.
Let us know what you think in the comments section below.
I also recommend the following article from our archive, which explores in more detail healthcare workers’ attitudes to glove use.