Practice team blog
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.
Patients with chronic obstructive pulmonary disease (COPD) must come to terms with having a progressive and incurable disease that will increasingly limit their capacity for physical activity, and is almost certain to cause their death. And the fact that it affects the ability to breathe means they are constantly reminded of this frightening prospect.
But these patients also experience acute exacerbations, in which their condition worsens in a terrifyingly short time – often requiring emergency admission to hospital.
Like many long-term conditions, the progression of COPD can be slowed, and its effect on quality of life can be minimised. This requires patients to have a good understanding of their condition, how to manage it themselves and when to call in specialist help – and for that specialist help to be available when needed.
The fourth national COPD secondary care audit, published last week, reveals that care for this group of patients has improved since the last audit in 2008. Unfortunately, it also reveals that specialist help is not always available.
Patients with COPD need to be cared for by a multidisciplinary respiratory team – particularly in times of crisis. These teams can help to slow disease progression and maintain patients’ quality of life. By teaching patients to manage their own condition and recognise the early signs of deterioration they can also reduce admissions to hospital of patients with COPD exacerbations that could have been averted with early intervention.
The audit reveals a range of aspects of care in which there are variations across the country. It is depressing to see that access to respiratory specialist nurses has declined; only 71% of units audited have access to these nurses for all their patients, compared with 80% in 2008. However, the audit also suggests this is not necessarily due to budget cuts: a total of 551 specialist nursing posts were vacant when the audit was completed.
It would be useful to investigate the reasons for this high level of vacancies – is the shortage due to staff levels lagging behind rising patient numbers, a shortage of funds to train respiratory nurses, or a large proportion having left the specialty in a short time?
Whatever the reason, patients with COPD – and other long-term respiratory conditions – need this gap in services to be filled as quickly as possible.
Last week we reported that staff at Doncaster Royal Infirmary are trialling a traffic light-style hand hygiene reminder tool.
The device is being used in the emergency department and on a ward. The badge-like device is worn on the upper body and detects hand movements and the presence of hand gel. Green means the hands are clean, amber shows they are ready for washing, and when the hands remain unwashed the device turns red and beeps.
Don’t get me wrong, I am all for new technology – and this seems like a clever device. But something about this new invention strikes me as wrong.
I think for me the hand hygiene light should be going on in every nurse’s head, not on a badge. The need to clean your hands between patients should an intuitive and automatic part of nursing practice. And of course every member of the multidisciplinary team has the same responsibility.
As with other pieces of technology, there is a danger that health professionals will start to rely on the device rather than taking responsibility for themselves. That they will start to think that the device means they no longer need to focus on the issue of hand hygiene.
Hand hygiene is essential – and particularly so at this time of year, with the winter pressures looming. However, carrying out effective hand hygiene is well within the scope of nursing staff and I would prefer to see the NHS spending money on new technology that cannot easily be replaced by the actions of staff.
Twitter is full of nurses. But when I told some non-nursing friends this, they didn’t believe me.
Nursing is seen as traditional and professional, whereas Twitter’s reputation is built more on tales of scandal and pictures of cats. It’s associated more with Kim Kardashian than Edith Cavell.
But, as well as being a provider of by-the-minute celebrity gossip, it’s also a valuable tool for sharing best practice and debating Jeremy Hunt and Dan Poulter’s latest scheme.
Almost daily, we receive tweets from nurses and students looking for advice – a quick retweet will result in dozens of answers from nurses and other health professionals eager to offer their support. Nurses who, without Twitter, would never have been able to connect.
This is why we’re launching Nursing Times’ Nurse Tweeter of the Year 2014.
We’re inviting all nurses and student nurses (sorry no organisations, just individuals only) to put themselves, or their colleagues, forward as Nurse Tweeter of the Year. All you need to do is tell us in 140 characters why you, or your nominee, should win – a character limit you should be comfortable with!
As well as the chance to win a luxury hamper from Waitrose, this is your opportunity to boost your following, increase your influence and demonstrate thought leadership. Twitter is being used more and more by nursing leaders and Nursing Times’ Nurse Tweeter of the Year will be someone who shows excellent communication skills and an ability to not only adapt to new ways of working, but to embrace change and make the absolute most of the tools available to you.
Entries close at midnight Saturday 15 November and the Nursing Times team will then shortlist 20 tweeters. But that’s the only input we’ll have – from then on it’s down to you and your followers to choose who deserves the Nurse Tweeter of the Year crown.
After all, it’s your opinion that matters; you decide who is worth following.
Here’s what happens next:
17 - 24 November: FIRST HEAT
10 of the shortlisted tweeters will be randomly chosen for the first heat, which is open to public vote. You will be able to visit this site to vote for who you think should get through to the semi-final, and invite your followers to do the same.
The five with the most votes will go through.
24 November - 1 December: SECOND HEAT
The second team of 10 face the public vote. As in the first heat, only the five with the most votes will go through – regardless of how many votes those in the first heat receive.
1 - 8 December: SEMI-FINAL
The five top-rated tweeters from each heat will again face the public vote – votes from the first round won’t count so you’ll be testing your followers’ dedication by asking them to again help you get through (voting takes just seconds so not a huge ask!)
8 - 15 December: FINAL
The scores are reset and the top 3 highest-rated tweeters battle it out as their followers are asked for the final time to vote for who deserves to be NT’s Nurse Tweeter of the Year.
Monday 15 December: Winner announced
This will be based solely on votes received in the final; the highest number of votes at midnight Sunday 14 December will be Nursing Times’ Nurse Tweeter of the Year 2014.
Good luck to all our entrants!
I was struck last night by a tweet which quoted a CEO of an NHS Trust saying “I’m running the biggest nursing home in Europe. We haven’t done any elective work in years”.
If this is true across the country, it raises some challenges for nurses working on acute wards.
The first is the perception of older people who cannot be discharged from hospital as a burden on services.
The Francis report raised an interesting question about the rights of older people to access services: “Although older people hold the same right of access to NHS services as any younger adults, why are older people accused of ‘blocking’ the beds?”
In my view a patient should never be considered a burden. If they cannot be discharged because they need nursing or social care then they have a right to that care.
“In my view a patient should never be considered a burden”
The next challenge is whether the acute services have sufficient appropriate skilled nurses to care for very dependent older people. This issue was raised by Mr Francis who asked, “When admitted to a general adult ward, where older adults now outnumber younger adults, why is specialist gerontological nursing not widely available to prevent readmission?”
However the suggestion by Mr Francis to develop a specialist role for older peoples’ nurses who could “change the care of older people and create a different value system” was rejected.
While initiatives such as the Health Education England one-year, part-time fellowship for older peoples nursing is developing leaders in the field, there are initially only two cohorts of 12 nurses which is unlikely to meet the growing demand for expertise in the acute sector this winter.
Which leads to the problem of staffing numbers.
“Failings in workforce planning are yet again challenging the standards of care nurses will deliver this winter”
Sadly, Nursing Times has reported this week that the Francis effect seems to have stalled with nursing numbers falling. Yet our ageing frail population who occupy large numbers of our acute beds need experienced motivated nurses to care for them but also pairs of hands so care can be delivered in a dignified and timely manner.
Failings in workforce planning are yet again challenging the standards of care nurses will deliver this winter.
It is nearly two years since the publication of the Francis report which laid down the challenges of providing care to older people in acute hospitals.
While we can discuss and attribute blame about failure to act on these challenges, it is nurses who will have to manage the fallout of poor planning. Poor morale, poor recruitment and retention of staff is the net result.
What will it take for people to realise that making money out of other people's misery is utterly unacceptable?
It’s Hallowe’en again, and as sure as ghouls emerge from graveyards, we have another crop of “hilarious” costumes making a joke out of mental illness.
Asda and Tesco were forced to apologise last year after coming in for a barrage of criticism for selling “mental patient” and “psycho ward” costumes, so you might think companies would have learnt that it’s really not on.
Well think again.
This year the cream of the crop comes from Joker’s Masquerade, which had a whole selection of “lunatic”, “schizo” and “psycho” costumes on sale a couple of weeks ago (it also had a couple of Ebola costumes in case you fancied having a laugh about people dying horrible deaths right now).
After a Twitter storm and stories run by the BBC and various local and national press, the company seems to have removed the bulk of the costumes from sale - although Adult Psycho Ward is still available as I write.
But the company isn’t remotely repentant, as its blog makes clear. Apparently the people who took exception are, among other things “incestuous Tweeters”, attacking an “ethical” company.
I’d love to see its ethical policy.
Many people with mental health problems already feel isolated and vulnerable - seeing themselves treated as figures of fun might just be the last straw for some.
What will it take for people to realise that making money out of other people’s misery is utterly unacceptable?
Some procedures are carried out in hospital wards across the country each and every day with no ill-effect to patients. However this does not mean that because a procedure is common, and generally problem free, that there are no dangers that staff need to watch out for.
One example is the removal of a naso-gastric tube.
Naso-gastric tubes are often used in healthcare and staff are now more familiar with the risks of this method of feeding patients. In the last few years there has been an emphasis on the importance of making sure naso-gastric tubes are correctly placed to avoid serious complications or even death.
Wrongly placed, naso-gastric tubes are a never event for the NHS.
Another potentially harmful issue around the use of naso-gastric tubes is when a tube can become looped or knotted. When removal of the tube is attempted this will cause the patient pain and distress.
As our expert article published this week explains, nurses need to be aware of the possibility of knotting so they know what to do if they experience resistance when removing a tube. As our author makes clear, it is important that a tube is removed in a slow controlled way not whipped out at speed. This will allow any resistance to be responded to and will not result in the knot causing damage. Knotted tubes need to be removed with an endoscopy.
Take a look at our article and have this issue in your and your team’s mind when carrying out this common procedure.